Minimal change in children’s lifestyle behaviours and adiposity following a home-based obesity intervention: results from a pilot study
© Spurrier et al. 2016
Received: 16 December 2014
Accepted: 10 December 2015
Published: 13 January 2016
Families of overweight and obese children require support to make sustainable lifestyle changes to improve their child’s diet and activity behaviours and in turn weight status. The aim of this pre-post intervention pilot study was to evaluate the feasibility of an individualised home-based intervention for treatment seeking overweight/obese 4–12 year olds and their caregivers. Baseline measures were used to develop a family-specific intervention to improve the quality of the home environment. The intervention was delivered as individualised written recommendations and resources plus phone call and home visit support. Baseline measures were repeated approximately 6 months later.
Complete data for 24 children was available. Parents reported that 43 % of intervention recommendations were implemented ‘very much’. Some descriptive changes were observed in the home environment, most commonly including fruit and vegetables in their child’s lunchbox, not providing food treats, and restricting children’s access to chips/savoury snack biscuits. At the group level, minimal change was detected in children’s diet and activity behaviours or weight status (all p > 0.05).
The study findings did not support intervention feasibility in its current form. Future interventions should target the family food and activity environment, but also utilise an approach to address the complex social circumstances which limit parent’s ability to prioritise healthy family lifestyle behaviours.
Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR) 3/12/2014. http://www.ANZCTR.org.au. ACTRN12614001264673
Childhood obesity is recognised as one of the most significant public health problems in developed countries. Families of overweight children need services and support to make sustainable lifestyle changes to improve their child’s diet and activity behaviours and in turn weight status [1, 2].
The obesity epidemic is largely considered to be due to increased availability of energy-dense foods and reduced opportunities for physical activity, characteristics of a modern society [3, 4]. Obesity-promoting environments have been described in terms of macro- and micro- environments . The family home is an important micro-environment with the potential to influence children’s lifestyle behaviours and weight status . Observational studies have identified modifiable characteristics of children’s home food and activity environments that are associated with diet quality and activity levels [6–10]. For example, we have previously characterised the home environment of 208 preschool children . Parental role-modelling of physical activity, a safe and engaging backyard, having rules for use of small screen entertainment, using appropriate child feeding behaviours, and stocking more healthy food and less energy-dense nutrient poor foods in the home were associated with greater physical activity levels, less sedentary behaviour and healthier dietary patterns .
Child weight management that is based on practical advice on how to create a supportive home environment may be more effective than prescribing strict dietary or physical activity regimens, particularly if changes can become incorporated into a daily routine and sustained long term [12, 13]. Strategies to improve the home environment are often provided as part of weight management advice in clinic settings. However it can be difficult for families to translate this advice into reality. Working with parents in their homes is a potential alternative intervention setting which may make it easier for health care providers to assess areas for change and better appreciate family barriers. Home visits may also facilitate development of supportive therapeutic relationships. Home visiting has been trialled in obesity prevention studies with young children , but to date this approach has not been used in obesity treatment interventions for children who are already overweight or obese.
The home has been shown to be a successful intervention setting in other health areas, the best example being home visiting by nurses or other trained health visitors to support mothers living in disadvantage during the early years of child rearing . Other examples in paediatrics include chronic diseases such as asthma [16, 17]. Some of the postulated reasons for the success of such programs include the increased ability for health visitors to build successful therapeutic relationships with family members and the fact that health visitors can more fully appreciate the socioeconomic and cultural environment in which families operate.
The aim of the current pilot intervention study was to assess the feasibility of an individualised home-based intervention for children with obesity whose parents were seeking treatment. Outcomes assessed included changes to the home environment and improvements in children’s dietary and physical activity behaviours and weight status.
Study design and recruitment
A pre-post design evaluated a home-based lifestyle support intervention conducted in 2008. It was hypothesized that an individualised home-based intervention would be a feasible child obesity treatment approach. Children aged 4–12 years who were overweight or obese according to the International Obesity Task Force (IOTF) Body Mass Index (BMI) cut-points  and who were living in metropolitan Adelaide were recruited via referrals to the Department of Paediatrics and Child Health, Flinders Medical Centre for management of obesity. Exclusion criteria were medical conditions affecting weight or growth or being enrolled in any other structured weight management program, however no child was excluded on these grounds. Children could continue to be managed by their general practitioner or paediatrician during the intervention. Written informed parent consent and child assent was obtained. The study was approved by the Flinders University Social and Behavioural Research Ethics committee.
