Evaluation of a Family Education Program: For Overweight Children and Adolescents

ABSTRACT

Increased child and youth overweight and obesity, as well as significant health effects associated with obesity, have led to recommendations for multicomponent prevention programs. In 2005 to 2006, the former Calgary Health Region (now Alberta Health Services) had an opportunity to develop, deliver, and evaluate an early intervention service for families with children at risk for overweight and obesity. Using available evidence and with access to key advisors, core team members developed and implemented a curriculum for a family-focused, behaviour-based education program entitled Make It HAPPEN. A health-centred approach based on the physical, mental, and social well-being of the whole child was used. Physical, selfesteem, and quality-of-life measures were included in program evaluation. After the program, statistically significant reductions in body mass index (BMI) percentile and z-score were seen, as were increases in quality of life. Self-esteem improved significantly for children with initial BMI percentiles of at least 98. Evaluation results indicate that an effective program can be developed with limited resources to meet best practice needs. Potentially, such programs could be integrated into other community obesity prevention programs or within primary health services models.

(Can J Diet Pract Res. 2011;72:191-196)

(DOI: 10.3148/72.4.2011.191)

R�SUM�

En raison de la hausse de la pr�valence d'exc�s de poids et d'ob�sit� chez les enfants et les jeunes et des effets significatifs sur la sant� associ�s � l'ob�sit�, il est recommand� de mettre en place des programmes de pr�vention � composantes multiples. De 2005 � 2006, l'ancienne Calgary Health Region (qui est devenue l'Alberta Health Services) a eu l'occasion de mettre au point, d'offrir et d'�valuer des services d'intervention pr�coce destin�s aux familles d'enfants � risque d'exc�s de poids et d'ob�sit�. Gr�ce aux donn�es probantes disponibles et � l'acc�s � des conseillers cl�s, les principaux membres de l'�quipe ont mis au point et implant� le curriculum d'un programme d'�ducation ax� sur la famille et le comportement qui s'intitule Make It HAPPEN. Une approche ax�e sur la sant� et bas�e sur le bien-�tre physique, mental et social de l'enfant a �t� employ�e. Des mesures du physique, de l'estime de soi et de la qualit� de vie ont �t� incluses dans l'�valuation du programme. Apr�s la mise en place du programme, une r�duction statistiquement significative des percentiles de l'indice de masse corporelle (IMC) et de l'�cart r�duit a �t� observ�e, de m�me qu'une hausse de la qualit� de vie. L'estime de soi s'est am�lior�e de mani�re significative chez les enfants dont le percentile de l'IMC initial �tait d'au moins 98. Les r�sultats de l'�valuation indiquent qu'un programme efficace peut �tre mis au point avec des ressources limit�es tout en satisfaisant aux meilleures pratiques. De tels programmes pourraient �tre int�gr�s � d'autres programmes communautaires de pr�vention de l'ob�sit� ou � des mod�les de services de sant� primaire.

(Rev can prat rech di�t�t. 2011;72:191-196)

(DOI: 10.3148/72.4.2011.191)

INTRODUCTION

In Canada, the prevalence of obesity, as measured by body mass index (BMI) among adults and children, has increased significantly in the past 30 to 40 years (1-3). Once children are obese they are likely to become overweight adolescents and adults (4,5). Adult obesity is associated with diabetes, kidney disease, orthopedic problems, and heart disease (4). Obese children experience more type 2 diabetes, elevated blood lipids, hypertension, and cardiac problems (3,6,7). The impact of obesity on quality of life and mental health is widely reported, and an inverse relationship exists between obesity and self-esteem in childhood (8). Wang et al. have reported that obese children are at risk for developing low self-esteem and may be affected by poor mental health later in life (9).

