Sjunnestrand et al. BMC Public Health(2024) 24:1695
https://doi.org/10.1186/s12889-024-19195-1

BMC Public HealthOpen Access

RESEARCH“A balancing act”: parents’ longitudinal
perspectives of weight-related discussions
with their children following obesity
treatment
My Sjunnestrand1*, Nicklas Neuman1, Kajsa Järvholm2, Anna Ek3, Karin Nordin3, Ximena Ramos Salas4, Karin Eli5 andPaulina Nowicka1
Abstract
Weight-related discussions during childhood may have long-lasting effects on children’s body image and wellbeing. However, little is known about how parents frame these discussions with children who have undergone
treatment for obesity. Our study aimed to explore how parents perceive weight-related discussions, several years
after their children started obesity treatment. This qualitative study is part of the 4-year follow-up of the More andLess study, a randomized controlled trial examining the effectiveness of a parental support program as part ofobesity treatment for preschool-aged children in Stockholm, Sweden. Semi-structured interviews were conductedwith 33 parents (79% mothers, 48% with a university degree, 47% with foreign background) of 33 children (meanage 9.3 years (SD 0.7), 46% girls), transcribed and analyzed using realist informed thematic analysis. Three main
themes, encompassing three subthemes were developed. Under the first theme, Parental attitudes and concerns,
parents emphasized the importance of discussing weight and health behaviors with their children, yet foundit challenging due to uncertainties about how to approach it safely and sensitively. A few parents found theconversation manageable, citing their own experiences of having overweight or their style of communication withthe child as facilitating the conversation. Under the second theme, The significance of time and context, parents
said they engaged in weight-related conversations with their children more frequently as the children matured,
driven by their growing self-awareness. Parents also expressed how contextual factors, such as gender and thepresence of others, shaped conversations. Parents perceived boys as more resilient, thus exposing them to morenegative weight talk. The third theme, Navigating weight stigma, revealed how parents employed strategies suchas nurturing their children’s self-confidence, downplaying the significance of appearance and emphasizing healthwhen discussing weight to shield their children from weight stigma. Taken together, we found that many parents
need support to navigate weight-related discussions. Addressing weight stigma is part of children’s obesity
management process, as children may be bullied, teased, or experience discrimination in different social settings.

*Correspondence:My Sjunnestrand
my.sjunnestrand@ikv.uu.se
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not includedin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you willneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
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Sjunnestrand et al. BMC Public Health(2024) 24:1695

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More research is needed to explore how young children undergoing obesity treatment experience weight stigma
and to understand gendered differences in these experiences.
Keywords Childhood obesity, Weight-related conversations, Qualitative research, Thematic analysis, Obesity stigma,
Weight bias

Background
Weight-related discussions may profoundly affect children’s body image and well-being [1, 2], but little is
known about how parents frame these discussions withchildren who have undergone obesity treatment of any
type. As early detection and treatment of obesity is crucial to prevent future co-morbidities, recent recommendations from the American Academy of Pediatrics (AAP)
advocate for the initiation of treatment as early as 2 yearsof age [3]. At this age, treatment primarily focuses on lifestyle support, revolves around parental involvement, andoften requires minimal participation from the child. Consequently, parents are required to translate the treatment
into everyday actions in their home, potentially prompting discussions about weight with their children.
However, due to the sensitive nature of childhood obesity, parents of children with overweight or obesity may
be reluctant to engage in childhood obesity treatment
and to handle discussions about their children’s bodyweight. Despite recent evidence showing no association between professional obesity treatment and risk ofeating disorders [4], many parents are concerned that
addressing obesity might harm their children’s well-being[5, 6], contribute to unhealthy weight fixation and trigger eating disorders [1, 7]. This reluctance may explain
why parents and grandparents often use euphemistic
expressions when referring to their child’s or grandchild’s
excess weight, such as ‘cute’ or ‘healthy’ [8]. Importantly,
weight-related conversations can take various forms, andprevious research has shown that the outcomes of such
conversations are determined by the approach parents
take [1].
Encouraging weight loss or commenting on eating habits has been associated with unhealthy weight control
behaviors, disordered eating [9, 10] and excess weight[11] in adolescents, which may last into adulthood [12].
Mothers’ negative comments about their own or others’ weight or body size negatively impact adolescents’
self-worth [13] and body image [14]. Moreover, parents’ weight-related discussions with their children may
involve weight-based teasing, with severe implications
for their mental health and overall well-being [2]. This
includes an increased risk of developing mental healthproblems, including depressive symptoms [15, 16], psychological distress, anxiety [17] and suicidal thoughts
and attempts [18].
On the other hand, weight-neutral discussions that
focus on health behaviors rather than body weight may

