Research concerning children who are overweight has historically focused on providing services to the affected individuals, and limited attention has been paid to their families. Further, childhood obesity prevention and clinical programs continue to be impacted by contextual factors that increase the likelihood of attrition when targeting underserved populations. This paper provides data with relevance for interventions aimed at promoting healthy eating and regular physical activity with low-income families. Participants in a childhood obesity exploratory study provided recommendations to improve programs by reflecting on specific family and contextual issues related to children who are overweight and obese. Following a thematic analysis approach, we conducted semi-structured interviews with 16 low-income, single, female parents. All participants had, at the time of the interview, at least one overweight or obese child between the ages of 3 and 8. We report the critical role of context in the etiology and challenges of childhood obesity among disadvantaged populations. Findings also highlight the need for interventions to be culturally relevant and sensitive and to create opportunities to address and discuss participant experiences of discrimination, cultural factors, and family of origin influences. Interventions that do not address these contextual factors run the risk of being unsuccessful. Our findings are important for mental and public health professionals who are interested in the direct provision of services using a combination of social determinants of systemic perspectives.
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American Psychological Association, APA Working Group on Stress and Health Disparities. (2017). Stress and health disparities: Contexts, mechanisms, and interventions among racial/ethnic minority and low-socioeconomic status populations. Retrieved 8/21/19 from https://www.apa.org/pi/health-disparities/resources/stress-report.aspx.
Ash, T., Agaronov, A., Young, T., Aftosmes-Tobio, A., & Davison, K. K. (2017). Family-based childhood obesity prevention intervention: A systemic review and quantitative analysis. International Journal of Behavioral Nutrition and Physical Activity, 14, 113. https://doi.org/10.1186/s12966-017-0571-2
Augustine, J. M., & Kimbro, R. T. (2013). Family structure and obesity among U.S. children. Journal of Applied Research on Children: Informing Policy for Children at Risk, 4, 5.
Ball, G. D., Ambler, K. A., Keaschuk, R. A., et al. (2012). Parents as agents of change (PAC) in pediatric weight management: The protocol for the PAC randomized clinical trial. BMC Pediatrics, 12, 114–127.
Barr-Anderson, D. J., Singleton, C., Cotwright, C. J., Floyd, M. F., & Affuso, O. (2014). Outside-of-school time obesity prevention and treatment interventions in African American youth. Obesity Review, 15, 26–45. https://doi.org/10.1111/obr.12204
Bell, C. N., Kerr, J., & Young, J. L. (2019). Associations between obesity, obesogenic environments, and structural racism vary by county-level racial composition. International Journal of Environmental Research and Public Health, 16, 861. https://doi.org/10.3390/ijerph16050861
Berge, J., & Everts, J. C. (2011). Family-based interventions targeting childhood obesity: A meta-analysis. Child Obesity, 7, 110–121.
Berge, J. M., Jin, S. W., Hanson, C., Doty, J., Jagaraj, K., Braaten, K., et al. (2016). Play it forward! A community-based participatory research approach to childhood obesity prevention. Families, Systems, and Health, 34, 15–30. https://doi.org/10.1037/fsh0000116
Boutelle, K. N., Cafri, G., & Crow, S. J. (2011). Parent-only treatment for childhood obesity: A randomized controlled trial. Obesity, 19, 574–580.
Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code development. Thousand Oaks, CA: Sage.
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.
Bronfenbrenner, U. (1986). Ecology of the family as a context for human development: Research perspectives. Developmental Psychology, 22, 723–742.
Brotman, L. M., Dawson-McClure, S., Huang, K.-Y., Thiese, R., Kamboukos, D., Wang, J., et al. (2012). Early childhood family intervention and long-term obesity prevention among high-risk minority youth. Pediatrics, 129, e621–e628.
Campbell, M. K. (2015). Biological, environmental, and social influences on childhood obesity. Pediatric Research, 79, 205–211.
Carroll, J. K., Yancey, A. K., Spring, B., Figueroa-Moseley, C., Mohr, D. C., Mustian, K. M., et al. (2011). What are successful recruitment and retention strategies for underserved populations? Examining physical activity interventions in primary care and community settings. Translational Behavioral Medicine, 1, 234–251.
Centers for Disease Control and Prevention (CDC). (2017). Preventing chronic disease: Public health research, practice, and policy. The childhood obesity research demonstration (CORD) project. U.S Department of Health and Human Services. Retrieved 8/29/19 from https://www.cdc.gov/pcd/collections/pdf/CORD_Collection.pdf.