Because of the significant health effects associated with childhood obesity, coordinated, multicomponent interventions aimed at prevention are recommended (2,10,11). Evidence supports a health-centred (rather than weight-centred) approach, which focuses on the whole child, physically, mentally, and socially (12). Key components of successful overweight intervention programs include the involvement of both parents and children (2,4,10-13), engagement in physical activity (2,10,12), and behaviour modification-focused group intervention (2,4,10,11,14). Teaching parents the skills to support child behaviour change mobilizes the family to address eating and activity changes as a unit; this creates a supportive home and family environment (15). Intervention programs should address self-esteem, the potential for weight prejudice, and the importance of media literacy (12), as well as reduced sedentary behaviours and screen time, increased active living, and healthy food choices (2,4,10,11). Understanding appropriate parental approaches for monitoring child growth and development, establishing realistic expectations for a child, supportive parenting, and the feeding and activity relationships are key curriculum content areas for parents (12,16-19).

PURPOSE

In 2005 to 2006, the former Calgary Health Region (now Alberta Health Services) had an opportunity to develop and deliver a curriculum for early intervention services to families with overweight children. The curriculum was based on key components of the available evidence. A family behaviour-based group education program entitled Make It HAPPEN (MIH) was developed. The initial MIH initiative included funding for evaluation to ensure that the program was meeting its objectives and to improve it.

We report characteristics of the MIH population and present quantitative outcomes gathered during program evaluation. Evaluation objectives were to summarize characteristics of the population served by MIH programs and to explore program outcomes, including follow-up results.

METHODS

Program development and modification

Through the use of available evidence, and with guidance from an advisory committee, principles were identified and a program was developed (Table 1). Committee members included child life specialists, nurses, a psychologist, physicians, parenting experts, and kinesiology consultants. Core team members developed and implemented a curriculum. The program goal was to encourage children and families to establish healthy eating habits, to adopt a healthy lifestyle through physical activity, and to develop and maintain healthy self-esteem.

Initially the program was offered over eight weeks, but later it was offered over 12 weeks because of parent feedback and the available literature (2,11,20). The three-month duration was further supported by consultation with professionals experienced in working with youth, as well as with a youth focus group. Both the consultation with professionals and the youth focus group informed planning for the program for 13- to 15-year-olds. Table 2 highlights these program changes over time.

Study participants

Participants were self-referred or referred by family physicians, pediatricians, or other health professionals. Eligible children were aged six to 12 years (extended to 15 years in 2007), were at or above the 85th BMI percentile for age and sex, and were physically able to participate in activities and classroom sessions. At least one parent was required to participate with the child in this no-fee group program. Asking families who missed three classes to leave the program established the importance of attendance. In addition, some families dropped out in the first or second week. Thirty-four courses were completed by January 2008 (the date of the second evaluation); 271 children and parents (78% of 345 registered) completed the program.

Data collection

Data were collected when participants entered the program, during regular program activities, when participants completed the program, and at six and 12 months after program completion. Outcomes of interest included self-esteem, as measured by the Piers-Harris Children's Self-Concept Scale, second edition (Piers-Harris 2) (21), and quality of life for parent and child, as measured by the Pediatric Quality of Life Inventory (PedsQL) (22). Height was measured with a wall-mounted stadiometer (SECA Model 240). Weight was measured with a digital scale (SECA), and a blood pressure screen was completed using an oscillometric device (GE Dinamap Pro 100).

Program content

Table 2 summarizes curriculum and format changes to the program, as well as collected evaluation data. Each group's session series was preceded by a group orientation and intake measurement by program staff with backgrounds in nursing, dietetics, and child life. Self-esteem scores were screened by the MIH advisory psychologist, who followed up with staff about any children whose self-esteem was of concern. Families then attended one of three possible community centres located in the northeast, southwest, and east central areas of Calgary. Weekly sessions lasted two hours, with the first hour dedicated to classroom instruction for the parent and the child together and the second hour dedicated to separate parent and child activities. During the second hour, the children's activity program focused on fun group physical activities and was conducted by certified activity staff from partnering community organizations. Parents either continued with classroom instruction (focusing on supportive parenting, behaviour change, etc.) or, occasionally, took part in physical activities with their children. Classroom instruction was presented by MIH facilitators, all of whom received certification in small-group facilitation and training in motivational interviewing as part of professional development.

