Background
Childhood overweight and obesity pose a primary healthcare challenge. Globally, among children under the age of five years, overweight and obesity have rapidly increased, such that 39 million young children are now thought to have overweight or obesity [
1]. In OECD countries, national data on the prevalence of obesity among preschoolers are still limited. However, in the US, the prevalence among 2–5-year-old children is reaching 16% [
2], and in the UK, about 10% of 6-year-old children have obesity [
3]. In Sweden, data from the child health care services, including height and weight measurements of 90% of 4-year-olds, show a prevalence of 9% for overweight and 2% for obesity, with a variation of 10 to 16% across different regions [
4]. This prevalence is a concern as young children with obesity are likely to have obesity throughout childhood [
5,
6], which is associated with immediate risk for low self-esteem and depression, as well as longer-term risks for type 2 diabetes and cardiovascular disease [
7]. To prevent these risks for mental and physical health, treatment should be initiated in early childhood: the latest Cochrane reviews on treatment across all ages found that treatment is most effective at the preschool age [
8]. In Sweden, conversations about children’s overweight and obesity must be initiated in the child health care (CHC) setting in order to initiate further support and referral to treatment. Sweden’s CHC settings are similar to primary pediatric care in other countries, with pediatric nurses offering regular follow-ups, support and guidance to all families of young children.
Over the years, as the prevalence of obesity among young children has increased, the responsibility of CHC nurses in the detection of childhood obesity and referral to treatment has increased in parallel [
9]. However, this responsibility has proven somewhat difficult to manage [
10]. In Sweden, the CHC nurse follows all children’s health and growth development in regular free-of-charge health care visits from birth to the age of 5. This makes the CHC an important arena to prevent overweight in preschool-aged children [
11]. Previous studies found that parents perceived CHC nurses, who often know families well and have established a trusting relationship with both children and parents, as best suited to address a child’s overweight [
12‐
14]. Although nurses consider conversations about overweight as an important task, their confidence in speaking to parents about a child’s increasing weight is low [
10,
11,
15]. In both Swedish and international studies, nurses report they lack training on childhood obesity, as well as time, staffing, and guidelines for how to initiate conversations in an appropriate way and thus enable further support and referral to treatment [
10,
15‐
17]. Across the studies, nurses have expressed apprehension about speaking to parents, reflecting the lack of consensus about how to initiate these conversations and the points to be discussed [
9]. Thus, although nurses know they should speak to parents about a child’s increasing weight status and support the family in making lifestyle changes, there is no agreed guidance on how to initiate and structure these conversations. Moreover, when nurses do initiate these conversations, they feel concerned about eroding the trusting relationships they have developed with the parents over the years [
10,
11,
18]. According to the Swedish Handbook in Child Health Care, the conversations are recommended to start with the CHC nurse showing the child’s growth chart to the parents, to visualize the child’s weight development. The conversation could then continue with the nurse first asking the parents about their thoughts, and then asking if she can share her thoughts [
19]. Nurses note that weight conversations can become difficult if parents do not agree with the nurse, do not find the child’s weight a problem, or do not want to discuss the child’s weight at all [
15,
18]. Successful conversations, on the other hand, are those where parents had already recognized the child’s overweight, or where parents are open to what the nurse says, ask questions and want to discuss the family’s habits [
10]. Best practice guidelines regarding weight conversations are under development and some practical tools have started to form for clinical use [
9,
20]. This type of research is key to minimize the risk that children with overweight and obesity may not receive the health care they need [
15,
16].