At baseline a socio-demographic questionnaire was completed by parents, and child weight, height and waist circumference were measured to the nearest 0.1 kg and 0.1 cm, using standardised scales and stadiometer. These measurements were undertaken in the paediatric outpatient department, Flinders Medical Centre, using the same set of scales and stadiometer for each child and at both baseline and follow-up. The research assistant undertaking these measurements was not involved in the home visit intervention and had been trained in anthropometry. Specifically, children were weighed on portable digital scales wearing light clothing, with shoes and socks removed. Height was measured using a wall-mounted stadiometer with shoes and socks removed, heels touching the wall and head in the ‘Frankfort’ plane. Waist circumference was measured using a standard metric tape measure held horizontally at a level midway between the lower rib margin and iliac crest (approximately in line with the umbilicus). BMI was calculated (weight, kg/height, m2) and weight status determined by applying the IOTF cut-points . BMI and waist circumference z-scores were calculated using LMSGrowth Excel add-in which is based on 1990 United Kingdom reference data [19, 20].
Parents completed the 24-item Children’s Dietary Questionnaire (CDQ)  which generates four continuous scores (i.e. fruit and vegetables, non-core foods, fat from dairy, sweetened beverages). Non-core foods are defined as foods that are not essential to meet nutrient requirements and contain excess energy, fat, sugar and salt . The CDQ shows acceptable reliability (ICC 0.5–0.9) and relative validity at the group level for the fruit and vegetables and non-core food scores (Cronbach alpha 0.62–0.72) .
Child activity patterns were measured using an adapted version of The Outdoor Play and Small Screen Entertainment Checklist [11, 23]. Parents reported the average time children spent per weekday and weekend day (in hours and minutes) (1) playing outdoors, (2) doing moderate-vigorous physical activity, and (3) using electronic media such as television and computers for both. Six items were added to the original checklist to explore average time spent per day (4) participating in physical activity and (5) using small screen entertainment. Times were averaged (weighted for type of day) to calculate (1) daily activity (vigorous physical activity + outdoor play) and (2) daily sedentary activity.
The Home Environment Inventory provides an assessment of 70+ family home characteristics associated with children’s dietary, physical activity, or sedentary behaviours . Items cover the outdoor environment to support children’s play, parental role modelling, accessibility of small screen entertainment, parent behaviours around food preparation and availability of healthy and non-core foods and beverages in the home and child’s lunchbox. Inventory items were assessed by either direct observation or by parental report (details described elsewhere ).
At Visit 2, time was made for the first follow-up phone call approximately 1 month after Visit 2. The purpose of this phone call was to gauge the family’s progress, provide ongoing support and encouragement with regards to the strategies and to provide further advice and support if requested. If families requested additional information, standard resources were posted to them (for example label reading) or a suggestion was provided about where they could access assistance (for example a child psychologist). The phone calls also provided opportunity to discuss any strategies that families felt were not working, and make alternative suggestions. At the end of the call, a time was made for the second follow-up phone call which was to occur approximately a month after the first phone call. And at the end of this call, a time for the final home visit (Visit 3) was made (aiming to be approximately 4 months after Visit 1). At Visit 3, the inventory was repeated. Encouragement for continuing to make lifestyle changes was also given to the families at this final visit.
Analyses were conducted using SPSS for Windows version 17.0. Descriptive statistics are presented as frequencies or mean (standard deviation)/median (IQ range). Wilcoxin signed-rank tests and paired t tests were used to assess changes from baseline to follow up in subscale scores for the CDQ, Physical Activity Questionnaire and anthropometric data. Categorical data from the Home Environment Inventory were analysed using Chi square tests for independence. Statistical significance was set at p < 0.05.
