Minimal change in children’s lifestyle behaviours and adiposity following a home-based obesity intervention: results from a pilot study

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 [4]. The family home is an important micro-environment with the potential to influence children’s lifestyle behaviours and weight status [5]. 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 [11]. 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 [11].

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 [14], 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 [15]. 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.

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 [12] 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 [29]. 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 [30].

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 [31]. 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 [31]. 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.