Theme 1: Identification of infant overweight and future risk
Subtheme 1a: Overweight as a concept that can be applied to infants
Participants readily accepted childhood obesity as a prevalent and significant issue within society, and did not challenge the idea that a conversation around infant overweight was appropriate.
“… the future is looking fat, isn’t it?” (P10).
Parents replied with little hesitation that they would be able to recognise overweight or rapid growth in their baby, justifying this as a matter of common sense and utilising norm-referencing and comparison to peers.
Well I think it is just a matter of common sense if they look really fat (P7).
“When I go to visit my friends and I saw two or three week old babies and they were smaller than mine (when he) was born just now it was oh he’s a big boy. And now he is big too because now he’s seven and half kilo around something, so it’s really big because he is just three and a half months, like my friend have a girl and she is eight months and just eight kilos” (P20).
Participants generally used socially constructed comparisons, to emphasise shape and form as descriptors by making visual comparisons to siblings and peers, or being able to fit into clothing with an appropriate age-label.
“He’s wearing one- to two-year-old clothes and he is not even one yet” (P16).
Although not explicitly asked to (as per the interview schedule), some parents went on to describe their own infant as overweight using terms ranging from overweight and obese, to big, massive, and chubby, and also chunky monkey.
Subtheme 1b: Trust and mistrust of professional growth assessment
Despite the positive attitude to self-identification, parents demonstrated hesitation about the role of health professionals in identifying infants as overweight.
“The first responsibility it’s with the parent but there should be some professional help …{to}…help parents recognise that the baby is becoming overweight” (P18).
Partly this was because it was felt to be unnecessary, since they as parents could be relied upon to identify it, but also due to experience of, or concerns about, being judged.
“I don’t think parents should need to be intervened because they should be able to see their child is obese…” (P14).
“..You wouldn’t be happy because you would feel like he was sectioned out from all the other babies … people would be saying oh that baby is fat, you wouldn’t be very happy.” (P15).
Parents were very aware of the growth charts and centiles used by health professionals, and referred to them as charts, the red book, or the line. However, accounts suggest some uncertainty about what the centile lines represent as well as widespread scepticism around the growth standards.
“In our baby’s health book um and the lines go from 0.4% all the way through to, well I think it’s through to 100% it might even be more than that and I’m guessing that your aiming for the 50th percentile on that um but nobody has ever really said anything about it…” (P1).
“But I think the line is pretty stupid anyway if I’m honest, because each child is individual and they will grow as they want” (P14).
Notably, some participants described circumstances in which the growth standards did not apply to them.
“Because she was born so heavy she didn’t seem to work so well with the growth charts in the little red book” (P7).
Despite lack of enthusiasm for growth standards, parents frequently attended baby-weighing clinics – a process described as checking – and were reassured when their baby was on the line or following the line.
“I mean I do look at him, everyone looks at him and says god he’s massive, he’s only six months and I say when you weigh him and put him on the chart he’s not, he’s bang on the middle…” (P12).
Subtheme 1c: Receptiveness to risk communication and modification of lifestyle behaviours
Notably, the possibility of predicting future obesity risk was treated with pleasant surprise and elicited very little questioning from parents. There was an overwhelmingly positive desire to receive information about both their infants’ current weight status, if it was a problem, and the future risk of their infant becoming overweight.
“…I would be happy for her to say it outright if that was a chance then so if she was to say that would be fine” (P13).
“Yeah definitely, definitely if there was something that could be done, or that I was doing wrong that I could do differently then, yeah I would want to know” (P8).
Provision of information about overweight risk was viewed as more acceptable or ‘believable’ when provided once an infant is walking.
“Well you have your two year check, so a two year check would probably be a good one because they are definitely walking then” (P12).
Walking was associated with an increase in energy expenditure and viewed as an important point at which those children with puppy fat (which can be naturally grown out of), are separated from those that will have persistent overweight tracking through life. The degree of parental concern about infant overweight status was linked to an infant’s stage of development. Participants repeatedly suggested that the point at which they would become concerned was when their infant remained overweight once walking.
“…my opinion is that when he starts walking about he’ll burn it off and I’m quite an active person, I walk pretty much everywhere unless isn’t in walking distance and so he will, it will come off him and he will be fine.” (P4).
Subtheme 1d: Perceived benefits and harms of risk communication
The primary benefit parents ascribed to knowing about their infant’s future risk was because it acted as a cue to action, with some parents specifying possible behavioural strategies.
“Well at least then you could sort things out a lot quicker…” (P2).
“I suppose if she started to become fat I’d probably think about the amount of calories we are giving her and giving her more vegetables and things that will give her nutrients…” (P7).
“..If I was told he was overweight I would probably be feed him fruit and making him go healthy …” (P14).
However, the possibility of negative behavioural change was raised.
“It would worry me because some mums might panic that their child is going to become overweight as a baby and not feed them as much” (P17).
When questioned about how they might feel after receiving risk information, parents focused on negative feelings; bad parent, ashamed, upset, worried, annoyed, offended, and shocked. Interestingly, participants were not only concerned about feeling guilty for serving their child’s best interests, but also by how this would be perceived (and judged negatively) by others. However, for parents in this study, the potential negative emotions although recognised did not supersede the desire for knowledge.
“… I said I’d feel ashamed, like you know, but I would rather be told I would rather know than not know” (P5).
Finally, the importance of a non-judgemental communication style to reduce negative emotions was identified.
