There is a paucity of high quality evidence on how best to treat childhood obesity, and “office-based” therapy usually has modest success.1 2 Guidelines suggest treatments should be family based with the participation of at least one parent fundamental to the outcome.3^–6 Yet there is little understanding of the motivation of parents to enter treatment and their continuing role in implementing and supporting recommended lifestyle changes. Qualitative methods can provide valuable information on patient’s perceptions of chronic disease management,7 but few qualitative studies have explored the parent’s feelings concerning their child’s obesity management. The aim of this study was to use qualitative methods to gain insight into the journey of parents of obese children to and through treatment. These findings will assist in the development of theories on parental influences on treatment outcomes and help health care professionals in their approaches to family based treatments.

METHODS

We undertook in-depth interviews with the principal carers of primary school age children who had taken part in 6-month dietetic interventions for childhood obesity (BMI>98th percentile, UK 1990 charts) previously described in detail.8

We used a purposive sampling strategy9 with the following criteria:

• successful outcome/unsuccessful outcome of treatment,

• age of child (5–8 years and 9–11 years),

• location (Edinburgh/Glasgow),

• gender of child,

• family situation, eg, two/one parent family, main carer not a parent.

Interviews took place 12 months after the start of treatment. Of the 79 families available, 17 parents (one from each family) consented to participate. The study received ethical approval from the multi-centre research ethics committee for Scotland.

Taped interviews followed a topic guide with no set questions. Interviews were conducted by two of the authors (LS and JC), who were unknown to the parents, and lasted for 50–80 min. Recordings were fully transcribed and the Framework method of content matrix data analysis was used.10 Both interviewers and VP developed the themes independently and then agreed principal themes and sub-themes. The themes were coded using Nvivo software (QSR International, Melbourne, Australia).

Peer consultation took place with all authors on coding of transcripts, charting and mapping data, and final interpretations. This was important to help counter any bias that may have emerged during data interpretation. To ensure a transparent audit trail, all the audiotapes, paperwork, Nvivo coding, charts and mappings are available for review.

RESULTS

Characteristics of participants

Seventeen principal carers (14 mothers, two fathers and one grandmother) from varied backgrounds and with diverse family circumstances were interviewed. The characteristics of participating families in the present study are noted in table 1 and were similar to those referred for obesity management to the two major paediatric centres in Scotland.11

Throughout this paper anonymised verbatim quotes from the parents are used where (1) indicates child’s BMI decreased and (2) indicates child’s BMI increased.

Beginning the journey: why enter treatment?

One parent in each family appeared to have the “lead” parenting role in the child’s weight management; this was generally, although not exclusively, the mother. Prior to seeking help for their child’s weight, there were varying degrees of awareness among parents regarding their child’s weight, ranging from being highly aware and actively seeking help to being oblivious to any problem. We distinguished between those parents who appeared to be aware of their child’s weight problem and those unaware of their child’s weight.

Among parents who talked of being aware of their child’s weight problem, there were two groups. The first group sought help after realising the problem and we called these “seekers”:

…because of the amount of food he was eating constantly and I thought I need to do something before it spirals out of control. Then going out and getting clothes, nothing would fit him and I thought, you know, I need to do something. (2)

There was a second group of aware parents who felt unable or unwilling to discuss their concerns with the child and/or raise the issue with health professionals and we called this group “avoiders”:

Not as sitting down and saying you’re over (weight), because at the age she was at you’re frightened you’re going to push them the other way. (1)

Parents who appeared to be unaware that their child was obese generally described their child as a normal weight for their age:

I didn’t realise he was so overweight, I didn’t realise he was that, because he doesn’t actually look it because he’s broad, so he carried it well, but I was quite shocked to find out his actual weight. (1)

Since all these children had BMIs above the 2 SD score, we called these parents “deniers”. These typologies are illustrated in fig 1.

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Figure 1 Diagram representing parents’ typologies at the beginning of the journey. Lead parent: parent who takes most responsibility for the child’s weight. Aware: parents who have recognised their child has a weight problem. Unaware: parents who have not recognised that their child has a weight problem. Seekers: parents who actively seek help for their child’s weight. Avoiders: parents who avoid discussing their child’s weight. Deniers: parents who are unaware of their child’s weight.

