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An integrated targeted intervention to prevent obesity in infants born into a diverse community.

Julie Greenway, Lynne Thompson and Sally Cornfield explore whether a nutrition and healthy-living course for mothers could influence three misleading beliefs that can lead to childhood obesity.

Authors

Julie Greenway* PhD, MA, BS,c RGN, RHV, health visitor team leader, Black Country Partnership Foundation Trust 
Lynne Thompson MSc BSc NNEB, senior health improvement practitioner at the Dudley Office of Public Health
Sally Cornfield MSc, BSc public health manager (children) at the Dudley Office of Public Health
*Correspondence to: jgreenway1@nhs.net

Abstract

The project aimed to establish whether attending a six-week ‘Let’s Get Kids Fit’ course changed mothers’ views on three key beliefs, which previous research suggests need to be changed in order to address the issue of childhood obesity. These beliefs are: that babies cannot be overfed, that crying always signals hunger and that growth is determined by genes rather than nutrition.

The course was delivered by health visitors and nursery nurses in local children’s centres. It covered basic nutrition, practical cooking skills and age-appropriate physical activity. Mothers were recruited from the Healthy Pregnancy Support Service (HPSS) with a Body Mass Index (BMI) above 26. Questionnaires and focus groups provided qualitative data on mothers’ views.

Results showed that the course was effective in changing mothers’ views, particularly around the belief that babies cannot be overfed. The course may therefore be effective in preventing obesity in infants who are at risk because of their mothers high BMI.

Key words: Childhood obesity, nutrition, physical activity, cooking skills, qualitative research.


Introduction

Obesity is one of the most serious public health challenges we face. In the Call to action on obesity (Department of Health (DH), 2011) the government set out an ambition to achieve a sustained downward trend in the level of excess weight prevalence in children by 2020.

Data submitted by the National Child Measurement Programme (NCMP) shows that 22.6% reception-aged children in England are overweight or obese, increasing to 34.2% in year 6 (NHS Digital, 2017). Obesity is an issue of concern across the whole UK, with 27.1% of reception-aged children in Wales reported to be overweight or obese (Public Health Wales, 2018), 22.9% of those in Scotland (Information Services Division Scotland, 2017), and 22.2% in Northern Ireland (Public Health Intelligence Unit, 2016).

Obesity is strongly correlated with socioeconomic status, with highest levels in the lowest socioeconomic groups, and this inequalities gap appears to be widening (Public Health England (PHE), 2014).

Being overweight increases the risk of many physiological and psychological complications in childhood. Children may have joint problems, breathing difficulties, high cholesterol and blood pressure (WHO, 2014) as well as low self-esteem (Rees et al, 2009) and emotional and behavioural problems (Griffiths et al, 2011).

Obese children have an increased risk of becoming obese adults with the associated risks of ill-health and premature mortality (Reilly and Kelly, 2011). This harms communities, as a less physically active population leads to reduced productivity, more sickness absence and an increased demand on social care services. In 2015 it was estimated that obesity costs the NHS £6.1bn annually, but the costs to the wider economy were estimated at around £27bn (PHE, 2015).

The need for effective early intervention

Infancy and early childhood are important life stages for the prevention of obesity in later childhood and adult life. Evidence points to a need for effective early intervention, which is achievable and risk factors for childhood obesity, such as parental weight (Sridhar et al, 2014) and rapid weight gain in infancy (Monteiro and Victoria, 2005), can be identified during infancy.

Mary Rudolf has highlighted the need for effective interventions in the early years as food preferences and activity levels are influenced by parenting and the home environment in the first years of life (Rudolf, 2009). It would seem that obesity prevention is best targeted at parents in these early years.

Within the Healthy Child Programme (DH, 2009), clear actions have been identified for health visitors to support delivery of the Healthy Weight/Healthy Nutrition High Impact Area. These focus on early identification and prevention of obesity in children, and include encouraging good maternal diet, breastfeeding, introducing solid food at six months of age, a healthy family diet, limiting snacking on foods that are high in fat, sugar or salt, and increasing activity levels in line with current guidelines (PHE, 2016).

