Dyadic reports of weight control practices, sedentary behaviors, and family functioning and communication between adult weight management patients and their children

Abstract Background Parents are increasingly pursuing weight loss in medical weight management programs, yet little is known about the presenting behaviors and practices of children who have parents initiating these programs. Objective To describe congruence in weight control practices, sedentary and screen time behaviors, and family functioning and communication between parents initiating a medical weight management program and their children (ages 7–18). Methods Twenty‐three dyads were enrolled and had measured height/weight and research packets completed including perceived weight status, weight control practices, sedentary and screen‐time behaviors, and family functioning and communication. Paired t‐tests and intraclass correlations assessed congruence; independent t‐tests determined differences based on child demographics (age, sex, and weight status). Results Parents underestimated children's use of weight control practices compared to child reports. Children with overweight, males, and older in age had increased weight control practices and sedentary and screen‐time behaviors. Children who perceived themselves to have overweight reported more impaired family communication than children perceived to be a healthy weight. Conclusions This study highlights the discrepancy between dyads' reports of children's behaviors, and identifies that specific child populations with overweight, older in age, and males are at‐risk of experiencing less healthy behaviors and impaired family communication. Future research should monitor changes over time in parental weight management programs to determine effects based on parental weight loss.


| INTRODUCTION
Adult obesity rates have steadily increased for the past 3 decades, 1,2 with half of all US adults pursuing weight loss, increasingly through medical weight management programs. 3,4 Given their shared genetics and children's exposure to parental behaviors in the home contributing to parental obesity, 5 children of parents in weight management programs are a particularly high-risk group for developing obesity. [6][7][8][9][10][11] Prior work has documented that parents in weight management programs and who had bariatric surgery report their older children and children with obesity engage in higher rates of weight control practices (i.e., dieting), 9 and more frequent talk about child weight and parental weight loss. 10,12 Additionally, parents report more impaired family functioning when their children have overweight/obesity. 6 , 7 However, a limitation of prior research with children of parents in weight management programs is the assessment of parent-only perspectives of children's behaviors. 6,7,[9][10][11][12] Parents and children often have different perceptions about their own behaviors and the behaviors of the other member of the dyad. 13,14 Lack of congruence between parents and children challenges researchers to understand the accuracy of individual assessments of behaviors or practices. 15 Additionally, lack of congruence in the assessment of relationship factors, may indicate problems in which one member of the dyad believes their relationship is functional while the other believes it is impaired. 16,17 Prospective assessment of parent-child dyads, in which both parent and child perceptions are obtained, are needed to understand significant factors to assess over parental weight management program duration that may be modifiable in future parent-child interventions.
The objective of this study was to describe the dyadic reports of weight control practices, sedentary and screen time behaviors, and family functioning and communication between parent-child dyads in which the parent is initiating an adult medical weight management programs. Agreement or congruence between parental and children's reports was explored, and between group differences based on child demographics (age, sex, and weight status) was conducted. Given the prior cross-sectional evidence on parents in weight management programs, 6,7,10-12 following hypotheses were assessed: (1) parents of children and children with overweight/obesity will report more impaired family functioning, and (2) parents of older children and children with overweight/obesity will report higher use of weight control practices compared to younger children and children with a healthy weight status.

| Recruitment and enrollment
Recruitment took place using a convenience sampling strategy from November 2018 to March 2020 at parents' weight management program orientation meeting. Details about The Ohio State University (OSU) Center for comprehensive weight management, metabolic and bariatric surgery have been described previously. 18 The 6 month   program includes nutrition, exercise, and behavioral components   delivered through group educational and support classes and individual consultations with registered dietitians, behavioral health providers, and exercise physiologists. There is an initial wellness orientation, in which patients have their resting metabolic rate tested and a fitness evaluation to formulate individualized meal and exercise plans, respectively. Weight, dietary, and exercise journals are reviewed weekly with a postprogram fitness evaluation. Inclusion criteria comprised: parent enrolled in the weight management program, child aged 7-18 years old living in the home ≥4 days per week with the parent, no history of bariatric surgeries, no life-threatening comorbidities for the parent or child (i.e., terminal cancer), and parent and child need to be free of conditions that would prevent engagement in physical activity (i.e., unable engage in movement-based physical activity). The child age range of 7-18 was selected due to appropriateness of child self-report measures. If multiple children met inclusion criteria, parents were encouraged to select their youngest child. Parents who indicated interest at their orientation were provided contact information to schedule with their child, in which consent/assent were obtained and dyads were enrolled. Parents and children completed a research packet and had height and weight measured. Children were offered support from a member of the research team if they needed assistance with completing the measures. Parents and children received a $20 retail gift card for participation. The study received OSU Institutional Review Board approval (IRB #2018H0308).

| Measures
Based on the measured height and weight using a wall-mounted stadiometer and a scale 19 and child date of birth, BMI and child BMI percentile was calculated, and weight status categories were made. 20 used a food substitute, skipped meals, took diet pills, used laxatives, used diuretics, smoked more cigarettes, made myself vomit) and five healthy (increased fruit and vegetables, cut out between meal snacking, exercised, decreased fat intake, reduced calorie intake) KEELEY J. ET AL.
-327 practices. Combining unhealthy and health weight control practices, the total score possible for all weight control practices was 15; 10 for unhealthy and five for healthy weight control practices. Higher scores indicate higher use.