Parents received written resources to support their learning about healthy eating and active living. Children received resources and weekly written exercises to encourage their skill development. An opportunity was provided at the next class for questions and follow-up learning with these materials. Formal evaluation of the benefit of these resources was not completed. Classroom topics included healthy lifestyles, goal setting, nutrition and familiarity with Canada's Food Guide (23), portion sizes, understanding how habits are developed and changed, recognizing media influences, interpreting and using food labels, self-esteem, healthy growth, and integrating active living into daily routines. (A copy of curriculum key messages for each MIH class is available from the authors.)

Information provided clearly stated that the program was not focused on dieting or weight loss, but rather on healthy eating and active living. When facilitators were asked clinical or therapeutic questions, they were required to emphasize general messages about healthy eating and healthy growth and to refer participants to dietitian facilitators for individual follow-up care, if this was required.

Post-program questionnaires and measures

During the final two weeks of the program, families completed post-program questionnaires and measures. Following program completion, families were invited to family fun nights every four to six months and received newsletters. These nights and newsletters provided an opportunity for sharing information on resources and for supporting families in lifestyle change and continued learning. Children and parents also completed follow-up questionnaires and measures.

All pre- and post-program questionnaire data were analyzed using SPSS software (version 15.0, SPSS Inc., Chicago, IL, 2007). Descriptive statistics, including means, ranges, counts, and frequencies, were used to describe the MIH population. Data for each continuous outcome measure were analyzed for normality using the Shapiro-Wilk test. Body mass index percentile by age and sex (W=0.639, p<0.000) and BMI z-scores (W=0.980, p<0.0003) were not normally distributed. Data from other outcome measures were normally distributed (Piers-Harris 2, W=0.994, p=0.15; PedsQL, W=0.994, p=0.35). Paired t -tests (for normally distributed data) and the Wilcoxon signed-rank test (for nonparametric data) were used to explore results of MIH participants' pre- and post-program scores. Participants' enrolment data were compared with their program completion data. For these analyses, two-tailed analyses were used and the significance level was set at 0.05.

RESULTS

Descriptive data on program participants appear in Table 3. Body mass index percentile (z=-3.42, p<0.001) and BMI zscores (z=-6.329, p<0.0001) were significantly reduced from the beginning to the end of the program (Table 4). Self-esteem was maintained for the group overall (t=-1.146, p=0.255). A subgroup analysis of those with a BMI percentile below 98 and those with a percentile above 98 on enrolment indicated no significant baseline difference in self-esteem (t=-0.796, p=0.428). However, by the end of the program, self-esteem increased significantly for children with a BMI at or above the 98th percentile (t=-2.25, p=0.029). Because of a lack of funding for a psychologist who could interpret the results, the Piers-Harris 2 was discontinued following the second evaluation report (March 2008). Quality-of-life measures increased significantly from onset to completion of the program with parent-completed measures (t=-5.78, p<0.0001, 95% confidence interval [CI]=-9.13, -4.48) and child-completed measures (t=-3.669, p<0.0001, 95% CI=-5.98, -1.79).

Blood-pressure (BP) screens were administered and reviewed against pediatric standards (24), and results suggested that up to 50% of children could be prehypertensive or hypertensive. With parental consent, results of the BP screen, as well as BMI data, were submitted to the child's family physician for follow-up evaluation.

DISCUSSION

An effective program can be developed with limited resources, and meet best practice needs. While this MIH initiative was targeted at families with overweight and obese children, the content is universal and could be foundational for those at risk for diabetes, hypertension, or heart disease. The program addressed lifestyle intervention recommendations (4) and contributed to evidence that community-based interventions can be effective without negative impacts on psychosocial well-being (2). The program also supported primary health care (11) integrated into and delivered with existing community services. Informal feedback from community agencies indicated enthusiasm about partnering with MIH, and agency staff reported positive engagement with participating children. Historically, such a program is uncommon because it falls between population health, which traditionally does not provide direct service, and clinical services, for which a comorbidity is required. The current program and partnership therefore are unique.