Dudley has higher than average levels of childhood obesity with 27.1% of reception children overweight or obese, and 39.1% if those in year 6 (NHS Digital, 2017). Black Country Partnership NHS Foundation Trust (BCPFT) and Dudley Office of Public Health worked together – partnership working has been identified as a key to successful outcomes in tackling obesity (PHE, 2015) – to develop the ‘Let’s Get Kids Fit’ programme. The aim was to produce an effective multi-component programme, incorporating the actions identified above, in order to prevent obesity in infants deemed to be at risk due to their mothers’ increased BMI.

Study aim

The aim of the study was to establish whether attending a six-week ‘Let’s Get Kids Fit’ course changed mothers’ attitudes around three key beliefs, which previous research (Lakshman et al, 2011) has suggested need to be changed in order to successfully address the issue of childhood obesity.

These key beliefs are:

  • Babies cannot be overfed
  • Crying always signals hunger
  • Growth is determined by genes rather than nutrition.

The courses were led by a health visitor team leader and a senior health improvement practitioner, with support from health visitors and nursery nurses. They emphasised that they were referring to formula-fed babies, and not breastfed babies. This is because breastmilk is tailored specifically to the needs of the baby, and it is quite normal for breastfed babies to feed frequently.

Methods

The mothers recruited onto the course were referred by the midwifery team who had supported them on the HPSS Programme because their BMI measurement was greater than 26.

They were given letters of invitation to take part in the study along with participant information booklets. Those interested in finding out more were asked to return a participant reply form. These mothers were subsequently invited to attend an informal coffee morning where they could discuss the study further and ask any questions about the research project. Mothers who chose to participate in the study gave their written consent. The consent form also confirmed that that their participation was voluntary and that they were free to withdraw from the study at any time.

Focus groups and questionnaires were completed before and after participants attended the six-week ‘Let’s Get Kids Fit’ course, in order to see if there were any changes in mothers’ views around these key beliefs. 

A topic guide was used to ensure areas of key importance were covered. This included: mother’s views on sources of support and information around feeding their babies; the best time to tackle childhood obesity; factors influencing our size/shape; the meaning of growth charts; whether you can overfeed a baby on milk; and their responses when their baby cried. Before conducting the main study, a pilot focus group was conducted to ensure that this topic guide gave information relevant to the research aims.

Focus groups were audio-recorded, transcribed and analysed thematically using an interpretive approach.

The ‘Let’s Get Kids Fit’ course required participants to attend a one-and-a-half to two-hour session once a week for six weeks. Each was divided into 45 minutes theory, which covered basic nutrition, child development, and age-appropriate physical activity, and 45 minutes practical cooking using basic ingredients.

The sessions were highly visual and designed to be interactive. Written resources to consolidate learning from the sessions were bright, colourful and user friendly. On completion of the course participants received a Sports England ‘My first start to play’ bag containing a variety of toys to encourage play.

The sessions took place in Children’s Centres as they were equipped with the necessary facilities to run the course. Lesson plans and resources were developed for the six-week course. The content is detailed below in Table 1.

Table 1

 

Topic

Week 1

Overview of healthy nutrition

  • Healthy eating using the Eatwell guide
  • The five food groups – what each provides for our body
  • Cooking skills, hygiene and kitchen safety.

Week 2

Fats, sugar and salt

  • Information about fat, sugar and salt – how they may affect health
  • Hidden fats, sugars and salt
  • Different types of fat
  • How to make recipes healthier.

Week 3

Introduction to solid food

  • How and when to introduce solid food
  • Feeding cues
  • Preparing food for baby
  • Healthy Start.

Week 4

Food labels

  • Understanding food labels
  • Making informed food choices
  • Healthier snacks.

Week 5

Physical activity, role models, sleep and fussy eating

  • Current physical activity guidelines
  • Importance of positive role models
  • Importance of sleep for young children
  • Fussy eating.

Week 6

Development

  • Development in the first 12 months
  • Supporting development through play
  • ‘My first start to play’ bag.

 

 

Research Ethics Committee (REC Reference 15/EM/0339) and Local Trust Research Ethics approval was obtained prior to starting the research.

Findings

In all 17 mothers started the ‘Let’s Get Kids Fit’ course, and 13 completed it (76%). Mothers were aged between 22 and 41 years, with an average age of 29.9 years. They came from a range of socio-economic backgrounds. One mother was of white/black Caribbean background, while the rest were white British. Their babies were aged between 10 and 38 weeks, with an average age of 21 weeks.