A further challenge is parents’ reluctance to initiate a conversation about their child’s weight, for fear of facing weight stigma socially and within healthcare settings. This encompasses parents’ concerns about how weight discussions might affect their child’s wellbeing and self-esteem, alongside concerns about being blamed for their child’s weight and being labelled a bad parent [
13,
14]. However, previous qualitative research has shown that parents feel responsible in preventing and handling their child’s overweight and that regular weight checkups are important [
13,
21,
22]. In an Australian study, parents of children aged 2–5 years with overweight reported feeling uncertainty and loneliness in handling their child’s weight [
23]. The feeling of loneliness could be even stronger if their concern for the child’s weight was not confirmed or taken seriously by the pediatric nurse [
23]. Another challenging aspect for parents of children with overweight is the balancing of obesity prevention with the promotion of a healthy body image. In Denmark, parents of children aged 3–6 years with overweight who participated in a project aiming to promote healthy habits, worried about whether there was too much focus on weight loss, and felt this focus could damage the children’s self-esteem and self-confidence [
24]. However, the parents also expressed what the authors termed a ‘moral dilemma’: although concerned that treatment would lead to eating disorders or a harmful body image, they also felt treatment was important for the child’s health and self-esteem later in life [
24]. An important angle on this dilemma was identified in a Norwegian study with parents of children aged 2.5–5.5 years who were classified as having overweight, where those parents who had overweight themselves favored treatment, saying they did not want their children to face the same difficulties they had been through as children [
22].
The importance of
how health care professionals provide information about children’s weight has been reported in several studies. Parents report that it is key that conversations are held in a non-blaming manner [
13,
21,
22]. Parents appreciate information about future risks associated with obesity but emphasize that conversations about growth and health are better than those that focus on weight [
13,
21]. This has also been recognized in a scoping review of best practices in how to talk to parents and children about overweight, where a more solution-focused conversation emphasizing health rather than weight was reported as especially helpful [
9]. Solution-focused conversations with carefully chosen words encourage parental involvement and subsequent action [
22,
25]. In addition to these findings, a mixed methods systematic review assessed parents’ and children’s experiences of communication in connection to routine weight screening measurements in health care and school settings [
26]. The authors report on the importance of clear communication both prior and post measurements to decrease worries and anxieties (e.g., what is going to happen during the measurement, what will happen afterwards, how to read a weight chart, who will have this information) but also to guide future actions [
26]. Also, the findings show that parents prefer that weighing and weight conversations take place in the health care setting rather than in the school setting [
26].
Studies conducted in different national contexts have increased our understanding about how to initiate conversations with parents about their children’s high weight [
9,
17,
26]. However, few of these studies have focused on the parents of preschool aged children [
13,
22‐
24,
27]. Moreover, little is known about parents’ experiences and actions in the aftermath of these conversations. In this study, we aim to shed light on the experiences of parents of preschoolers with overweight or obesity, following conversations about their child’s weight with a CHC nurse.
Discussion
In this interview-based study, we examined parents’ experiences following conversations with CHC nurses about their preschool-aged child’s weight. Interviewed before starting a childhood obesity RCT, all participating parents had young children with overweight or obesity. We found that parents described weight conversations with CHC nurses either as empowering or as provoking resistance. Parents described conversations as empowering when nurses opened a dialogue, inviting parents to express their needs and reflect together on how to introduce lifestyle changes. In contrast, conversations that provoked resistance were those where parents felt that the nurse provided inadequate information or portrayed their child’s condition using bleak and blaming framings, which could be characterized as stigmatizing. The effects of these conversations reverberated beyond the clinic, as parents attempted to integrate the information they had been given, leading to lifestyle changes and socio-emotional challenges. Parents often felt conflicted, wishing to enact lifestyle changes but worrying that managing their child’s weight might lead their child to develop poor body image and disordered eating. In making lifestyle changes, parents sought the cooperation of family and other people in the child’s life, although this also meant coping with minimizing or unsupportive reactions. Alongside this, parents also sought additional professional support from dieticians and therapists, but often felt the support they had been given was limited.
