Introduction
In today's world, where fast food and processed meals are readily available, it's easy to fall into unhealthy eating habits. Nutrition literacy, or the ability to understand and use information about healthy eating, is crucial for making informed food choices. Parents play a significant role in shaping their children's diets, and dietary patterns established early in life often persist into adulthood. This article explores the role of intervention programs in improving parent diet and, consequently, the health of their families.
The Importance of Parental Influence on Child Diet
Parents significantly influence their child's diet by providing opportunities to make healthy or unhealthy choices. These choices are influenced by a combination of individual factors, socio-cultural factors, and environmental factors. Food parenting practices, which refer to behaviors parents use to influence what and how much their children eat, are also crucial. Since food choices are directly related to energy intake and obesity risk, parent involvement in interventions designed to improve child dietary habits is essential.
Mobile Interventions: A Promising Approach
One innovative approach to improving parent diet is the use of mobile interventions. The Nutricity program, for instance, aims to engage parents and their young children (1-5 years of age) by providing them with community-tailored healthy eating advice through a mobile app. By giving a small sample of parent-child pairs access to Nutricity for three months, the program aims to improve child eating patterns using minimal resources from clinics.
The Need for Targeted Intervention
Obesity during childhood is associated with increased disease risk and morbidities during young adulthood, and increased mortality later in life. Dietary habits acquired in childhood track to adulthood, and changes in diet during childhood are significant predictors of diet quality in adults. Moreover, studies have revealed that obesity prevention interventions are not one-size-fits-all. Low-income families, for example, are more likely to experience food insecurity and lack of access to healthy foods, necessitating targeted intervention and prevention efforts.
A Systematic Review of Intervention Trials
To understand the effectiveness of parent-focused dietary interventions, a systematic review of randomized controlled trials was conducted. The review included studies designed to prevent obesity, prevent disease, and/or promote health in children and adolescents through dietary behavior changes that involved parents. The review considered studies published in peer-reviewed, English language journals between January 1st, 1980 and December 31st, 2008, that recruited children (2-12 years) or adolescents (13-18 years) and included a parent component.
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The parent component was defined as an intervention strategy that indirectly or directly engaged parents to support or assist children or adolescents to achieve changes in dietary intake. The review excluded intervention programs designed solely to treat overweight or obese children, programs that enrolled children with a specific medical problem that could impact diet or weight, studies for which statistics of outcome data were not reported, studies without an intervention component, literature reviews, studies with diet as a correlate and not an outcome, qualitative studies, pilot studies, and non-randomized studies.
The initial search yielded 1,774 citations, and after screening the titles and abstracts, 100 papers were retrieved and the full article reviewed. Data from the studies were extracted using standardized forms, including information on the lead author, year published, geographic location of intervention, sample size, age, sex, ethnicity, and SES of participants, primary intervention location, study design, theoretical framework used to guide intervention design, primary and secondary outcomes, dietary measurement methods, adiposity measurement methods, description of intervention, intervention frequency and duration, main findings, methods of parental involvement in intervention activities, and any analysis that assessed whether subsequent changes in child or parent behavior could be attributed to this involvement.
Methods of Parental Involvement
Methods of parental involvement used in studies were summarized based on the type and intensity of parental involvement represented, broadly categorized as “indirect” or “direct” strategies. Three types of indirect strategies were identified: i) provision of information that did not require a parental response; ii) invitations to parents and children to participate in activities sponsored by the study; and, iii) communications directed at child and/or parent meant to involve parents in intervention activities. Two categories of direct strategies were identified: i) parents' presence requested at nutrition education sessions; ii) parent attendance and participation requested for family behavior counseling or parent training sessions.
The majority of interventions (n=16) were delivered in a school setting, while the remaining eight studies were implemented in community settings, including Girl Scouts meetings, an after-school tutoring program, Head Start/preschool centers, clinics, or at the child's home. Sample sizes varied from thousands to fewer than one hundred participants.
Behavioral Theories Informing Dietary Interventions
Behavioral theories may inform the design of dietary interventions to provide a rationale for the strategies used to change behavior, thereby increasing the probability that they will be effective. The most frequently reported behavioral theory was the Social Cognitive Theory, followed by its predecessor, Social Learning Theory. Methods to quantify dietary intake included 24-hour food recalls, food frequency questionnaires, diet records, and observation by research staff.