“… not being so abrupt and like out right blaming the parents I think it needs to be done you know in a sensitive way because some parents will, aren’t going to be happy with the fact that you know…” (P17).
Theme 2 – The consequences of infant overweight status
Subtheme 2a: The relative impact of overweight vs. underweight
Concerns about underweight or poor growth were evident and often regarded as more worrying than overweight. High levels of anxiety were articulated about poor infant growth or falling short of the line (see subtheme 1b), which were felt to be caused by the response of alarmist healthcare professionals.
“… they were like we have to get the weight on we have to get the weight on so I found it traumatic for at least the first two weeks” (P6).
Subtheme 2b: The progressive nature of consequences associated with overweight
Overwhelmingly parents problematised infant overweight in terms of the likely continuation of excessive weight from infancy into both childhood- and adulthood.
“…I think it’s a real concern, I mean you do not want an overweight child and the concern, I suppose the concern is that if you have an overweight baby they become an overweight child” (P1).
The immediate concerns relating to overweight were in relation to initiation of walking and other developmental milestones.
“…..Just that she’s going to get really obese and by the time she’s a year old not be able to walk because she’s going to be too fat to lift her own weight..” (P19).
Intermediate concerns related to bullying at school, and it was only in relation to adult overweight that health consequences, most notably diabetes and heart attacks, were referenced.
“…I am not fussed at the moment, but when he starts going to nursery or starts going to school then I wouldn’t want him to be overweight at that age.” (P2).
“I’ll try to prevent illness, because I know that being overweight you’ve got a risk of so many like, so many things, arteries, heart attacks in the future and so I know the side effects of being overweight” (P4).
Subtheme 2c: The importance of infant contentment
For some the goal of infant contentment over-rode concerns about overfeeding and overweight. Interestingly, participants most frequently discussed a baby’s contentment in the context of regular, ample feeding, and maternal happiness was centred on infant happiness.
“Obviously I think he is pretty chubby, but I don’t see a problem with it because he is happy so” (P15).
“I don’t know, because I don’t know I suppose like if a baby is hungry then a baby is hungry and to sort of reduce their milk if they are still hungry that seems really cruel” (P13).
Subtheme 2d: Good parenting and fear of negative judgement
Participants repeatedly voiced concerns about being judged as a bad parent by others for having an overweight child, and some reported experiences of this. When asked about from whom they feared judgement, other parents and people in the street were typical responses.
“As she gets older, and obviously whatever people are going to think about me as a parent for letting her get like it, if she’s like ridiculously overweight or anything like that” (P11).
“I don’t know really just like random people, if you’re walking down the road or something you don’t want someone to shout out, oi your baby’s fat” (P15).
Societal stigma surrounding adult obesity was also apparent in parent narratives, particularly amongst participants who were themselves overweight.
“Yeah they think a fat girl with a fat baby” (P2).
Theme 3 – Parental attributions of causality, responsibility, and control.
Subtheme 3a: High parental responsibility for overfeeding
When questioned about preventing the onset of excess weight gain during infancy all participants stated - without hesitation - that it was their responsibility as parents, and cited overfeeding as the main contributing factor.
“I have all of it, I have all the control at the end of the day I am the one, she is not feeding herself at the moment…” (P17).
“I have not really thought about weight I think it is, the only thing I think it really could be at the moment is overfeeding, feeding when it’s not necessary” (P17).
Overfeeding was discussed primarily in relation to formula milk and solid foods as they described how breastfed babies could not be overweight or, if they were, that this was not unhealthy and would naturally resolve itself.
“If you’re breastfed you can’t, you can’t over eat so if they are gaining weight that is their natural …” (P6).
The sense of responsibility for overfeeding translated into self-blame for parents describing their babies as overweight, which contrasts with the general ease of self-identification (subtheme 1a).
“...I do feel the blame is solely on yourselves because you’re looking after um, you’re the one that’s giving them food and letting them eat it” (P5).
Subtheme 3b: Low parental self-efficacy for modifying infant feeding
Contrasting with the sense of parental responsibility, participants voiced a limited sense of control regarding weight-related behaviours. When (voluntarily) disclosing that their baby was overweight, participants went on to comment upon their child’s eating behaviour and openly acknowledged their child had a big appetite or was a hungry baby.
“…so she was just, ate more and more and more, the more you offer the more she will have” (P19).
Although parents did not use terminology such as responsive feeding, they distinguished feeding cues and described using strategies such distraction, the use of a dummy, and water to reduce the frequency of feeds. However, there was also a deep reluctance to implement any changes to their child’s milk diet beyond what they perceived their infant needed, regardless of any effect on weight.
“…I think if she is hungry then she is hungry … they obviously say that they need all your nutrients from milk and I’d feel, I’d feel bad sort of taking that away from her, but I think when she is weaning I think that’s when I would sort of think about what I am giving her” (P13).
Weaning was considered to be a more suitable window of opportunity to change feeding practices than milk-only diets. However, parents expressed anxieties and a lack of confidence associated with feeding their baby “correctly” and achieving the perceived social expectations of infant feeding.
“Yeah, we are a bit clueless to be honest” (P14).
“…I used to sit and cry over it when she’d gone to bed …” (P10).
Participants reported a lack of information and support around weaning from health professionals and described searching for information and reassurance that they were doing things correctly on the internet or talking to peers.
“Cos the one thing I would say that’s not out there is that you have no idea of what portion size to give your baby they, no one really tells you how much you should be giving a baby” (P6).