Overwhelmingly, general practitioners (GPs) were the main gatekeepers to dietetic referrals for weight management. Seekers approached their GP asking for help, while avoiders and deniers were typically attending for another reason and the GP raised the child’s weight. A number of avoiders and deniers became seekers once the weight concerns had been pointed out to them. When discussed, there was a feeling that the health professional who had raised the issue had been insensitive to the feelings of the child and/or the parent.

This pre-treatment phase highlighted the parents’ intense and often conflicting feeling and anxieties:

…all my childhood bad feelings that I had were coming back. It is cruel to let a child overeat, I know that, but some times, and I’m not a stupid person– I’m quite a bright person, but some times commonsense doesn’t come into it, when you love someone you want to make them feel happy. (1)

During treatment: the need for support

Parents strongly and persistently voiced their need for support. Repeatedly the parents talked of looking for “someone” outside of the family who could motivate the child and in particular give the child “a wake-up call”. Support and help was sought for the child’s self-esteem, focus on necessary changes and to reinforce changes already implemented. Less persistently but intensely voiced was the need for support in justifying to other family members (including the other parent) the necessity for an intervention and lifestyle changes:

I just knew I wanted help ‘cause I felt that my husband wasn’t listening to me, my friends, my mum was very similar. I need someone then to say so– also I could say to my husband, I have been to the doctor and there is a problem. (2)

All parents described to varying degrees the support that they needed from significant others, summarised as

• not offering/giving/tempting the child with foods they should be avoiding/cutting down (commonly mentioned were sweets, chocolate biscuits, cakes),

• not undermining the actions and lifestyle changes agreed with/being imposed by the lead parent,

• reinforcing to the child, both by action and verbally, the agreed lifestyle changes,

• supporting the initial decision to seek and enter treatment.

Parents often conveyed a distinction in the level of support given by the nucleus family (those in the same house) and the extended family (eg, grandparents, separated parents, aunts, cousins and significant family friends). The nucleus family was generally discussed as being supportive. However, it was less typical for the extended family and friends to be seen as supportive (Q1, Q2, Q3, Q4 and Q5 in table 2). The group most persistently mentioned by most parents as being unsupportive were grandparents (Q6, Q7 and Q8 in table 2). Most parents consistently reported that grandparents were not understanding, gave foods the parents had repeatedly asked them not to and sneaked little treats to the child. However, in the minority of cases where the extended family including grandparents was supportive this was appreciated:

…no, even his gran was helping and his aunty was helping, was saying to him try this and you’re not having this. Try and maybe give him a bit of fruit and he was quite happy with that, because if it was going to help him no one was too bothered. (2)

In one family where the grandparents were the child’s main guardians with the grandmother in the lead parent role, the child’s natural parents took over the typical unsupportive grandparent role:

They (mum and dad) want to treat them, but you know that is what I was saying to my husband– I often end up as the baddie. (1)

Post treatment: was it all worth it?

Parents commonly felt that the outside support ceased when the treatment finished. They noted that continuing treatment and support “such as that given by Weight Watchers” would have benefited the child and that continuous support was needed for treatment to be successful. There was a widespread view that parents and children had not adhered to all of the changes implemented during treatment but had continued with relevant positive lifestyle changes. Parents talked of having made lots of changes and a complete change in what was eaten and of trying to maintain changes.

The persistent feeling of most parents was that their and their child’s overall experience of obesity treatment had been positive and successful. Parents repeatedly talked of the interventions being worthwhile, educational, the best thing they had done and being treated with respect by the dietician. An exceptional but strongly voiced view was that the experience had been negative, the treatment not as successful as hoped and there was a poor relationship with the dietician:

I didn’t think it would make a difference where it was, I just think he felt that the whole experience was a bit negative for him. I don’t think he enjoyed any of it. That’s why I left and never came back. (1)

Parents expressed these positive and negative views regardless of the child’s weight outcome.

