August 2011 // Volume 49 // Number 4 // Tools of the Trade // v49-4tt10
Review of Healthy, Happy Families
The number of obese children has nearly tripled in the past 30 years. Research has identified a clear connection between parental income, education, ethnicity, and the risk for obesity. Recent research demonstrates that parenting style may also impact the ability to establish healthy eating environments. This article reviews a program, currently being piloted, that integrates parenting and nutrition—Healthy, Happy Families.
Need for Integrated Parenting and Nutrition Programs
Over the past 30 years, there has been a dramatic increase in childhood obesity. Trends show that there is an increase in the number of overweight children that occurs between preschool (ages 2-5) up to 26% and grade school (ages 6-11) an estimated 37% (Rhee, 2008). As a result, many Extension faculty are concerned about the importance of the effects of environmental factors on dietary behavior.
Factors related to obesity in childhood include parental educational level, income, ethnicity, and childhood behavioral problems (Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006). More malleable factors within control of parents and Extension agents are parents' behaviors, parenting styles (e.g., authoritarian, authoritative, permissive) and family functioning (e.g., how the family manages daily routines, fulfills parenting roles, and communicates) (Rhee, 2008). Previous literature has supported authoritative parenting styles in addressing childhood obesity issues. Authoritative parents are more likely to demonstrate reasonable control, nurturance, limit setting, and communicate clearly with their children (Ontai, Williams, Lamp, & Smith, 2007).
Parents are children's primary teachers of food and eating habits (Nicklas et al., 2001). Eating patterns can be fully developed by age three, so parents need research-based information on nutrition and parenting when their children approach toddlerhood. Barriers preventing parents from helping their children establish these environments include lack of knowledge, training, and experience (Birkett, Johnson, Thompson, & Oberg, 2004).
There is a need for a client-centered program that addresses both nutrition and parenting in the same program. Client-centered programs focus on recognizing clients' issues and helping them explore their feelings and attitudes related to their problem areas (in this case establishing healthy eating habits and limits within their family) (Rogers, 1965). There is a gap in the literature relating parenting styles to childhood obesity and eating behaviors (Rhee et al., 2006). The purposes of this article are to review one such program—Healthy, Happy Families—and encourage Extension faculty to teach integrated parenting and nutrition education programs.
Healthy, Happy Families is an Extension program created by Lenna Ontai at the University of California Davis. The Healthy, Happy Families team conducted preliminary evaluations with the program and is analyzing the results for publication. Healthy, Happy Families has two goals: to increase the overall health of children through parent support and to better understand the effects of parent education in a nutrition program. The program delivers information to participants via mini-lessons and workshops. Both are designed to educate parents about nutrition or parenting.
The first method focuses on nutrition but not parenting and includes eight mini-lessons that are 15-20 minutes each. Each lesson provides parents information about parenting and child development. Ontai designed the mini-lessons to be presented with nutrition education programs like the Expanded Food and Nutrition Education Program (EFNEP), a program designed to help individuals with limited resources attain knowledge, skills, and attitudes necessary for nutritional diets and well being <http://www.csrees.usda.gov/nea/food/efnep/efnep.html>.
The second method includes 1-hour, stand-alone workshops focused on parenting, child development, and child feeding but not nutrition. Workshops are more experiential in nature and include hands-on activities that highlight the theme of the lesson. One activity focuses on a parenting skill; the other focuses on making use of that parenting skill in daily feeding. Ontai recently completed pilot testing and evaluation with this method, and is finalizing the results for peer review.
Participant evaluation included the Parenting Dimensions Inventory (PDI) (Slater & Power, 1987), the Nutrition Attitude Questionnaire (NEAT), and a Positive Parenting subscale (Alabama Parenting Survey).
The only program evaluation study included 236 mothers of various ethnicities—79% Hispanic (77% were Spanish speaking), 17% white, 2% black, and 3% other. Fourteen counties were randomly assigned to one of three experimental groups: 1) no-treatment control group (n = 111); 2) Tip Sheet Only (n = 59); and 3) Tip Sheet and Educator Materials (n = 66). Participants in the Tip Sheet Only group received only parenting tool handouts. Participants in the Tip Sheet and Educator Materials group received the same parenting tool handouts plus a reinforcing activity. Mini-lesson participants completed self-report, pre- and post-test surveys. Some participants participated in a follow-up 1 month later. Workshop participants were asked to complete assessments by describing their child before and after the mini-lessons.
Preliminary analyses demonstrated that the Tip Sheet Only and the Tip Sheet and Educator Materials groups did not differ in level or degree of change on any of the measures and were therefore combined to form one group. After the intervention, parents in the intervention groups showed greater improvement in nutrition attitudes regarding Limit Setting, Introducing New Foods, and Having Family Meals than did the no-treatment control group. The intervention group increased their Consistency in Parenting as well as improved in Following through with Discipline compared to the comparison group. There was no difference in level or degree of change on any of the measures from pre- to post-test in the two intervention groups.
One month later via follow-up phone calls, 82% of parents reported eating together more often as a family after receiving Healthy, Happy Families materials, and 88% reported using their tip sheets at home. All the parents in the intervention groups reported that Healthy, Happy Families would be useful to other parents.
Although Healthy, Happy Families has been empirically studied only once with 236 mothers, the curriculum shows strengths. The curriculum is research based and used valid measures to assess the amount of participant change. A pilot study showed improvement in the goal of increasing the overall health of children through parent support as seen in attitudinal changes about limit setting and bringing new foods to the family. The program also showed improvement in better understanding the effects of parent education in a nutrition program through participants' reporting increased consistency in parenting, as well as improved follow through with discipline. Further research is needed to test its effectiveness with experimental and wait-list control groups, more diverse participants, and larger samples of mothers and fathers.
Birkett, D., Johnson, D., Thompson, J., & Oberg, D. (2004). Reaching low-income families: Focus group results provide direction for a behavioral approach to WIC services. Journal of the American Dietetic Association, 104(8), 1277-1280.
Nicklas, T., Baranowski, T., Baranowski, J., Cullen, K., Rittenberry, L., & Olvera, N. (2001). Family and child-care provider influences on preschool children's fruit, juice, and vegetable consumption. Nutrition Reviews, 59(7), 224.
Ontai, L., Williams, S., Lamp, C., & Smith, D. (2007). An integrative approach to addressing childhood overweight: Inclusion of parenting information in nutrition education programs. Journal of Extension [On-line], 45(3) Article 3FEA2. Available at http://www.joe.org/joe/2007june/a2.php
Rhee, K. (2008). Childhood overweight and the relationship between parent behaviors, parenting style, and family functioning. Annals of the American Academy of Political and Social Science, 615, 12-37.
Rhee, K., Lumeng, J., Appugliese, D., Kaciroti, N., & Bradley, R. (2006). Parenting styles and overweight status in first grade. Pediatrics, 117(6), 2047-2054.
Rogers, C. (1965). Client-centered therapy: Its current practice, implications and theory. Boston, MA: Houghton Mifflin.
Slater, M.A., & Power, T.G. (1987). Multidimensional assessment of parenting in single-parent families. In J. P. Vincent (Ed.), Advances in family interaction, assessment, and theory, Vol. 4 (pp. 197-228). Greenwich, CT: JAI.