have positive effects on children’s well-being [1, 19]. Suchapproaches may also protect against disordered eating and dieting in adolescents, as compared to avoiding
the subject or solely focusing on body weight [20]. Similarly, conversations in which parents emphasize healthyeating rather than weight are linked to a reduced risk ofunhealthy weight-control behaviors and dieting among
adolescents with overweight [10]. However, as previous
studies on weight-related conversations within the homehave mostly focused on adolescents, little is known about
how parents frame such conversations with younger children. It is crucial to uncover this, as early childhood is a
critical period for the development of body image andyounger children may be particularly vulnerable to how
those around them, including their parents, speak aboutbody weight and size [21]. Understanding how parents
perceive weight-related conversations with children as
they grow from preschoolers to pre-adolescents is essential to foster positive conversations around body weight.
This study addresses a present gap in the literature by
exploring how parents experience and shape weightrelated discussions with their children, several years after
the children started obesity treatment. It explores how
parents of children who underwent obesity treatment
approach and experience weight-related discussions, andthus provides a unique retrospective account of parents’evolving experiences of weight-related discussions, fromthe time of the obesity intervention, when their children
were 4–6 years old, to the time of the interview, 4 years
later. In our previous publication [22], based on interviews conducted immediately after the obesity treatment, parents expressed social and emotional challenges
related to handling their child’s obesity, managing theirchild’s appetite, seeking obesity treatment, and copingwith the social stigma surrounding obesity. Here, we further explore these, and other aspects of parents’ experiences, in depth.

Methods
The More and Less study

The data for this study were collected as part of a 4-year
follow-up of the More and Less (ML) study, a randomized controlled trial (RCT) examining the effectivenessof a parent support program as treatment of obesity inpreschool-aged children in Stockholm, Sweden [23].
Between 2012 and 2016, parents of 177 children identified as having obesity according to age and sex-adjusted
reference data [24] participated. The participants were

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randomly assigned to one of three groups: a 10-weekparental support program (1.5 h/week); the same program with additional follow-up sessions (boosters); or
standard treatment offered at an outpatient pediatricclinic. Half of the participants received the parental support intervention, covering supportive parenting practices and lifestyle behaviors. These sessions required
participation from parents only, hence, no children were
present. Those who had been allocated to additional follow-up sessions received a booster telephone call every
4–6 weeks of the remaining 9 months.
Participants in the standard treatment group received
at least 4 visits at a pediatric outpatient clinic focusing onfood and physical activity advice, with the child present.
Table 1 Characteristics of the included families in this interview
study

Parent support group
Standard treatment
ChildrenAge (years)
Weight category
Normal weight
Overweight
Obesity
Severe obesity
Sex
FemaleMaleParents
Age (years)
BMI (kg/m2)
Sex
FemaleMale
Foreign background
Yes
No
Weight category
Normal weight
Overweight
Obesity
Missing
Highest school grade
Grade school
High school
College/University
Missing

N = 33N (%)
16 (49)17 (52)
Mean value (SD)
9.3 (0.7)
N (%)
1 (3)
12 (36)
10 (30)10 (39)15 (46)18 (54)
Mean age (SD)41.1 (5.6)
28.6 (5.6)
N (%)
26 (79)7 (21)
14 (47)16 (53)6 (18)
12 (36)8 (24)
7 (21)1 (3)
13 (39)16 (48)3 (9)Abbreviations: SD, standard deviation; BMI, Body mass index
Foreign background: parent and both grandparents born in a country otherthan Sweden or parent born in Sweden and grandparents born abroad
Parents were classified as having normal weight, overweight or obesity
according to the World Health Organization’s cut-off criteria for BMI (WHO,2019)