While study numbers are small, the findings suggest an encouraging change in mothers’ attitudes regarding the three key beliefs between the beginning and end of the course.

Overfeeding on milk

The biggest change concerned the belief that babies cannot be overfed on milk. At the beginning of the course 47% mothers agreed with the statement, compared with only 8% at the end. Typical pre-course comments supporting this view were:

‘No – they will bring it up.’

‘They push it away.’

Crying always signals hunger

Most mothers in our study recognised that their babies had different cries for different reasons and, although it was not easy in the beginning, they soon learnt to recognise these cries. 76% of mothers disagreed that crying always signals hunger at the beginning, compared to 85% – showing a small positive change. Mothers reported going through a mental checklist such as ‘does he need changing?’, ‘Is he too hot, too cold, tired, hungry or bored?’.

Others shared their feelings of concern due to their lack of experience:

‘My natural response is to panic because he never cries, so I immediately think that there is something wrong. I get paranoid about anything… not got much experience.’

Size is determined by genes rather than nutrition

A positive change in attitude was noted here, with 35% of mothers believing that size is determined by genes rather than nutrition at the beginning of the course, compared to only 23% at the end:

‘I think genetics do play some part but not all because you can control what you put in your mouth.’

There was also acknowledgement that, while we should be in control of what we eat, cultural, social and lifestyle factors have a major impact. Some cultures have healthier diets than others:

 ‘Culture – some countries might have a rice and vegetables diet, but in our country it is fish and chips and bangers and mash.’

‘Social eating – when everybody is eating it’s hard not to.’

Stress and lack of sleep was reported to impact food choices, for example having more sugar when tired.

Key finding

A key finding was that, as a result of doing the course, mothers recognised the importance of healthy eating right from the start. By the end of the course, 100% of mothers disagreed with the statement that it was too early to start thinking about obesity, compared with 76% at the beginning.

Typical comments regarding the best time to tackle the problem of childhood obesity were:

‘From the beginning before it becomes a problem…’

‘I think it is from the very start…’

‘I know that now from coming here… I didn’t know before.’

Internet use and feeding support

With regards to obtaining support and information, the internet was cited as the key information source, with the reason being that it is always available.

YouTube was used to access visual demonstrations of how to bath a baby, or to find out why a baby might be crying. Other internet-based sources of support were Netmums and Mumsnet. Friends, family and health professionals such as midwives, health visitors, GPs and breastfeeding buddies were also mentioned as sources of support.

Focus groups highlighted issues around participants’ experiences of breastfeeding, with the general feeling being that there was not enough support immediately following the birth. The support they did receive depended on which staff were on duty and whether they delivered their baby during the hours that the breastfeeding support staff were available. Some participants did not feel that they were listened to or that their concerns were dismissed. This had a negative impact on their feeling towards breastfeeding. Members of the group became very emotional when talking about their experiences. Mothers also felt that once they had been discharged home there was more support available for breastfeeding mothers than for formula-fed babies, and this made them feel guilty for not breastfeeding.

There was mixed understanding and some confusion regarding the meaning of information on growth charts. One mother reported carrying out her own research to find out about them:

‘Shows that baby is gaining weight as they should be – aim to follow the line which is a guideline to see how they are developing.’

Another mother admitted to not knowing anything about them:

‘I haven’t got a clue what the line is in the red book.’

By the end of the course the participants had greater understanding of the purpose of growth charts in showing whether a baby was putting on too much weight, as well as showing that a baby was gaining enough weight.

Feedback from the course was positive, with mothers reporting that they liked the recipes and the cooking sessions. They found the handouts and information helpful. One mother commented that her thinking had changed as a result of doing the course, and she now saw the importance of trying to:

‘Make the right choices in terms of what you give your child as you are responsible for what you put into them – healthier choices…’

The programme encouraged them to do more cooking, gave them more confidence regarding foods they could offer their babies and increased awareness of the importance of cooking fresh foods.

One mother said:

‘I think as well it’s about the importance of making stuff from scratch. That’s the biggest thing I’ll take from the course… not that I didn’t think it was important before, but after all the things we did on food labels and salt and sugar and fat, that’s the better way to go, just so that you know what you are putting into your baby.’