A key finding was that parents felt empowered by competent and empathetic health care communication, with the CHC conversation conducted as a dialogue and the nurse displaying sensitivity and engagement. Although an evidence-based best-practice for weight communication is still lacking, our findings are aligned with previous studies which showed that clinicians’ attitudes and tone during conversations about children’s weight are of paramount importance [
9,
27]. Together with this earlier body of work, our findings suggest that effective conversations about children’s weight should be non-judgmental, consider parents’ needs and prior knowledge, and provide concrete and individualized advice [
12,
27]. According to the participating parents, an important part of non-judgmental speech was the avoidance of loaded language about weight, a finding that echoes previous research [
27]. Although, as in earlier studies, parents noted the importance of being provided clear, factual information [
10,
11], and also wanted to know, as early as possible, if their child’s weight was too high [
9,
13,
21], they cited words such as ‘obesity’ as problematic. A similar finding was reported by McPherson et al. 2017, who found that, while the words ‘overweight’ and ‘obesity’ were accepted in the context of describing clinical charts together with a non-judgmental approach, both parents and clinicians preferred the terms ‘weight’, ‘unhealthy weight’, ‘high BMI’ and ‘weight problem’ when speaking about individual children [
9]. The authors concluded that the health care practitioner explore what terms the family use and if appropriate, use these words [
9].
Many parents were concerned about how to manage their child’s weight without negatively affecting their child’s body image, eating habits and self-esteem. A similar finding was reported in a Norwegian focus group study, which found that parents worried that their children, aged 4–11 years, would feel less accepted by friends and family once lifestyle changes had been implemented, and that they may develop negative self-perception or eating disorders [
33]. Likewise, a Danish interview study reported that parents expressed a dilemma, fearing that in improving their child’s physical health they were risking the child’s self-worth [
24]. The worries parents expressed, both in our study and in earlier research, are likely related to obesity stigma [
34]. The impact of obesity stigma on caregivers’ perceptions and practices has emerged most clearly in a US-based study, where parents and grandparents of children with overweight or obesity, aged 3–5 years, described their child or grandchild using terms such as ‘cute’, or ‘chunky’, distancing themselves from ‘obesity’ and the social stigma and bullying it implied [
35]. Our findings convey the sensitive balance parents must strike when beginning to manage their child’s weight and suggest that health care professionals should be careful to steer conversations away from weight and appearance and toward health [
9]. Because parents of children with overweight or obesity often experience self-stigmatization, guilt, and blame, a sensitive, health-focused communication approach may encourage parents to engage more openly with treatment [
36,
37].
Parents appreciated clinical advice that was tailored to their needs and knowledge. Thus, rather than receiving generic advice focused on healthier food habits to improve energy balance (e.g., eat less sugar and more vegetables and be more physically active), parents wanted information on practical strategies to use in everyday life, for example, how to estimate an appropriate portion size and how to handle a constantly hungry child. In a previous study, we found that parents of children with obesity knew what lifestyle changes to enact but needed advice on how to implement these lifestyle changes in the family [
38]. Although some CHC nurses are competent in advising parents about weight management strategies, these lie outside primary care pediatric nurses’ area of expertise [
15,
18]. This underlines the importance of employing a multi-disciplinary team in the CHC, including dietitians and psychologists, to provide better care to families of children with overweight. Moreover, in addition to improving the support parents are given, our findings also suggest it is important to discuss realistic expectations for the child’s weight development and behavior change processes, to reduce frustration among parents who find lifestyle changes difficult to implement or whose efforts yield limited results.
A notable finding was that, for several parents, the CHC weight conversation was instrumental in starting a dialogue with their partners or co-parents. Following the CHC conversation, these parents reported, they began to reflect together on their child’s weight problem and search for solutions as a team. This finding is novel, as similar findings have not been reported in earlier studies focused on parents’ experiences of weight conversations in primary health care. However, in our previous study, which focused on parents’ experiences of participating in parent group-based childhood obesity treatment, parents reported that the parent group discussions helped them “to start working as a team” within the family [
38]. While the CHC conversation sparked teamwork in some families, it is important to note that some parents felt unsupported, faced resistance from family members, and were left to cope with their child’s condition on their own, a finding aligned with earlier research [
39,
40]. Taken together, our findings suggest that pediatric clinicians should strive to involve both parents in managing the child’s weight, as well as support parents in communicating effectively with friends and family members about their child’s weight, for example, by providing them with talking points about healthy weight and lifestyle changes.