Demographic characteristics of study participants at baseline
N (%) or mean (SD)
Child’s age (years) n = 24
Child’s gender n = 24
Household structure (n = 22)
Two parent household
Single parent household
Mother’s education level (n = 21)
Some years of high school
Year 12, HSC or equivalent
Technical, trade, or TAFE certificate
Father’s education level (n = 22)
Some years of high school
Year 12, HSC or equivalent
Technical, trade, or TAFE certificate
Mother in paid employment (n = 21)
Father in paid employment (n = 22)
Household income (per week) (n = 17)
Home environment characteristics
Common intervention recommendations and caregiver-reported success in implementing change at home (n = 22 families)
Number of families given this recommendation
How well were changes implemented? (self-reported)
Not at all
Encourage all household members to spend some active time outside each day
Spend time outside with your child daily
Restrict availability of non-core foods (e.g. savoury snacks, cake)
Include fruit and vegetables in your child’s lunch box every day
Reduce portion sizes
Avoid family members eating in front of TV
Limit takeaway food to 1–2 times per month
Restrict sweetened beverages (including fruit-juice)
Try new strategies to avoid wasting food
Avoid having the TV on during mealtimes
Avoid putting non-core snack foods in your child’s lunch box (including muesli/health/breakfast bars)
Frequency (percentage) of selected home environment inventory variables pre- and post-intervention (n = 22)
Parental role modelling of physical activity
Mother walks for ≥ 30 min
Once/month or more
Father walks for ≥ 30 min
Once/month or more
Hours of TV mother watches/day
Hours of TV father watches/day
Opportunities for outdoor play
Child taken to the playground
Child taken to the park
Child eats evening meal in front of TV
Other family members eat food in front TV
Adults set rules for child’s TV viewing
Very much/quite a bit
Adults limit child’s exposure to TV advertising
Very much/quite a bit
How often adults restrict child access to
High fat/high sugar foods
Adults give child food ‘treats’
Portion size of child’s main meal
>1/2 average dinner plate
Feels about wasted food
Availability of food in the home
All reduced fat
Chips/savoury snack biscuits
Availability of food in the child’s lunchbox
How often lunchbox contains
Chips/savoury snack biscuits
Children’s lifestyle and anthropometry
Children’s anthropometry, dietary and activity scores pre- and post-intervention (n = 24)
135.2 ± 14.3
138.7 ± 13.8
45.7 ± 13.8
48.6 ± 13.0
24.5 ± 3.2
24.8 ± 3.1
BMI z score
2.9 ± 0.7
2.8 ± 0.7
Waist circumference (cm)
77.8 ± 9.7
77.7 ± 8.7
Waist circumference Z score
3.2 ± 0.6
3.0 ± 0.5
Fruit and vegetables
11.4 ± 4.4
10.9 ± 4.1
Fat from dairy
0.9 ± 0.9
1.0 ± 1.2
1.4 ± 1.1
1.3 ± 1.0
2.0 ± 0.8
1.7 ± 0.6
6.7 ± 3.5
6.8 ± 3.3
2.9 ± 1.9
2.7 ± 1.4
Minutes daily activity
163 ± 61
174 ± 109
Minutes sedentary activity
140 ± 74
132 ± 69
This pilot study explored the feasibility of a home-based child weight management intervention. Families from a range of different socioeconomic backgrounds participated in the study. The intervention involved direct assessment of the family food and activity environment which informed individualised recommendations for family change. It was hypothesised that improving the family food and activity environment would lead to improvements in children’s dietary and physical activity behaviours, and thus weight status. While the study findings support the family environment as a target for intervention, provision of simple individualised recommendations appeared to be insufficient to enable families to significantly alter their home food and activity environment.
Baseline findings demonstrated the potential for improvement in the home environments of this sample of overweight and obese children. For example, while it was common for families to eat together, so was eating meals in front of the television. Likewise, while healthy foods such as fruit and vegetables were available in homes, so were large amounts of energy dense, nutrient poor foods. In terms of physical activity, role modelling of television viewing was more common than modelling of activity and in general there were limited opportunities for active play.
The most frequent intervention recommendations made to families targeted parental role modelling of physical activity, encouragement of outdoor active play, reducing children’s exposure to energy dense nutrient poor foods and increasing availability of fruit and vegetables in lunchboxes. Post-intervention, small positive changes in the home environment were observed. Most related to children’s access to food in the home and lunchbox; greater access to vegetables and restriction of high fat/high salt non-core foods and food ‘treats’. Recommendations which appeared difficult for parents to implement were purchasing take-away food, eating food in front of the TV, having large amounts of non-core food in the home, and taking children to playgrounds or parks. Whilst some individual change occurred in lifestyle behaviours, at the group level few changes were detected in children’s diet and activity patterns. While BMI and Waist Circumference z scores improved for approximately two-thirds of children, at the group level the changes were small relative to the effects observed in other child weight management intervention studies  even accounting for the small sample size.