The mothers felt that this type of group was really important from the socialising aspect, as becoming a new mum was a big change in their lives. They valued the opportunity to talk to other parents and share experiences. Some participants exchanged contact details at the end of the programme so that they could keep in touch.

Discussion

The course was effective in changing mother’s views. The largest effect was on their views about whether it is possible to overfeed a baby on milk. It is important that parents are given information about feeding cues to prevent overfeeding as ‘responsive feeding’ may be interpreted as the requirement to feed their baby each time they cry.

There was a positive change regarding the belief about size being determined by genes rather than nutrition. Participants recognised that the ready availability of calorie-rich foods impacted on their food choices, which supports the view that government should take action to change the environment in order to support individuals to changing their behaviour (DH, 2011).

The smallest change was around their views on crying always signalling hunger. This small change may be due to the fact that the average age of babies in the study was four months and mothers reported that they had learned to recognise their baby’s different cries over time. New parents may need support in distinguishing hunger from other causes of crying in order to avoid offering milk as the first response to calm a crying baby.

The course was effective in encouraging mothers to prepare home-cooked meals. For families on low incomes this may be important as it is often cheaper to cook from scratch rather than buying ready-prepared convenience foods. The rise in food prices has a greater impact on lower income households as they spend a greater proportion of their income on food. In 2015, the average household spent 11.1% of their income on food, whereas families in the lowest 20% spent 15.4% of their income on food (Department for Environment, Food and Rural Affairs, 2016).

Mothers reported that they were now reading food labels when doing their supermarket shopping as they now knew how to choose healthier options. The Childhood Obesity Plan (HM Government, 2016) supports clearer food labelling, such as the voluntary ‘traffic light’ labelling scheme, in order to help families make healthier food choices, while the Change4Life sugar smart app shows how much sugar is in popular food and drink.

Regarding growth charts, it is important that health professionals take time to fully explain these to parents; a number of mothers thought they were only used to give information about whether their child was putting on enough weight, and not if they were putting on too much weight. This is important as research shows that half of parents do not recognise that their child is overweight or obese (Lundahl et al, 2014) and if obesity is not recognised then it will not be addressed (PHE, 2015).

The benefits of encouraging active movement, such as tummy-time and active play sessions, and reducing sedentary behaviour, such as watching television, were discussed within the group. It is important that this message is given out from an early age as data shows that only one in ten children aged two to four years meet the Governments recommended guidelines of at least 180 minutes of physical activity spread throughout the day (Health and Social Care Information Centre, 2013).

Strengths and limitations of the research

Participants were recruited on an ‘opt-in’ basis from across Dudley and, although it is an area with ethnic diversity, the majority of those who opted into the study were white British mothers. Attempts need to be made to address other ethnic groups. A particular strength of the research was that the topic guide allowed participants to discuss issues that they perceived as important, such as a lack of support for breastfeeding mothers in the early days after birth, a general lack of support for formula-feeding mothers, and very few groups for mothers to attend postnatally.

Conclusion and recommendations

The causes of obesity are extremely complex, encompassing biology and behaviour, and set within a cultural, environmental and social framework (Butland et al, 2007). Current government policy to tackle obesity sets out a ‘whole systems’ approach, as sustained changes to individuals’ behaviour will require multiple actions across all parts of the system, including changes to the food, physical activity and social environment.

It is important to continue to take action on obesity as this can lead to reduced health inequalities, greater social cohesion, stronger local economy, reduced demand on health and social care services, better quality of life, less discrimination and bullying, fewer people with long-term conditions and an improved local environment (PHE, 2015).

The ‘Let’s Get Kids Fit’ course was shown to be effective in changing attitudes regarding three key beliefs. It was also successful in encouraging mothers to cook freshly prepared foods rather than use convenience foods, and to look carefully at food labels in order to choose healthier options.

As a result of these findings, and the fact that mothers expressed a need for more postnatal groups for parents to offer support with both breast and formula feeding, it is now planned to roll out the ‘Let’s Get Kids Fit’ course to all first-time parents in Dudley in order to help reduce levels of childhood obesity.

BCPFT and Dudley Office of Public Health are also continuing to work together to implement a local weight management pathway in line with NICE guidance recommendations (NICE, 2013).

Acknowledgements

The authors would like to thank BCPFT nursery nurses and health visitors for their help with running the ‘Let’s Get Kids Fit’ courses.

 

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