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Effectiveness of Parent Involvement
To determine whether parent involvement enhanced program effectiveness and what type of parent involvement was most effective, studies were categorized based on dietary outcomes (positive, mixed, no effect) and cross-tabulated with method of parental involvement. “Positive” indicated dietary changes that occurred in the desired or hypothesized direction; “mixed” indicated changes that occurred for some subgroups but not others, or for some but not all outcomes; and “no effect” meant that there were no reported changes in child diet.
Four of twenty-four studies were designed to assess whether parent involvement enhanced the effectiveness of interventions that aimed to change child dietary intake. The effect of parent involvement was estimated by including “parent-only” and/or “parent-plus” comparison arms. Of those four studies, one achieved significant changes in the primary dietary outcome (reduced intake of total fat and increased intake of complex carbohydrates) for children enrolled in the home-based (parent) arm of the study compared to the control group. Two other studies reported changes in dietary outcomes that differed by gender.
Nineteen studies used indirect methods to engage parents in intervention activities, while five used direct methods. Of the nineteen studies using indirect methods to engage parents, seven reported achieving statistically significant changes in the desired directions, seven reported mixed intervention outcomes, and five reported no significant intervention effects. Of the five studies using direct methods to involve parents in the intervention, two reported positive outcomes.
Samen Happie!: An App-Based Parenting Program
The Samen Happie! program is an app-based prevention program developed using the Intervention Mapping Protocol (IMP). The central goal of the program is to stimulate healthy energy balance-related parenting practices to prevent early childhood obesity among children of families with a lower SEP. The program was developed through the 6 iterative and nonlinear steps of the IMP: (1) conducting a needs assessment; (2) preparing matrices of change objectives; (3) selecting theoretical methods and practical strategies; (4) developing the intervention program; (5) planning for adoption, implementation, and sustainability; and (6) planning the program evaluation.
The needs assessment included a literature search, focus groups with parents with a lower SEP, and discussions with youth health care professionals. The focus groups discussed the hindering and facilitating factors for healthy parenting and parenting practices in difficult parenting situations, with a focus on parenting practices regarding food and dietary intake. The discussions with youth health care professionals served to explore key parenting-related themes and issues that existed among the target group and as a sounding board for concrete questions during program development.
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In step 2, the behavioral outcomes were translated into performance objectives. To influence these objectives, in step 3, theory-based intervention methods were selected for each of the determinants. In step 4, the knowledge derived from the previous steps allowed for the development of the app-based program Samen Happie! through a process of continuous cocreation with parents and health professionals. In step 5, community health services were identified as potential adopters for the app. Finally, in step 6, 2 randomized controlled trials were designed to evaluate the process and effects of the app among Dutch parents of infants (trial 1) and preschoolers (trial 2).
Findings from Qualitative Studies
Qualitative studies have explored parents' preferences for practical intervention strategies. Interventions via online food shopping platforms and nudging strategies in grocery stores were mostly cited by higher SES parents, but these were less applicable for lower SES parents as they buy less online and mainly consider the price of products. Mobile applications that provide inspiration for healthy and sustainable recipes and easily accessible shopping lists received moderate support among lower and higher SES parents. Furthermore, both lower and higher SES parents showed interest in meal boxes delivered at home, but lower SES parents have not yet tried such meal boxes because of their higher prices. Still, both groups of SES parents mentioned many advantages of these meal boxes, such as the convenience and time-saving component, as well as the cooking inspiration aspect.
Other Intervention Programs
Other intervention programs, such as the Together, We Inspire Smart Eating (WISE) program, aim to increase fruit and vegetable consumption in children in early education programs as well as in the home. WISE delivers developmentally appropriate food experiences and promotes behavior change through its 3 components: classroom curricula, parent engagement content, and educator training. The program is designed to be delivered across a 9-month term with food experiences and supporting activities executed weekly.
Another approach involves improving home food preparation practices among families with young children through peer mentoring interventions. The American Academy of Pediatrics (AAP) recommends family healthy weight programs (FHWPs) as multi-component behavioral interventions to help treat childhood obesity. These programs help children with overweight or obesity make progress toward a healthier weight through positive behavior changes.
The Importance of Family Meals
Evidence suggests that regular family meals protect against unhealthy eating and obesity during childhood and adolescence. Interventions that assess family meals as an outcome and summarize strategies that have been used in these interventions have shown promising results. Common strategies include goal setting and interactive group activities, and intervention targets include cooking and food preparation, cost, shopping, and adolescent influence.
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