When discussing their child’s weight, all parents’ comments had varying degrees of ambivalence and ambiguity. The most frequent comment was that even though weight had increased, it probably would have been worse if they had not taken part (Q1, Q2, Q3 and Q4 in table 3). Importantly, what most parents did note as a positive and concrete outcome were improvements in the child’s self-esteem and confidence. This was generally discussed in terms of style of clothes they could now wear, increased enjoyment in participating in PE and improved peer relationships (Q5, Q6, Q7 and Q8 in table 3). Indeed by this stage of the journey, most parents overwhelmingly saw these positive changes in self-esteem as the key outcome, more important than weight change, and for them an affirmation of successful treatment.

DISCUSSION

In this study we set out to identify and understand– from the parents’ perspective– factors that may have influenced the decision to seek treatment, barriers to engaging during treatment and the parents’ perceived key outcomes of treatment (summarised in table 4). Resource limitations did not allow us to interview more parents or to further explore our findings with other groups. However, this study contributes by adding to a very limited evidence base on the feelings and influences of the parents of obese children in treatment programmes. For the parents there appeared to be several distinct phases characterised by us as a “journey”. Parents interviewed cited the child’s low self-esteem, poor quality of life, awareness of the child being called names and worries about the child’s future self-esteem as reasons for seeking treatment; health was not commonly mentioned as a motivation for seeking treatment.

We identified parents whom we called deniers and others as avoiders. A number of studies have reported that parents often do not appear to recognise their children as being obese or overweight or the health implications of their child’s weight.12^–16 However, none have investigated parents who are aware of their child’s weight but feel unable or unwillingly to discuss these concerns. The qualitative study of Murtagh et al17 supports some of these observations, but from the child’s point of view.

Being a parent who actively sought treatment was not an obvious indicator of family motivation during treatment or of a successful clinical outcome. Avoiders and deniers often converted to seekers after the issue of weight had been raised. The discussing of weight by GPs was acceptable to these parents. This is an important message for GPs not to avoid the issue of excess weight but to raise it in a sensitive manner and offer parents help.

The present study suggests that support mechanisms within the family may be of great importance in achieving and maintaining lifestyle changes. The lead parent may often need help and full cooperation from the nucleus and extended family to make and sustain such changes. We have identified the type of support the parents need from significant others. The strength of feelings voiced by the parents regarding the role of the unsupportive extended family (in undermining lifestyle changes) raises issues for those working with obese children and their parents. Similar problems, particularly with grandparents, have also been raised by Dixey et al.18 Those developing treatment programmes and clinicians delivering treatment should consider engaging the whole nucleus family and possibly the extended family in treatment to improve success, although this would require a form of care quite different to current office-based and low intensity treatments usually directed at the mother and child.1 The level of support provided by highly intensive treatments may be an important contributor to their success.3

An overwhelming theme that emerged from the parents we interviewed was a perceived positive outcome of treatment regarding their child’s self-esteem and quality of life. Indeed, this appeared to be more important to parents than a successful weight outcome. The parents interviewed by Dixey et al18 reported comparable views concerning self-esteem as a positive outcome. Murtagh et al17 illustrated the importance of self-esteem for clinical samples of obese children, and we have previously shown in this sample that quality of life was significantly impaired.19 For the children in the study by Murtagh et al, it was the desire to be “socially acceptable” in the school playground and not long-term health which motivated them to seek treatment for obesity. Health professionals may need to be aware of the importance of this issue for the parents and the child and have more understanding of the need to support self-confidence and self-esteem in obese children. For clinicians, outcomes such as weight and BMI SD scores are of fundamental importance in the treatment of childhood obesity. However for the parents interviewed, weight and BMI were not a priority at the end of treatment. There is perhaps a need for health care professionals to reconsider their outcome measures and perhaps seek greater concordance between the priorities of the family and those of the health system.

CONCLUSIONS

Qualitative research is a powerful tool for illuminating peoples’ feelings and capturing participants’ stories of experiences and how programmes felt from the inside.20 The present study may aid in the development of theories and practices on how to empower and support parents through treatment for their child’s obesity. In particular, our study highlights potential opportunities for future treatment such as providing more support for families than can be achieved by short office-based consultations, describing to families the types of feelings which other families undergoing treatment have experienced, helping parents make lifestyle changes by addressing the wider family environment, and giving outcomes of treatment which are important to parents (psycho-social outcomes) higher priority in management.