Dietary habits and metabolic response improve in obese children whose mothers received an intervention to promote healthy eating: randomized clinical trial

In recent decades, obesity in children and adolescents has been on the rise worldwide [1, 2]. The distribution of overweight and obesity varies widely according to age group, race, region, urbanization and socioeconomic status. Metabolically, obesity is caused by an imbalance in which energy intake exceeds expenditure in a persistent fashion. Low energy expenditure is caused by decreased physical activity and increased sedentary. The energy imbalance of overweight children results from the unhealthy lifestyles acquired at home, and health providers need to inform parents on how to change unhealthy feeding and sedentary habits to preserve the children health [3‐5]. People are consuming more energy-intensive industrialized foods and beverages than natural foods and water. Meanwhile, they perform less physical activity and are more sedentary [6, 7]. The National Nutrition Surveys showed that from 1999 to 2018 the prevalence increased from 26.9 to 35.6%, indicating that this problem prevails with unacceptably high figures for this age group [8‐10]. Obesity is associated from childhood with comorbidities such as metabolic syndrome, hypertriglyceridemia and type 2 diabetes constituting a major public health problem [10‐12]. Therefore, it is important to develop alternative strategies to prevent this health problem since early age. Additionally, obesity decreases children’s self-esteem, thus deteriorating their psychosocial well-being [13]. Parents with obese children turn to health clinics for assistance with this problem; once diagnosed, and after clinical and metabolic procedures, given the shortage of pharmacological resources, they are prescribed an initial diet plan in accordance to their age and gender [14], with mothers receiving instruction on how to prepare and follow this plan at home. An evaluation of this management proven little effectiveness in reducing children’s body weight and has shown elevated dropout rates [15]. When the study was conducted, the Obesity Clinic at the Federico Gomez Children’s Hospital of Mexico had not yet implemented programs to assist families in changing their lifestyles. Interventions involving parents and thatinclude healthy food, physical activity, and behavioral changes components, are accepted as the path with the best results for treating child obesity [16] however, these interventions are complex and costly. The next option is to direct interventions at both parents, considering that they are agents of change in their children’s habits. Results depend on the design and duration of the study, with studies of over a year and more frequent contact leading to better results; but success also depends on the expected outcome variable; success is rare when programs are designed to reduce children’s body mass index [17]. In large cities, interventions directed at both parents face many complications, which leave the option of directing interventions specifically at mothers, who most often take children to the hospital. Also, they are the main agent behind dietary habits in the household [18]. In this context, the aim of this study is to evaluate the change in eating behaviors, metabolic condition, and nutritional status measured by anthropometry, in children with obesity who were prescribed a diet to reduce their body weight in the usual nutritional consultation, in comparison to children whose mothers participated in an intervention of six group sessions to acquire healthy dietary habits.

In the intervention group, 44/90 pairs (49%) completed the follow-up; in the control group 48/87 pairs (55%) completed the follow-up, as shown in Fig. 1.

Table 2 features the children’s baseline anthropometric, clinical, and metabolic characteristics, showing that both groups are comparable. Both groups BMI was >95pc, and both had HOMA-IR indexes of ≥3.4. Regarding physical and sedentary activities, the intervention group children spent 5.5 and 13 h/wk. on each of these activities; control group children spent 7 and 14 h per week on each of these activities, respectively.

Table 3 shows the effect of the educational intervention on children’s dietary habits and behaviors, both within each group and between groups. In terms of dietary habits, intervention group participants showed greater behavioral changes than control group participants.

Today, people of all ages around the globe are immersed in a culture that intakes more energy than it can use. Mass media encourage children to eat foods that are dense in saturated fat, refined sugars, and salt [27]. Meanwhile, educational and health institutions promote healthy dietary habits and physical activity but fail to counteract the culture of unhealthy food consumption. The result is an obesity epidemic that has coined the term “Globesity” in an attempt to address both the causes of this epidemic and its severe and onerous consequences [28].

In this study, HOMA-IR changes were observed in obese children belonging to the intervention group, this may be associated with a change in children’s nutritional status but mainly by changes in eating habits. Likewise, it has been observed that people who are obese and reduce their body weight improve their metabolic biomarkers and increase their insulin sensitivity [29, 30]. Programs encouraging healthy eating should be promoted among the population as a way of improving lipid profiles and preventing or reverting insulin resistance, as well as preventing chronic disease.