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A more detailed description of the study has been published elsewhere [23]. Four years after study start, allparents were invited to take part in follow-up interviews
to explore long-term experiences of managing their children’s weight. These interviews constitute the data forthis study. The interviews are treated as a single set, without comparison between groups, as the focus is on parents’ experiences rather than the RCT.
Recruitment and participants

Families from the first two years of the ML program(n = 67) were contacted by telephone and invited to participate in the interviews. Fourteen families (21%) could
not be reached, 2 families (3%) had moved abroad, and
18 families (27%) declined participation. Reasons for
declining participation included lack of interest, family reasons (illness, separation), a preference not to discuss their child’s weight, language barriers, and a lack oftime. Hence, a total of 33 families agreed to participate
in the interviews. All participants received a participant
information sheet and signed an informed consent form.
Table 1 outlines the characteristics of the participating
families at the time of interview. The anthropometricmeasures were conducted at a clinic and obtained fromdata collected during the More and Less study.
Data collection

Individual, semi-structured interviews were conducted
by KN, a female pediatric nurse and research assistantwith extensive experience in qualitive research. The interviews followed an interview guide developed by an expert
team consisting of KN, four senior researchers withexpertise in parenting and childhood obesity, and one
doctoral student. The expert team created an initial draftof the interview guide where each question was evaluatedusing Content Validity Index (CVI). CVI is an assessment
tool that can be used to measure the question’s relevancein relation to the concept the questionnaire is intended
to study [32]. In order to evaluate CVI for the questionsin the interview guide, each member of the expert groupfilled out a form to assess the relevance of the selected
questions (See Supplementary file 1). All expert opinions
were collected, and based on these, the CVI was calculated for each item (I-CVI), as well as for each subscale(S-CVI, mean), following the recommendations of Polit& Beck (2006).
The interview guide focused on lifestyle changes following participation in the ML program (i.e. “Whatresources that your family has been offered related toyour child’s weight have been helpful?”, “What lifestylechanges related to diet and physical activity has yourfamily made during the last four years?”, “Who has been
involved in your child’s obesity management?”). Questions were constructed to capture parental experiences

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of having a child aged 8–10 years who might still haveoverweight or obesity (i.e. “In what way has your child’s
body image changed over the past four years?”, “Has it
become easier or more difficult to deal with these questions, in what way?”, “How do you talk about your child’s
weight with him/her?”, “What do you think is important
to consider in such conversations?”, “How would you sayit?”). Follow-up questions were asked based on the parents’ responses and field notes were made during theinterview. The interview guide was pilot tested on one ofthe participants, however no changes were deemed necessary. For the participants’ convenience, all interviews
took place over the telephone. Only KN and the participant were present during the interviews, which lasted
28–70 min (45 min on average). The interviews wereaudio recorded and transcribed verbatim by two undergraduate students. The reporting of this study follows theConsolidated criteria for REporting Qualitative research(COREQ) checklist (See Supplementary file 2).
Data analysis

The interviews were analyzed using realist informed
thematic analysis according to Braun and Clarke [33].
Thematic analysis is a qualitative research method for
identifying, analyzing, and reporting patterns or themes
within data. All the transcribed interviews were read by
two authors (MS and PN). As the interviews included
parental perspectives on both the obesity intervention
and parenting a child with overweight/obesity, we firstextracted only the interview data concerning parenting. MS and PN screened the first five interviews andMS screened the rest of the interviews. This enabled
us to focus our inductive analysis only on data relevantto the research question. When this first screening was
finished, the material was re-read, extracted into an
Excel spreadsheet and coded by MS using an inductive
approach. An inductive approach allows the researcher todevelop data-driven codes and themes, rather than workwith a pre-determined coding frame [33]. When half of
the interviews were coded, MS, PN, and NN met anddiscussed potential themes based on the codes. Following this, MS coded the remaining material and regularly
met with PN and NN to discuss and refine the themes.
The proposed themes were documented and shared
twice with all co-authors. The wider team’s critical feedback was used to revise the themes until consensus wasreached by all co-authors.

