(5 choices: Not at all likely - Very likely)
Two child participants and their family’s primary meal preparer were chosen from the intervention group: Oliver Jorgenson, a ten-year-old male, and Sophia Lee, a nine-year-old female. Both identified from underrepresented minority populations. Selection criteria included high program participation (≥70% attendance) and a reduction in BMI z-scores over the course of the program. These two cases were chosen subjectively, but represent a wide range of health challenges encountered by many families in the study. MI phone call notes were reviewed to evaluate participant’s ongoing progress and goal attainment. To provide context for the magnitude of the cases’ data, behavioral changes were compared to average changes in the entire HOME Plus intervention group.
Oliver Jorgenson’s anthropometric data placed him in the “obese” weight category at baseline (BMI percentile = 97.3%). After the intervention, his BMI decreased and he was considered “overweight” ( Table 2 ). Oliver and his primary meal-preparing parent attended 90% of the HOME Plus group sessions and participated in all of the MI phone calls.
Participant Change in BMI and Weight Status Category
Participant | Baseline BMI percentile | Weight status category at baseline | Post-Intervention BMI percentile | Weight status category at post-intervention |
---|---|---|---|---|
Oliver | 97.3% | Obese | 94.1% | Overweight |
Sophia | 86.3% | Overweight | 75.0% | Normal |
Note. Normal weight = child age and gender adjusted BMI < 85%; Overweight = child age and gender adjusted BMI 85% ≤ but < 95%; Obese = child age and gender adjusted BMI ≥ 95%
Many of the topics brought up by Oliver’s parent during the phone calls aligned with behavioral objectives one ( plan healthful meals with family) and three ( improve healthfulness of foods available at home). During the first few calls, Oliver’s parent expressed surprise upon learning many of the foods the family was eating were considered unhealthful. Throughout the calls, Oliver’s parent showed progressive learning in regards to nutrition and healthy meal planning. The family incorporated several changes in their meal routine including decreased portion sizes, having fruit for snacks, adding vegetables to pizza, and exchanging some white rice for brown rice at meals. During the last call, Oliver’s parent conveyed more confidence in using strategies learned through the HOME Plus program.
Aligned with their focus on behavioral objectives one ( plan healthful meals with family) and three ( improve healthfulness of foods available at home,) during MI phone calls, Oliver and his family also showed improvement in these behavioral objectives as measured by their psychosocial survey scale scores ( Table 3 ). Compared to the average scores of the HOME Plus intervention group, Oliver experienced greater improvement in all aspects under behavioral objective one ( plan healthful meals with family) , including parent’s self-efficacy to cook healthful meals, parent’s perception of the frequency child helps choose and prepare meals and snacks, and parent’s perception of child cooking skills. Oliver and his family also showed development under behavioral objective three ( improve the healthfulness of foods available at home) . Although the family’s obesogenic home food availability (HFI) score increased, Oliver’s food neophobia score improved when compared to the intervention group’s average change ( Table 3 ). In addition, compared to his baseline intake, Oliver reported eating more servings of fruit and vegetables after the intervention ( Table 3 ).
Behavioral Objectives and Dietary Outcome
Behavioral Objective #1: Plan healthful meals and snack with family more often | Oliver | Sophia | Intervention Group | ||||||
---|---|---|---|---|---|---|---|---|---|
BL | P | Δ | BL | P | Δ | BL | P | Δ | |
Parent’s self-efficacy to cook healthy meals | 6 | 11 | 8 | 10 | 12.00 | 12.96 | |||
Parent’s perception of frequency child helps choose and prepare meals and snacks | 2 | 10 | 16 | 6 | 10.69 | 11.97 | |||
Parent’s perception of child’s cooking skills | 1 | 9 | 6 | 2 | 4.01 | 5.55 | |||
| |||||||||
Parent’s perception of frequency of family meals | 15 | 18 | 13 | 18 | 22.09 | 22.69 | |||
Child’s perception of family connectedness and dinner enjoyment | 25 | 24 | 17 | 23 | 19.40 | 20.00 | |||
Parent’s perception of family meal expectations and discussions | 22 | - | 18 | 24 | 27.19 | 27.54 | |||
| |||||||||
Home Food Inventory (HFI) obesogenic score | 15 | 18 | 38 | 29 | 28.78 | 23.10 | |||
Parent’s food restriction practices (CFQ) | 31 | 33 | 27 | 36 | 27.22 | 24.86 | |||
Child’s neophobia | 18 | 11 | 18 | 15 | 17.32 | 15.46 | |||
Child’s average daily servings of fruit | 0 | .92 | 1.08 | 1.04 | 1.07 | 1.23 | |||
Child’s average daily servings of vegetables | 0.94 | 1.52 | .0227 | .3827 | 1.41 | 1.61 |
Note. BL= baseline, P=post-intervention, Δ=difference between baseline and post-intervention scores
In comparison to behavioral objectives one and three, survey responses from Oliver and his parent showed less change in behavioral objective two ( have meals with your family at home more often). Parental perception of frequency of family meals increased while child’s perception of family connectedness and dinner enjoyment decreased, no data were available on parental perceptions of family meal expectations and discussions.