A home visit approach enables direct assessment of the home environment so that families can receive tailored advice about changes to improve children’s diet, activity patterns and weight status. However in this pilot study, families either did not achieve the necessary change or the degree of change was not sufficient to detect improvements in children’s diet and activity behaviours or weight status. The lack of intervention effect may reflect the need for more intensive and ongoing support particularly with respect to competing demands on family time and resources. Multidisciplinary expertise is often needed to appreciate and confront the complex psychosocial and environmental constraints families are challenged with, particularly those living in disadvantage. By this we mean that the skill-set of the team needs to include provision of support for social and emotional issues of both the child and family when necessary. Whilst our home visitors attempted to provide some of this support, it was not the focus of this intervention.
In addition, only the top ten environmental factors were targeted for each family. It may well be that these initial suggestions were just the first step in change and that subsequent visits were needed to focus on other aspects of the home environment to allow a greater intervention effect. Finally, it should be noted that only 36/66 (55 %) caregivers who sought information about this study, agreed to enrol their child. Whilst we had considered home visits to be more convenient for parents, parental anxiety around possible negative judgement about their home and household circumstances may well have contributed to this poor recruitment response.
Trials of home based intervention in other areas of health have had variable success. Segal et al. undertook an extensive review of home visiting for prevention of child maltreatment . They demonstrated that those trials clearly grounded in a theory or mechanism of change and with an intervention most consistently based on this theory were successful. On the other hand, trials where no underlying theory was described were not successful. A positive feature of our current study was that we based the intervention on ecological theory; that is we sought to change the home environments of children with obesity [3, 24]. However, one of the reasons that our intervention may have had limited success, is that ecological theory regarding obesity development suggests that macro-environments exert greater influence on obesity development/maintenance than parent’s ability to optimise the family home environment .
In the area of childhood asthma, Brown et al. discussed other possible reasons for the limited benefit observed following regular nurse home visits compared to standard clinic care . Nurses cited poor time management, personal problems or the family’s living environment as the greatest barriers to program success for about 40 % of families. As our study progressed, the complex and sometimes chaotic social issues faced by many families became more obvious and these took priority for families over positive lifestyle change. Brown et al. also reported that nurses who were more judgemental and less flexible were least successful in terms of taking families through completion of the asthma education program . In contrast, the home visitors in our study had been chosen because of their interpersonal style and we had specifically addressed the issue of obesity stigmatisation and importance of not being judgemental in our pre-intervention training.
The findings of this study must be interpreted in the context of its strengths and limitations. This is one of few studies to measure elements of the home environment by direct observation instead of parental report. The study included both assessments of dietary and physical activity patterns rather than focusing on only one side of the energy balance equation. However, as with any self-report methodologies these data could be at risk of measurement and social desirability bias. Practical aspects of ensuring a healthy lifestyle for children by parents were examined resulting in data that has real utility for health professionals dealing with overweight children and their families. However the sample size of this pilot study was small. Results should be viewed with caution and be useful primarily to inform future intervention studies rather than clinical practice.
In conclusion, this home-based intervention pilot study in which families of overweight and obese children were advised to change aspects of their home environment was not effective in improving children’s dietary and physical activity behaviours, or weight status. Future child obesity interventions should target factors which families struggle to change, provide additional behaviour modification support, and utilise a multi-disciplinary approach to address the complex social circumstances which limit parents’ ability to prioritise healthy family lifestyle behaviours.
NS, RG, AM conceived and designed the study. LL, AW were responsible for data collection. NS, LB analysed the data. All authors were involved in interpreting the data and drafting or revising the manuscript. All authors read and approved the final manuscript.
This study was funded by a Channel 7 Children’s Research Foundation Grant. RKG was supported by a National Health and Medical Research Council (NHMRC) Public Health Postdoctoral Fellowship (478115). Support for LB included funds from a FellowshipsSA grant.
The authors declare that they have no competing interests.
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