Results
ThemesThree main themes, encompassing three subthemes
each, were developed. These are presented in Fig. 1
and described in detail below. Each theme includes

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illustrative quotes from parents (M for mother; F forfather), followed by a personal identification code.
Parental attitudes and concerns

This theme revolves around parents’ emotions anduncertainties regarding weight-related conversations.
The theme encompasses three subthemes: Uncomplicated conversation, Flying in the dark, and Worrying
about consequences.
Uncomplicated conversation

Several parents emphasized the importance of having
weight-related discussions with their children, recognizing this as a way to help them develop necessary and sustainable self-care skills to manage their obesity. However,their approaches differed markedly. One mother put it
as: “You teach the child to walk and you teach the child to
eat with cutlery, you also have to teach the children how
to manage their sensitivity to excess calories” (code M23).
Thus, helping the child understand her “calorie sensitivity” was compared to any other life skill, adding to the listof responsibilities for parents.
Furthermore, as many of the children had dealt withoverweight for many years, parents found themselves
having such conversations with their children several
times. “I have probably learned along the way how tohandle it”, one mother said (code M12). “Throughout thejourney”, as she put it, she gradually became more at easewith having weight-related discussions with her son. Thismother, and a few other parents sharing similar views,
tended to perceive the conversation as less challenging.
The parents, particularly those who had personal experiences of overweight, expressed that having an open andtrusting relationship with their child helped these conversations. One mother, for instance, considered thisconversation part of a general openness in her relationship with her child:
No, I don’t think it’s challenging [to talk to my son
about his weight]. I have been in that situation
myself. We are open with each other, and we havealways had that relationship. (code M27)
Several parents also said that speaking with other parents about how to approach weight-related conversations
helped them gain confidence, suggesting that sensitive
conversations could be aided by social support.
Experiencing weight-related conversations as uncomplicated did not mean that parents used weight-neutral
approaches. A few parents directly commented on theirchild’s appearance, telling them that they were overweight and emphasizing the need for change, by pointing
out that the child’s clothes no longer fit, or by showing them pictures where they appeared thinner. They

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Fig. 1 Identified themes from the thematic analysis

believed that making their child aware of their excess
weight was a good step in motivating them to change
their health behaviors. Moreover, some parents conveyed that having overweight was undesirable and should
be avoided, indicating the presence of weight bias, as
described by this father:
He once said very angrily and annoyed that hedoesn’t care about what he looks like and what
people talk about, this was after his mother had
explained that it wasn’t good for him to look likethat. ‘Look at you’ [she said] […] He can’t wear
clothes, normal clothes, because the waist is huge
and we buy trousers in three sizes bigger, they are
too long and he knows that it’s a problem […] He willprobably accept it eventually, understand that being
overweight, being strong and big is one thing, but justbeing fat and stuff like that… He should have muscles, as big muscles as he can get, but not the belly,

big belly, waist, fat… yes. He… sometimes, it feels like
he is accepting it [eating less], but when he sees food,he seems to forget everything. (code F33)
Flying in the dark

Several parents experienced a great deal of uncertainty
and worry about weight-related conversations, saying
they found these sensitive and difficult, with some feeling
reluctant to speak about weight at all. As one mother succinctly put it: “It’s always a balancing act. How much you
should talk about it.” (code M87).
Parents experienced a dilemma between wanting tohelp their children with weight management and fearing
they might harm them in doing so. This concern, as wellas an uncertainty about when and how often to raise thediscussion and what language to use, was often cited as abarrier to the conversation.

Sjunnestrand et al. BMC Public Health(2024) 24:1695

It’s just that it’s so sensitive and I don’t want it tohave consequences and I don’t want her to feel likethere’s something wrong with her. She’s totally awarethat she’s bigger than everyone else, I don’t want totell her things that are obvious. (code M67)
Some parents expressed concerns about being mean tothe child, feeling that the discussions created a negative
atmosphere and led to constant nagging. Additionally,some parents reported feeling frustrated during weightrelated conversations, often arising from the uncertainty
of how to navigate the sensitive topic. This frustrationoccasionally led parents losing their patience and saying
things they later regretted.
You often get frustrated and then you might say
things you don’t mean. Because you don’t know how
to say it sometimes. He doesn’t really understandeither and sometimes you have to speak clearly. And
then you feel mean. (code M87)