Baseline anthropometric data indicated Sophia Lee was “overweight” (BMI percentile = 86.3%). At post intervention, Sophia’s BMI decreased and was categorized as “normal” weight ( Table 2 ). Sophia and her primary meal-preparing parent attended 70% of the HOME Plus intervention sessions and participated in all of the MI calls.
Throughout MI phone calls, Sophia’s parent focused on topics related to behavioral objectives two ( have meals with your family at home more often) and three ( improve healthfulness of foods available at home) . During the initial MI call, Sophia’s parent expressed feeling “busy and overwhelmed,” and stated healthful eating “was not a priority.” During the last two calls, Sophia’s parent reported the family was eating together more often, trying new foods, and having a greater variety of food choices in their home.
Aligned with the focus on behavioral objectives two ( have meals with your family at home more often) and three ( improve healthfulness of foods available at home) in the MI phone calls, analysis of psychosocial survey data showed Sophia and her family improved in these areas ( Table 3 ). Specifically, Sophia showed consistent improvement in measures under behavioral objective number two ( have meals with your family at home more often) , showing increases in parent’s perception of frequency of family meals, parent’s perception of family meal expectations and discussions, and child’s perception of family connectedness and dinner enjoyment ( Table 3 ). The family also showed changes under behavioral objective three ( improves the healthfulness of foods available at home) . Sophia’s family showed a decrease in their HFI obesogenic score while their parental food restriction practices increased, especially when compared with the intervention group’s average change ( Table 3 ). In addition, compared to baseline, Sophia reported eating more servings of vegetables at post-intervention. Sophia’s family showed less improvement in behavioral objective one ( plan healthful meals and snack with family more often). Data showed decreases in parental perception of both frequency in which child helps choose and prepare meals and snacks and in child’s cooking skills.
The HOME Plus program is a family-focused, multi-component, childhood obesity prevention program incorporating group and individualized approaches to healthful lifestyle modifications, particularly related to frequent and healthful family meals. The program offered participants the opportunity to learn about and employ nutritional knowledge, hands-on cooking skills and meal planning strategies. This multi-component approach provided participants with consistent healthful lifestyle messages and tools and strategies to promote and attain better health while allowing for individualization. Currently, most of the research published on similar programs only analyzes and reports on program effectiveness as a whole without consideration of individual participant differences. Therefore, these two case studies are unique, illustrating how families choose to adopt/incorporate lifestyle changes into their daily routines.
MI phone calls with Oliver’s family revealed the benefit of nutrition education obtained from the group sessions, which provided the initial building blocks needed to make healthful lifestyle changes. This finding is consistent with studies that have shown the positive effects of nutritional education on children’s dietary intake ( Evans, Christian, Cleghorn, Greenwood, & Cade, 2012 ; Howerton et al., 2007 ). Oliver’s family was also able to increase cooking self-efficacy, child cooking skills and child frequency of helping with meal preparation. Cooking instruction emphasizing healthier ways to prepare meals to have a positive impact on dietary intake and behaviors and nutrition education incorporating hands-on cooking skills increases participants’ confidence, knowledge and attitudes towards cooking, while improving overall healthy eating behaviors such as vegetable and fruit intake ( Fulkerson et al., 2015 ; Hersch, Perdue, Ambroz, & Boucher, 2014 ; Reicks, Trofholz, Stang, & Laska, 2014 ). In addition, children who develop cooking skills are also more likely to try new foods and less likely to depict food neophobic traits, a change seen in Oliver’s case. Oliver and his family are an example of how developing practical cooking skills can empower families. Families gain more control over what and how their food is prepared by participating in hands-on programming that includes cooking skills.