Many of the elements of the preferred conversation style described by the participating parents can be found in motivational interviewing (MI). MI is the recommended method to use in the CHC, to help families find their own resources and strengths to enable any lifestyle changes [
19]. MI is primarily about assessing whether change should occur and, if so, finding motivation to implement change, without determining how change should happen [
41]. This way, MI creates a conversation that is relationship-building. While MI has been used in many studies internationally to improve conversations between parents and clinicians [
9], it has yet to show effectiveness in the prevention and treatment of overweight and obesity in children. In a large Swedish prevention study on childhood obesity [
42,
43], using MI in CHC did not appear to be effective in influencing the child’s weight over time [
42,
43]. Similarly, a well-conducted treatment study in Italy showed that using MI had no effects long-term [
44]. Still, MI includes many of the conversational elements cited as valuable by the parents who participated in the present study. This suggests that MI should be evaluated further in the childhood obesity management context, with potential adaptations to this population of patients and parents. One possible adaptation would be to introduce a weight bias reduction program for clinicians, in tandem with training in MI. Although research is still needed to establish the effectiveness of such programs, studies have suggested that weight bias reduction interventions lead to positive changes in clinicians’ beliefs [
45]. This, in turn, may help clinicians in communicating with parents and addressing their concerns about obesity stigma. Another adaptation would be to train clinicians in how to explore with parents factors which might have contributed to the child’s overweight/obesity, beyond dietary intake and physical activity, including familial history, significant childhood life events, and exposure to an obesogenic environment, so that they can better support families and offer personalised advice.
Strengths and limitations
The main strength of this study is its focus on an understudied population: parents of preschoolers with overweight or obesity. The study’s semi-structured interview design has allowed us to explore these parents’ experiences and thereby generate new findings that may inform future research questions. However, some limitations need to be acknowledged. Although we tried to recruit a heterogenous sample of parents, fewer fathers than mothers were interviewed. Additionally, most parents had a university degree and were born in Sweden, meaning that families of lower SES and migrant background were underrepresented. This can be explained, in part, by the inclusion criteria of ML Europe, which stipulated that all participants should understand and speak Swedish, to be able to participate in a comprehensive RCT with group discussion elements.
Future studies
In ML Europe, more interview studies are planned to investigate parents’ experiences of parenting a child with obesity, as well as undergoing intensive childhood obesity treatment as a family. Additionally, we plan to explore what facilitates and what hinders families’ engagement in treatment, as well as why families decline or leave treatment. Within and beyond ML Europe, future studies should recruit families of lower socioeconomic status and families of diverse cultural backgrounds, to better understand how parents across society perceive and experience child weight and weight management. Although qualitative research on weight-related conversations is increasing, best practices for weight-related conversations in pediatric contexts are still lacking. We would encourage future studies to focus on evaluating best conversational practices, as this is urgently needed to improve weight management for children of all ages and across medical settings, including those focused on treatment for obesity, feeding disorders, and eating disorders.
Conclusions
In this qualitative analysis of parents’ experiences following conversations with CHC nurses about their children’s overweight/obesity, we found that parents wanted to discuss their child’s weight, provided that the nurse met them in a knowledgeable, professional, and engaging way. Parents appreciated conversations in which nurses invited reflection and dialogue, while using supportive language and avoiding negatively charged words. When these criteria were not met, however, parents described feeling helpless, judged, and resistant to the message. Furthermore, while parents described weight conversations as difficult, they wished nurses would initiate these conversations as early as possible; indeed, some parents wondered whether their child’s health would have been better had the nurse initiated the weight conversation earlier. Additionally, weight conversations with CHC nurses led to changes in communication within families, prompting cooperation between parents and other relatives to facilitate the child’s weight management and implement behavioral changes as a family. The main difficulty parents associated with weight conversations was the negative impact these could have on the child’s body image, either via the conversation itself, if the child was present, or following the conversation, when parents began to implement changes for the child’s weight management. Taken together, the findings convey that weight conversations in pediatric primary care, are essential in encouraging parents of children with overweight or obesity to make positive changes. Future studies should evaluate best practices in these conversations, as a crucial component of children’s weight management and long-term mental and social wellbeing.
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