Quality of life

Results for children who returned for postprogram measures indicated significant improvement in parents' and children's perception of quality of life, as well as in weight status. Other family-based group programs have shown weight reduction. For example, a group treatment program in Finland stressed health-promoting lifestyle changes for parents and children separately. The investigators reported a significant reduction in BMI and weight for height in comparison with individual counselling (25). Their reductions in BMI and BMI z-score were similar to those seen in our study, a finding that supports our group approach. A report of the Mind, Exercise, Nutrition, Do it (MEND) wait-list control trial with children whose weight was above the 98th BMI percentile also revealed significant BMI zscore reductions at program end (26), another finding that supports this type of intervention.

Self-esteem scores

No significant difference was seen in self-esteem scores for the groups at or above the 98th BMI percentile and the groups below the 98th percentile at program entry, and average selfesteem scores revealed no significant change for the combined group of participants at program end. However, children with an initial BMI percentile of at least 98 showed significantly improved self-esteem, a finding similar to that reported in Sacher's intervention program for children whose weight was at or above the 98th BMI percentile (26).

Study limitations

Results for this program evaluation must be interpreted with caution. This was not a research study but a real-life program that did not include a control group. Unfortunately, only 78% of those in the group that began the MIH program completed it. While maintaining the same group over time and following up with all initial participants are ideal, occasionally people move, stop attending sessions, or (in our case) are asked to drop out because of poor attendance. In addition, to ensure integrity in program evaluation, ideally nothing should change over time. However, real-life programs do change because of experience, evaluation, feedback from partners, staff, and families, and the literature. Flynn et al. recommend that processes for program design and delivery "allow continual incorporation of new elements" associated with improving effectiveness (2, p. 55). The MIH program is no exception.

In addition, we had limited six-month post-program data. Only 61 children (23% of those eligible) returned for those measurements, and the initial preprogram data from these 61 children are different from the overall MIH participant population. Further work is required to improve our follow-up evaluation of participants and data collection.

RELEVANCE TO PRACTICE

Potentially, programs similar in structure, content, and delivery could be further integrated into a community network, such as a primary care model, that supports primary health services. In addition, possibly the existing curriculum and trained facilitators could be used to build capacity in community agencies. The relatively low cost for positive outcomes (approximately $500 per family, including administrative overhead, for groups of 10) is helpful, particularly in view of the cost of individual counselling and the potential long-term costs of obesity (27). Encouraging evidence exists that children who achieve a healthy weight are able to lower their risk factors for cardiac disease (high BP, cholesterol, and insulin levels) (28). These types of initiatives have the potential to foster supportive environments for children and families in their own neighbourhoods and community centres. We believe this MIH program, or programs similar in structure, content, and delivery, can be one part of a multicomponent intervention that may contribute to reduced obesity in children and youth.

Acknowledgements

We gratefully acknowledge members of the Make It HAPPEN Advisory Committee, many of whom fulfilled several roles and contributed much time and energy. These include the following from pediatric endocrinology: Rebecca Trussell, MD, FRCPC; Mary Moreau, RN; Eileen Pyra, RN; Lesley McCoy, RD; Liz Young, RN, Trym Gym, University of Calgary. Staff members who also contributed to development and delivery of curriculum were Kristina Campbell, MSc, RD; Tina deFreitas, RN; Kristyn Hall, MSc, RD; Mary Waterman, BA, Child Life; Tara Porteous, RD. We also wish to acknowledge the support of many colleagues in mental health, child life, parenting, eating disorders, and nutrition and active living. Special appreciation is extended to our community partners, Southland and Village Square Leisure Centres of the City of Calgary and TRICO Centre for Family Wellness. Appreciation also goes to Tanis Fenton, RD, PhD, and Carol Fenton for assistance in data collection and interpretation for the final data set. Finally, we thank the Calgary Health Trust and Alberta Children's Hospital for providing initial funding toward program planning and service access.

[Sidebar]

Families completed post-program questionnaires.

[Reference]

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[Author Affiliation]

KAY WATSON-JARVIS, RD, MNS, FDC, CYNE JOHNSTON, PhD, Alberta Health Services, Calgary, AB;

CAMILLIA CLARK, PhD, R Psych, Department of Pediatrics, University of Calgary, and Alberta Health Services, Calgary, AB