Claydon, E., Austin, A., & Smith, M. V. (2016). Linking obesity prevention and mental health promotion to address health disparities. Community Mental Health Journal, 52, 395–398. https://doi.org/10.1007/s10597-015-9915-z
Coughlin, S. S., & Smith, S. A. (2017). Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-Americans: A literature review. Journal of Racial and Ethnic Health Disparities, 4, 259–268. https://doi.org/10.1007/s40615-016-0225-0
Domoff, S. E., & Niec, L. N. (2018). Parent-child interaction therapy as a prevention model for childhood obesity: A novel application for high-risk families. Children and Youth Services Review, 91, 77–84.
Duriancik, D. M., & Goff, C. R. (2019). Children of single-parent households are at a higher risk of obesity: A systematic review. Journal of Child Health Care, 23, 358–369.
Frontini, R., Moreira, H., & Canavarro, M. C. (2016). Parenting stress and quality of life in pediatric obesity: The mediating role of parenting styles. Journal of Child and Family Studies, 25, 1011–1023.
Golden, S. D., & Earp, J. A. L. (2012). Social ecological approaches to individuals and their contexts twenty years of health education & behavior health promotion interventions. Health Education & Behavior, 39, 364–372.
Greaves, C. J., Sheppard, K. E., Abraham, C., Hardeman, W., Roden, M., Evans, P. H., et al. (2011). Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health, 11, 119. https://doi.org/10.1186/1471-2458-11-119
Hampl, S., Demeule, M., Eneli, I., Frank, M., Hawkins, M. J., Kirk, S., et al. (2013). Parent perspectives on attrition from tertiary care pediatric weight management programs. Clinical Pediatrics, 52, 513–519.
Han, J. C., Lawlor, D. A., & Kimm, S. Y. (2010). Childhood obesity. Lancet, 375, 1737–1748.
Hartman, A. (1995). Diagrammatic assessment of family relationships. Families in Society, 1, 111–122.
Herbst, R. B., Khalsa, A. S., Schlottman, H., Kerrey, M. K., Glass, K., & Burkhardt, M. C. (2019). Effective implementation of culturally appropriate tools in addressing overweight and obesity in an urban underserved early childhood population in pediatric primary care. Clinical Pediatrics, 58, 511–520.
Hill, C. E., & Lambert, M. J. (2004). Methodological issues in studying psychotherapy processes and outcomes. In M. J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (Vol. 5, pp. 84–135). New York: John Wiley and Sons.
Huang, T. T., Drewnosksi, A., Kumanyika, S. K., & Glass, T. A. (2009). A systems-oriented multilevel framework for addressing obesity in the 21st century. Preventing Chronic Disease, 6, A82.
Huffman, F. G., Kanikireddy, S., & Patel, M. (2010). Parenthood—A contributing factor to childhood obesity. International Journal of Environmental Research and Public Health, 7, 2800–2810.
Isong, I. A., Rao, S. R., Bind, M.-A., Avendaño, M., Kawachi, I., & Richmond, T. K. (2018). Racial and ethnic disparities in early childhood obesity. Pediatrics, 141, e20170865.
Israel, B., Coombe, C., Cheezum, R., Schulz, A. J., McGranaghan, R. J., Lichtenstein, R., et al. (2010). Community-based participatory research: A capacity-building approach for policy advocacy aimed at eliminating health disparities. American Journal of Public Health, 100, 2094–2102.
Kakinami, L., Barnett, T. A., Séguin, L., & Paradis, G. (2015). Parenting style and obesity risk in children. Preventive Medicine, 75, 18–22.
Kirschenbaum, D., & Gierut, K. (2012). Treatment of childhood and adolescent obesity: An integrative review of recent recommendations from five expert groups. Journal of Consulting and Clinical Psychology, 81, 347–360.
Kitzman-Ulirch, H., Wilson, D., George, S., Lawman, H., Segal, M., & Fairchild, A. (2010). The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs. Clinical Child and Family Psychology Review, 13, 231–253.
Kreuger, P. M., & Reither, E. N. (2015). Mind the gap: Race/ethnic and socioeconomic disparities in obesity. Current Diabetes Reports, 15, 95. https://doi.org/10.1007/s11892-015-0666-6
Kumanyika, S., Taylor, W. C., Grier, S. A., Lassiter, V., Lancaster, K. J., Morssink, C. B., et al. (2012). Community energy balance: A framework for contextualizing cultural influences on high risk of obesity in ethnic minority populations. Preventive Medicine, 55, 371–381.
Lappan, S., Parra-Cardona, J., Carolan, M., & Weatherspoon, L. (2019). Risk and protective factors associated with childhood obesity in a sample of low-income, single, female, parent/guardian households: Implications for family therapists. Family Process, 59, 597–617. https://doi.org/10.1111/famp.12440
Lee, J. S., Sheer, J. L., Lopez, N., & Rosenbaum, S. (2010). Coverage of obesity treatment: A state-by-state analysis of Medicaid and state insurance laws. Public Health Reports, 125, 596–604.
