An Apple a Day: A Parental Education Program to Reduce Childhood Obesity

by Trenton Goff, M.S., Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Review and Summary of:  Gomes AI, Barros L, Pereira AI, Roberto MS. Effectiveness of a parental school-based intervention to improve young children's eating patterns: a pilot study. Public Health Nutr. 2018 Sep;21(13):2485-2496.

The percentage of children and adults who are obese continue to climb in the United States and worldwide.  The World Health Organization (WHO) estimates that obesity has nearly tripled since 1975, with more than 650 million adults considered obese and 1.9 billion adults overweight in 2016.  Moreover, 38 million children under the age of 5 were considered obese in 2019.¹ As a student pharmacist, I am interested in weight management because so many chronic illnesses are the result of obesity.  There are diet pills and weight loss drugs aplenty, but medications are generally NOT the healthiest options.² While obesity may be a physical sign of disease, the real problems lie in the harmful metabolic changes that develop after weight gain, and children are not immune.  Young children depend on their parents, or guardians, to provide them with daily meals and nutrition.  A recent study conducted in Portugal caught my eye because the researchers created a school-based parental education program to improve children’s eating patterns and behaviors.³ Targeting and educating individuals, adults and children, before the onset of chronic complications, is the best chance we have at combating the obesity epidemic.  Giving parents the tools necessary to make healthy dietary choices for their children would be a step in the right direction.  Developing healthy eating habits early in life can have an impact on the rest of a child’s life.

In this longitudinal cohort study, parents of children 3-to 6-year-old who attended a public kindergarten were assigned to one of three groups: Complete Intervention Group (CIG), Minimal Intervention Group (MIG), and a Control Group (CG).  In the CIG, the primary instructional intervention was the “Red Apple” curriculum, which consisted of 90-minute educational sessions every other week for a total of four sessions.  These sessions focused on the young child’s growth and development, nutrition guidelines, and strategies for parents to promote healthy eating behaviors in their children.  In addition to the in-person instruction, the CIG was also given “homework assignments” to practice what was learned and a weekly newsletter was distributed to parents.  The MIG was provided with only one nutritional counseling session, one “homework assignment”, and one follow-up newsletter.  The CG was given no nutritional or behavioral instruction. All parents completed a series of evaluations and surveys at baseline.  Parents were evaluated on their self-efficacy in promoting healthy food intake, their ability to rate their child’s current weight against CDC standards, their nutritional knowledge, and recognize the healthy and unhealthy eating habits of their children.  The initial evaluations were meant to provide a baseline for follow-up analysis upon completion of the intervention.

Immediately following, 6-months, and 1-year after the educational program, parents in the three groups completed the same surveys they were given at baseline.  Nutritional knowledge and parent self-efficacy improved in both the CIG and MIG at the conclusion of the intervention and these improvements persisted 1 year later.  Conversely, nutritional knowledge and parental self-efficacy actually decreased in the CG during the same assessment periods.  Healthy food intake also increased in the CIG at the completion of the intervention, but the improvement did not persist at the six-month and one-year follow-up assessments.

This study, and the “Red Apple” curriculum, was very comprehensive.  The authors provide a detailed account of their intervention and results and clearly discuss the limitations and barriers that were observed in their study.  Participant recruitment and attrition, for instance, were key issues that resulted in a smaller than expected sample size in the intervention group.  The curriculum was well developed and could be used in other settings.  The curriculum included group discussions after each session and at-home assignments both of which support long-term knowledge retention.

From an instructional design perspective, I noticed a few key issues with the “Red Apple” program.  An outline of the curriculum was provided in the article.  Each session had a theme and particular objectives to cover, which is important, but the objectives reflect the intent of the instructor.  Objectives should state what the learner is expected to do and this allows the creation of assessment to measure their learning.  For example, “encourage parents to implement dietary and behavior changes according to age-appropriate strategies,” could be changed to “Parents will be able to verbalize two strategies to implement healthy dietary changes in their child.”  This example provides a clearer expectation of what the learner is expected to do.

The “Red Apple” program is a well-designed curriculum for universal application, but it does not assess the learner’s prior knowledge to tailor the curriculum.  The authors discuss this issue of individualization by stating, “…the general objectives of the sessions may not fully match the needs of all participants.” Perhaps a better approach for this program would be to use the pre-intervention surveys to modify the content and learning activities.  In this way, the program can be customized to meet the individual learner’s needs.

In any educational program, it’s important to gain the learner’s attention.  In one study conducted in England, nearly 80% of parents of obese/overweight children did not perceive their child’s weight to be a health risk.⁴ The “Red Apple” curriculum taught parents how to calculate their child’s BMI and how to interpret the results, but there may not have been enough attention given to the long-term health risks associated with elevated BMI.  Gaining attention by discussing the health concerns associated with obesity in children may increase the learner’s motivation to adopt behavior change.

While the “Red Apple” program was an intensive and comprehensive course in nutrition, healthy eating, and behavior modification for parents of young children, unfortunately, improvements in dietary habits did not persist long-term.  Thus, to have a sustained impact, we’ll need to consider additional ways of reinforcing learning and the development of healthy habits over time.  Educating parents on how to improve their children’s health is a noble endeavor.  Adequate instruction on diet and health in children could improve the health of an entire generation.  Children have the most to gain from developing healthy lifestyles – and the most to lose from unhealthy ones. 

References

1. World Health Organization. Obesity and Overweight. Key Facts [Internet]. Geneva, Switzerland.: World Health Organization. 2020 April [cited 2020 Nov 2].
2. Grundlingh J, Dargan PI, El-Zanfaly M, Wood DM. 2,4-dinitrophenol (DNP): a weight loss agent with significant acute toxicity and risk of death. J Med Toxicol. 2011 Sep;7(3):205-12.
3. Gomes AI, Barros L, Pereira AI, Roberto MS. Effectiveness of a parental school-based intervention to improve young children's eating patterns: a pilot study. Public Health Nutr. 2018 Sep;21(13):2485-2496.
4. Park MH, Falconer CL, Saxena S, et al. Perceptions of health risk among parents of overweight children: a cross-sectional study within a cohort. Prev Med. 2013 Jul;57(1):55-9.