Sophia and her family showed substantive changes in behavioral outcome two ( having meals at home with family more often) . Despite their busy schedule, Sophia’s family increased their family meal frequency and improved the quality of their family mealtime dynamics. Numerous studies have shown significant associations between family meal frequency and physical and psychological benefits for children and adolescents ( Fulkerson, Larson, Horning, & Neumark-Sztainer, 2014 ; Hammons & Fiese, 2011 ). Family meals provide an informal “check-in” time for children and parents to connect; children are able to express emotions or concerns, while parents can validate their child’s feelings and provide support. By creating a consistent, supportive mealtime environment, Sophia’s family may be providing her with the foundation needed to make healthful lifestyle changes.
Sophia’s parent reported lower scores at post-intervention measurements compared to baseline measurement for parent’s perception of the frequency their child helps choose and prepare meals and snacks and also parent’s perception of their child’s cooking skills. This decrease was inconsistent with the rest of the intervention families. It could be that Sophia was helping with cooking and meal preparation less at the time of the post-intervention measurement. However, the decrease may have occurred as Sophia’s parent gained a more realistic perception of Sophia’s cooking skills and abilities after participating in the HOME Plus program. Sophia’s family did not focus on behavioral outcome one ( plan healthful meals and snack with family more often) during their MI calls, suggesting this was not a focus for their family.
Oliver and Sophia both experienced an overall improvement in behavioral outcome number three ( improving the healthfulness in food availability at home) . They both decreased their food neophobia scores, indicating more willingness to try new foods. In addition, both reported higher parental food restriction practices. Although severely restrictive parenting styles have been associated with an increase in eating impulsivity and high BMI in children, discrete restriction tactics such as limiting unhealthful home food availability have been shown to be beneficial for controlling adolescent intake ( Loth, MacLehose, Larson, Berge, & Neumark-Sztainer, 2016 ). By limiting the availability of unhealthful foods in the home, as indicated by the decreased HFI obesogenic score, Sophia’s parent may have been exercising the appropriate level of restriction needed to encourage Sophia’s healthier dietary intake.
Looking only at anthropometric data, both Oliver and Sophia experienced a decrease in BMI after participating in the HOME Plus program ( Table 1 ). However, a more refined story emerges when looking at the different paths each family took to become healthier. Although both families showed healthier home food availability, Oliver’s family (but not Sophia’s family) showed clear improvements in planning healthful meals. In contrast, Sophia’s family (but not Oliver’s family) showed greater improvement in having family meals together. Childhood obesity continues to be a major concern in public health today and finding effective yet efficient interventions for lowering community obesity rates can be challenging. The cases of Oliver and Sophia are examples of how multi-component programing can be used in the public health arena to deliver effective interventions to a large community, while still recognizing and capitalizing on participants’ differences, strengths and needs. When working at the community level of practice, using a multi-component approach to prevent childhood obesity may benefit future obesity prevention program effectiveness, as it can allow for some customization for participants.
This case study description has limitations. As a case study, it merely aims to describe changes and not predict nor denote statistical significance between groups. In addition, all survey data were self-reported and may be influenced by social desirability. In-person interviews may have provided this study with a greater, more in-depth understanding of families’ perspectives. Nonetheless, this case review used data from a variety of well-validated scales to help paint a multi-dimensional picture of two HOME Plus study participants who managed success in weight change but in different ways. Future direction for multi-component obesity prevention programs should examine the value of providing group and individual support across systems. Intervention programs, such as HOME Plus, should consider collaboration with schools and other community programs, such as park and recreation, in order to reach populations within and across different settings.
Analysis of the study cases shows how the HOME Plus program meet needs of different families, providing them with choice and support to make healthful behavior change. Traditionally, group-based obesity prevention programs have offered families a broad, blanket approach to encourage behavior change, but families are vastly different, varying in lifestyle habits, cultural preferences, daily routines and values. Ultimately, one lifestyle change may be helpful for one family, but not for another. By taking the time to understand how components are integrated into families’ lives by analyzing individual cases, public health nurses may be better able to tailor obesity prevention programs to better meet participants’ needs and leverage their strengths. In addition, offering individualized components in a multi-faceted intervention may be important for maximal participant engagement as well as support and follow-up during behavior change. Healthful living is a lifestyle change requiring active participation and dedication from the participants. For this reason, it is imperative public health nurses help families feel empowered to take charge and play an active role in their health.
This publication was completed as a capstone project for a Master’s of Nursing degree at the University of Minnesota. This study and publication was supported by Grant R01 DK08400 by the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the views of the NIH. Software support was also provided by the University of Minnesota’s Clinical and Translational Science Institute (Grant 1UL1RR033183 from the National Center for Research Resources of the NIH). The HOME Plus trial is registered with ClinicalTrials.gov Identifier: NCT01538615.
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