Legard, R., Keegan, J., & Ward, K. (2003). In Richie, J., & Lewis, J., (eds.). In-depth interviews, pp. 138–169. Thousand Oaks, CA: Sage.
Ludwig, D. S., Blumenthal, S. J., & Willett, W. C. (2012). Opportunities to reduce childhood hunger and obesity: Restructuring the Supplemental Nutrition Assistance Program (SNAP) beneficiaries. Journal of the Academy of Nutrition and Dietetics, 113, 70–76.
Lwin, M. O., Shin, W., Yee, A. Z., & Wardoyo, R. J. (2017). A parental health education model of children’s food consumption: Influence on children’s attitudes, intention, and consumption of healthy and unhealthy foods. Journal of Health Communication, 22, 403–412.
Millstein, R. A., Oreskovic, N. M., Quintiliani, L. M., James, P., & Intille, S. (2018). The need for local, multidisciplinary collaboration to promote advances in physical activity research and policy change: The creation of the Boston Physical Activity Resource Collaborative (BPARC). Journal of Physical Activity Research, 3, 74–77.
Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52, 250–260.
Noonan, M., & Turchi, J. (2019). Childhood obesity differences in single-father and single-mother families. Sociological Focus, 52, 216–230. https://doi.org/10.1080/00380237.2019.1624234
Ogden, C., Carroll, M., Kit, B., & Flegal, K. (2014). Prevalence of obesity and trends in body mass index among US children and adolescents, 2011–2012. JAMA, 311, 806–814.
Pereira, M. M. C. E., Padez, C. M. P., & Nogueira, H. G. D. S. M. (2019). Describing studies on childhood obesity determinants by Socio-Ecological Model level: A scoping review to identify gaps and provide guidance for future research. International Journal of Obesity, 43, 1883–1890. https://doi.org/10.1038/s41366-019-0411-3
Perez, A. J., Kebbe, M., Holt, N. L., Gokiert, R., Chanoine, J.-P., Lagault, L., et al. (2018). Parent recommendations to enhance enrollment in multidisciplinary clinical care for pediatric weight management. The Journal of Pediatrics, 192, 122–129.
Pilkey, D., Skopec, L., Gee, E., Finegold, K., Amaya, K., & Robinson, W. (2013). The Affordable Care Act and adolescents. U.S. Department of Health and Human Services. Retrieved 7/30/19 from https://aspe.hhs.gov/sites/default/files/pdf/180281/rb_adolescent.pdf.
Pollack, K. M., Rossen, L. M., Roman, C., et al. (2014). Obesity interventions in underserved communities: Evidence and direction. In S. K. Kumanyika & R. E. Zambrana (Eds.), VM Brennan (pp. 162–175). Baltimore: John Hopkins University Press.
Rajkumar, R., Conway, P. H., & Tavenner, M. (2014). CMS—engaging multiple payers in payment reform. JAMA, 311, 1967–1968.
Richard, L., Gauvin, L., & Raine, K. (2011). Ecological models revisited: Their uses and evolution in health promotion over two decades. Annual Review of Public Health, 32, 307–326.
Rodenburg, G., Kremers, S., Oenema, A., & van de Mheen, D. (2014). Associations of parental feeding styles with child snacking behaviour and weight in the context of general parenting. Public Health Nutrition, 17, 960–969.
Sabo, S., Ingram, M., Reinschmidt, K., Schachter, K., Jacobs, L., Guernsey de Zapien, J., et al. (2013). Predictors and a framework for fostering community advocacy as a community health worker core function to eliminate health disparities. American Journal of Public Health, 103, e67–e73.
Sallinen-Gaffka, B., Frank, M., Hampl, S., et al. (2013). Parents and pediatric weight management attrition: Experiences and recommendations. Childhood Obesity, 9, 409–417.
Shloim, N., Edelson, L. R., Martin, N., & Hetherington, M. M. (2015). Parenting styles, feeding styles, feeding practices, and weight status in 4–12 year-old children: A systematic review of the literature. Frontiers in Psychology, 6, 1849. https://doi.org/10.3389/fpsyg.2015.01849
Sikorski, C., Luppa, M., Kaiser, M., Glaesmer, H., Schomerus, G., König, H.-H., et al. (2011). The stigma of obesity in the general public and its implications for public health: A systematic review. BMC Public Health, 11, 661–668.
Skelton, J., & Beech, B. (2011). Attrition in paediatric management: A review of the literature and new directions. Obesity Review, 12, e273–e281.
Skelton, J., Buehler, C., Irby, M., & Grzywacz, J. G. (2012). Where are family theories in family-based obesity treatment?: Conceptualizing the study of families in pediatric weight management. International Journal of Obesity, 36, 891–900.