In the present, more than a third of children in Mexico of ages 5–11 and adolescents 12–19 are overweight and obese [9]. Hypothetically speaking, if they were all to seek help for their problem from health services, these institutions would be unable to cope. On the other hand, conditions are so limited that health workers often issue parents diets for their children and physical activity recommendations the way they would prescribe medication. This medical-style approach has not had the expected results. Modifying habits, in this case dietary habits, requires an educational process that involves mothers because they are largely in charge of household food practices [31, 32]. This educational intervention, where the mothers of obese children participated in a group, took place in a clinical setting, in a hospital, and not in homes. However, its messages sought to modify daily or routine feeding behaviors at home, in the microsystem where obese children reside according to Bronfenbrenner’s ecological model [33], as opposed to having to prepare a menu as prescribed in the usual nutritional consultation, to which children would have to adhere to improve their health. The priority during education sessions was for mothers to identify behaviors that promoted greater energy intake either by quantity, density or frequency, to then modify their children’s dietary habits and improve their nutritional status. The content provided at the sessions did not include information or activities for increasing physical activities that would promote energy output.

By the end of the study, there was an improvement in intervention group feeding behaviors, such as reducing portion sizes, avoiding full plates, not forcing children to finish their meals and accepting food substitutions. Both groups became less prone to putting salt and bottled soft drinks on the table, and reduced the habit of repeating servings, but without difference between groups. In terms of food consumption, the intervention group participants increased fruit and vegetable intake in their diets, a change that is key within the healthy diet model [19], while control group participants increased their consumption of grilled or shallow-fried foods.

Regarding beverages, intervention group participants decreased their intake of domestic and industrially-produced sweetened beverages, while control group participants only reduced their consumption of natural juice. A note worthy observation is that neither group modified their water intake, which suggests that the information given to families highlighted the risk of sweetened drinks to the health of obese children more than the benefit of simple water intake. Other studies conducted on school-aged children and their parents addressing a range of components including greater fruit, vegetable, and water intake have had positive impacts on children [34, 35].

In other noted behaviors, control group children became less prone to finishing their meal in under 30 min; the occurrence of intervention group children watching television at mealtimes decreased, which, as is known, encourages them to taste their food without distractions or subliminal messages from advertisers [27, 36].

After 3 months, aside from a decrease in BMI percentile that registered no difference between groups, changes in eating behaviors did not improve anthropometric indicators in children from either group. In a study conducted in a school setting in which parents and children attended 15 educational sessions promoting healthy eating and physical activity, as opposed to another group that only attended two sessions, participants in the group with the highest number of contacts improved their anthropometric indicators [37]. Other studies on children ages 4–12 that were conducted in homes over a 1 year-period achieved minimal changes in diet, physical activity, and body weight [38].

Among the weaknesses encountered during this study, the high desertion rate is the most relevant. Holding face-to-face sessions for mothers who live in large cities such as Mexico City can be complicated by distance, prolonged travel times, and transport costs. Another important consideration is the reduced size and scarcity of spaces for educational activities within health institutions. For these reasons, technological alternatives such as the internet and mobile phones must be explored as means of sending users relevant information and as a way of eliminating the need for mothers to travel to health clinics [39]. Also, parents who are less participative in these duties may become more engaged [40]. Another important consideration is that follow-up sessions and duration of contact between researchers and mothers was not enough to achieve the desired anthropometric objectives [17].

In regard to strengths, behavioral changes in intervention groupchildren surrounding meals and food preparation can be considered relevant, along with a significant HOMA-IR index decrease which was significant between groups. Metabolic profiles in obese children have been found to improve with physical activity interventions that do not include dietary provisions [41]. In this study, which did not address physical activity, we found that modifying dietary habits can also achieve these benefits, possibly in a longer-lasting way.

Involving the mothers of obese children in group sessions where they are given information on how to modify dietary habits in the home microsystem leads to beneficial health changes in their children, though more time is required to achieve effects on anthropometric measurements.

The intervention aimed at children suffering from obesity and their mothers modified some dietary habits and behaviors at home and improved insulin levels and HOMA-IR in a context where they were not given a specific diet as a treatment nor did they receive intervention on physical activity. Therefore, group sessions aimed at the mother to modify dietary habits at home can be an extra resource in the management of childhood obesity in the health institutions.