Worrying about consequences

Several parents expressed worries over weight-related
conversations negatively affecting their children. Specifically, parents worried their children would become preoccupied with food intake, weight, and appearance. “I don’t
want him to be like seven or eight years and already thinking about getting chubby by what he puts in his mouth”, amother said (code M12). This quote is representative ofseveral parents who referred to their children’s young age
as a crucial period for body image development, expressing concerns about their children being concerned about
their weight so early in life. Parents feared that excessiveemphasis on their child’s weight and eating habits could
potentially trigger unhealthy thoughts and contribute toa distorted body image. A mother said:
He can be like that sometimes, asking questions like
‘Is this unhealthy, is this healthy?‘, you know, to thepoint where I can almost become a bit worried sometimes, that I’m nagging too much. I just want what’s
best for him, but at the same time, I don’t want it to
go to the extent where he starts feeling bad about his
eating habits and his appearance. (code M87)
Worries about children developing an unhealthy body
image or obsession over food ultimately boiled down
to parents’ fear of triggering eating disorders, especiallyamong girls. In relation to this, a few parents also sharedpersonal experiences of having had eating disorders intheir youth due to weight-related comments from others.
Lastly, a few parents said that their uncertainty about
addressing weight-related issues with their children in a

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safe and sensitive manner led them to avoid the conversation completely. Instead, they attempted to manage theirchild’s weight without their awareness or involvement.
“I’ve had some issues myself, and I was also overweight asa child. So, I don’t want to discuss it too much because I
know it can turn in the other direction and become justas difficult or even more so”, one mother said (code M25).
Thus, her personal negative experiences with frequent
weight-related conversations in her youth made her cautious about discussing it extensively with her own son,concerned about possible adverse consequences.
The significance of time and context

This theme includes parental perspectives on how they
perceived and adapted weight-related discussions with
their children in response to contextual factors. Within
this theme, three subthemes were identified: A growing
child, Gendered conversations, and Being around others.
A growing child

As four years had elapsed since the families started
obesity treatment, parents reflected on how the child’s
becoming older affected weight conversations. Several
parents said they had noted a gradual increase in theirchildren’s self-awareness, a trait less prevalent during
their younger years. A mother said: “On a few occasions,for instance, he stood in front of the mirror […] and thenhe looked at himself, and he said, ‘Oh, I’m big and fat,’ you
know, like that.” (code M87). Similar experiences wereshared by several parents, noticing how their children
had started to compare themselves to peers and express
self-criticism or insecurity about their appearance.
Consequently, parents observed how their children
began attaching greater importance to their clothingstyle and overall appearance, sometimes feeling uncomfortable in situations like sports, showering, or changing
clothes in front of others. Some even employed strategies
to appear slimmer, as illustrated by this mother’s account:
What I can see is that sometimes, in front of the mirror when she thinks I’m not watching, she tries on ashirt that’s too small and sucks in her stomach, trying to look thinner than she is. […] I notice how she’s
figured out ways to look slimmer, so it’s clear thatshe’s fully aware that she’s bigger than all the otherchildren (code M67).
As children became increasingly self-aware about theirweight and appearance, parents noted that they engaged
in weight-related conversations with them more frequently than before. Some said they had recently started
to have these conversations. Given that many children
had become more self-conscious about their appearance,

Sjunnestrand et al. BMC Public Health(2024) 24:1695

according to the parents, some felt that the discussions
had become more challenging over the years.
As he grows older, it gets more challenging, because
he’s also more aware. Both in terms of… I mean,
body perception and how it affects him emotionally,
not just, what should I say, the purely practical ortheoretical aspect” ( code M72).
In contrast, some parents found that as their child grewolder and matured, the conversation became easier. Now
they felt that they could engage their children differently
as they were more cognitively developed. Other parents
acknowledged the mixed aspects of their child’s age, as
expressed by this mother:
Yes, it’s easier to talk to them when they’re older
because they understand a lot more. However, I findthat they’re a lot less easily influenced when they’reolder because they have their own thoughts, and I
know from my own experience how I used to think
like, “Mom is being silly” [laughs]. So, in that sense,
it’s quite difficult to influence them (code M5).