Skelton, J. A., Martin, S., & Irby, M. B. (2016). Satisfaction and attrition in paediatric weight management. Clinical Obesity, 6, 143–153.
Staniford, L. J., Copeland, R. J., & Breckon, J. D. (2019). ‘What’s the point when you only lose a pound?’ Reasons for attrition from a multi-component childhood obesity treatment intervention: a qualitative inquiry. Qualitative Research in Sport, Exercise, and Health, 11, 382–397. https://doi.org/10.1080/2159676X.2018.1474375
Story, M. T., Neumark-Stzainer, D. R., Sherwood, N. E., Holt, K., Sofka, D., Trowbridge, F. L., & Barlow, S. E. (2002). Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics, 110, 210–214.
Strauss, W. J., Nagaraja, J., Landgraf, A. J., Arteaga, S. S., Fawcett, S. B., Ritchie, L. D., et al. (2018). The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: The Healthy Communities Study. Pediatric Obesity, 13, 82–92.
Subica, A. M., Grills, C. T., Douglas, J. A., & Villanueva, S. (2016). Communities of color creating healthy environments to combat childhood obesity. American Journal of Public Health, 106, 79–86. https://doi.org/10.2105/AJPH.2015.302887
Sullivan, C. M., & Bybee, D. I. (1999). Reducing violence using community-based advocacy for women with abusive partners. Journal of Consulting and Clinical Psychology, 67, 43–53.
Tershakovec, A. M., Watson, M. H., Wenner, W. J., & Marx, A. L. (1999). Insurance reimbursement for the treatment of obesity in children. Journal of Pediatrics, 134, 573–578.
U.S. Census Bureau. (2019). Current population survey, 2019 annual social and economic supplement. Retrieved 8/20/20 from https://www.census.gov/data/tables/2019/demo/families/cps-2019.html.
U. S. Census Bureau. (2018). Historical poverty tables: People and families - 1959 to 2018. Retrieved 7/31/19 from https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-people.html.
U.S. Census Bureau. (2016). The majority of children live with two parents, Census Bureau reports. Retrieved 7/31/19 from https://www.census.gov/newsroom/press-releases/2016/cb16-192.html.
U.S. Department of Health and Human Services. (2015). U.S. poverty guidelines. Retrieved 7/30/19 from https://aspe.hhs.gov/2015-poverty-guidelines.
Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing and Health Sciences, 15, 398–405.
Venturelli, F., Ferrari, F., Broccoli, S., Bonvicini, L., Mancuso, P., Bargellini, A., et al. (2019). The effect of public health/pediatric obesity interventions on socioeconomic inequalities in childhood obesity: A scoping review. Obesity Reviews, 20, 1720–1739.
Vollmer, R. L., & Mobley, A. R. (2013). Paretning styles, feeding styles, and their influence on child obesogenic behaviors and body weight: A review. Appetite, 71, 232–241.
Weihrauch-Bluher, S., Kromeyer-Hauschild, K., Graf, C., Widhalm, K., Korsten-Reck, U., Joicke, B., et al. (2018). Current guidelines for obesity prevention in childhood and adolescence. Obesity Facts, 11, 263–276.
Whitlock, E. P., O-Connor, E. A., Williams, S. B., Beil, T. L., & Lutz, K. W. (2010). Effectiveness of weight management interventions in children: A targeted systematic review for the USPSTF. Pediatrics, 125, e396–e418.
Wifley, D. E., Staiano, A. E., Altman, M., Lindros, J., Lima, A., Hassink, S. G., et al. (2017). Improving access and systems of care for evidence-based childhood obesity treatment: Conference key findings and next steps. Obesity (Spring Silver), 25, 16–29.
Williams, D. R., & Cooper, L. A. (2019). Reducing racial inequities in health: Using what we already know to take action. International Journal of Environmental Research and Public Health, 16, 606.
Williams, E. P., Mesidor, M., Winters, K., Dubbert, P. M., & Wyatt, S. B. (2015). Overweight and obesity: Prevalence, consequences, and causes of a growing public health problem. Current Obesity Report, 4, 363–370.
World Health Organization. (2011). Obesity and overweight: WHO global strategy on diet, physical activity and health. Geneva, Switzerland: World Health Organization.
Yavus, H. M., & Selcuk, B. (2018). Predictors of obesity and overweight in preschoolers: The role of parenting styles and feeding practices. Appetite, 120, 491–199.
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Lappan, S.N., Carolan, M., Parra-Cardona, J.R. et al. Promoting Healthy Eating and Regular Physical Activity in Low-Income Families Through Family-Centered Programs: Implications for Practice. J Primary Prevent 41, 503–528 (2020). https://doi.org/10.1007/s10935-020-00612-1