Children's sedentary and screen-time behaviors were assessed from
Project EAT 22 with the following stem for each question, "In your (or your child's) free time on an average weekday (or weekend), how many hours do you (do they) spend doing the following activities?" Activities included watching TV, using a computer, playing video games (both interactive and sitting), and mobile device use. Parents and children responded with, "none, less and ½ hour a week, 1/2 h to 2 h a week, 2 to 4 h a week, 4 ½ to 6 h a week, or 6þ hours a week." A total of score weekday/weekend use was calculated for parent and child reports of children's total sedentary behaviors and individual totals TV, computer, videogame and interactive videogame, and mobile use. Higher scores indicate higher weekly utilization.

| Family functioning and communication
The Family Assessment Device-General Functioning Scale was completed by parents and children to measure current family functioning. 23 A clinical cut-off score was used to note clinically impaired (≥2.0) or healthy family functioning (<2.0). 15,23 Fmily Assessment Device-Communication Scale was used to assess the clarity and directness of communication between family members. 23 The clinical cut-off score notes clinically impaired (≥2.2) or healthy family communication (<2.2). 20 Higher scores on both scales indicate more impairment.
These scales have been previously validated with school age children and adolescents; however, children younger than 12 years old had slightly lower reliability but concurrent validity with parent report. 24

| RESULTS
Fifty-three parents with children who met inclusion criteria were invited to participate. Of the 53, 23 (43.3%) dyads provided consent/ assent and completed the data collection. Of the 30 (56.7%) who did not agree to participate, 10 parents indicated initial interest at their orientation but did not return follow-up calls. Of the other 20, eight declined due to lack of interest from child, six due to child time constraints, and six declined to give a reason. Demographic characteristics and scale descriptives are in Tables 1 and 2, respectively.

| Congruence between parent and child parallel reports
3.1.1 | Perception of Children's weight status Children were split between a healthy weight status (52%) and overweight or obesity (48%) based on objective measurements.
Parents and children primarily perceived children's weight status to be a "healthy weight" (70% and 74%, respectively). The majority of children were accurate in perceiving their weight status (19, 83%), four children had inaccurate perceptions (two, 9% underestimated and two, 9% overestimated). The majority of parents (18, 78%) also accurately perceived their child's weight status, with five (22%) underestimating their child's weight status.

| Weight control practices
Parents' self-reports of their total weight control practices were significantly higher than their reports of their children's total weight control practices (p < 0.001), and their children's self-reports (p < 0.001). However, parents reports of their children's weight control practices were lower than children's self-reports (p ¼ 0.019).
These results were consistent for healthy and unhealthy practices (see Table 3). There was moderate inter-rater agreement across these scales (ICC ¼ 0.54-0.65).

| Sedentary and screen-time behaviors
Although not significant, parents reported that their children had higher utilization rates of sedentary and screen-time behaviors than children self-reported (see Table 3). There was one exception for interactive video games, in which parents reported significantly lower child use than children self-reported (p ¼ 0.05). Inter-rater agreement ranged from low to good across these scales (ICC ¼ 0. 27

| DISCUSSION
This appears to be the first study to enroll parents and their children when a parent is initiating a medical weight management program to determine the congruence between parent and children reports in weight control practices, sedentary and screen time behaviors, and family functioning and communication. By comparing agreement between parental and child reports, it was identified that parents underestimated their children's use of weight control practices.
Based on the child demographics, children perceived to have overweight/obesity reported using more weight control practices and reported more impaired family communication. Additionally, older children reported higher use of weight control practices, and older children and male children had increased sedentary and screen-time behaviors. The prevalence of overweight/obesity that parents perceived their children to have in this study (30%), was similar to prior reports of parents' perceptions of their child's weight status (44% 7 ; 23% 6 ). In this study 22% of parents underestimated their child's weight status. Parental underestimation of children's obesity is well documented, [25][26][27] but not among parents who are actively seeking weight loss in weight management programs. Parents were more likely to underestimate their child's weight status than children were to underestimate their own weight status (22% vs. 9%). Future assessment of the effects of parental weight loss in weight management programs on perceptions of and changes in actual child weight status will provide objective means of determining if children of parents in weight management programs loss or gain weight at unhealthy rates, and use unhealthy means of weight control, during parental program participation.
Parents underestimated their child's weight control practices. In prior work utilizing parent-only reports, Pratt et al. 9 found that parents in weight management programs and who had bariatric surgery reported that their older children and children with obesity were more likely to use weight control practices. Similarly, in this study, but based on child reports, older children reported using more unhealthy weight control practices, and children with overweight/ obesity reported using more healthy weight control practices. Children who perceived their weight status to be overweight/obese reported greater total, healthy, and unhealthy weight control practices compared to children who perceived themselves to be a healthy weight. Developmentally, older children are more likely to be aware of their parents' behaviors and practices related to weight loss, and are exposed to more social pressure to be slim or a healthy weight, and children with overweight/obesity experience increased pressure to reduce their weight. 28  The rate of impaired family functioning in this study (26%) was similar to reports of parents in weight management programs or pursuing bariatric surgery (45% 7 ; 25% 6 ), but high compared to most child populations and those in pediatric primary care (i.e., 13%). 29,30 Children reported significantly more impaired family communication compared to parents, especially for children who perceived their