Gendered conversations

In addition to the temporal aspect, parents reflectedon how the nature and dynamic of weight-related conversations was influenced by their child’s gender. Bothmothers and fathers acknowledged being more cautious
when discussing weight-related issues with their daughters compared to their sons, based on a general perception that girls are more vulnerable to such conversations.
According to some parents, this could be attributed to
the greater societal pressure on girls regarding thinness
and appearance. A few parents also expressed the belief
that girls are inherently more sensitive than boys, while
asserting that boys should be able to handle weightrelated discussions with less concern. “[Girls] are moresensitive … they take it more seriously”, one mother said
(code M7).
Another mother shared this view and expressed relief
over being mother to a boy, implying that she had fewer
concerns about her son’s body image compared to if she
had been raising daughters:
Now, I’m lucky since it’s a boy. I imagine it can beeven worse for girls … Then, of course, when it comesto comparing themselves against others… I get the
feeling that boys don’t do it in the same way. (codeM72)
Of note, throughout the interviews, most parents who
discussed body image at length did so in reference toPage 7 of 12

their sons; however, they expressed explicit concerns
about body image issues and disordered eating mostly in
relation to girls.
Being around others

Parents found it challenging to attend to and limit theirchild’s food intake in social situations such as parties orgatherings.
It doesn’t feel good when you’re away, having to say
in front of everyone ‘No, now you can’t eat any more’and stuff like that. It can be a little … I feel it can bea little sensitive for her. (code M14)
Several parents found it difficult to limit their child’s foodintake in front of other children. They expressed discomfort in instructing their child to avoid excessive intake
of food and sweets in these situations, as they feared it
would draw attention to their child and cause feelingsof shame. This was perceived as particularly challenging
when being around children without food intake restrictions. A few parents noted that their children compared
their food intake to others, showing awareness that otherchildren were allowed to consume larger quantities
of food. A mother said: “She can reflect on [her] friends
sometimes eating much more than her, saying ‘Thesefriends can eat so much candy, mom, it’s really strange!‘”(code M58). Such situations could also prompt questions
from the child:
Like, the cousins get to have more, they’re reallythin, they have trouble gaining weight, it’s the opposite there. [Her son says] ‘Why does he get to eat…?’
What should I say, ‘He hasn’t eaten all day’? […] It
becomes difficult in such situations (code M27).
This last quote illustrated the mother’s balancing act of
selecting the right words to use. Her son felt confused in
the company of other children without dietary restrictions, and the mother found herself searching for theappropriate response.
Navigating weight stigma

This theme explores how parents navigated the social
stigma associated with obesity, highlighting positive
framings parents used to counteract stigma and boost
their children’s wellbeing and self-esteem. It encompasses
three subthemes: Promoting health, Fostering self-acceptance, and Recognizing and coping with stigmatizing acts.
Promoting health

For several parents, weight-related conversations with
their children primarily focused on overall health. Parents addressed potential long-term health implications

Sjunnestrand et al. BMC Public Health(2024) 24:1695

of excessive weight gain or highlighted the importance ofdental health and physiological well-being. Some parents
also educated their children about healthy and unhealthy
food choices and how these choices impact the body, forexample, saying that food provides the body with energy,
but that the body needs “the right [type of ] energy” (codeM58). Moreover, they emphasized the physical aspects ofweight, explaining that excess weight can make it moredifficult to engage in activities such as playing, running,jumping, and climbing. Like a mother who stated that“[w]e’re discussing it in terms of your ability to keep up
with school, to participate in sports, and to feel well” (codeM58).
To reduce feelings of blame and stigmatization, parents
referred to the well-being of the whole family. “We talka lot about what we as a family need to feel good and behealthy”, another mother concluded, “to approach thisfrom a larger perspective” (code M21). This view wasshared by several parents, suggesting that they actively
tried not to make their child the focus of weight-related
conversations.
Moreover, some parents emphasized the importanceof approaching their children in a sensitive and nonjudgmental way and avoided negative, possibly stigmatizing language. They did so by refraining from mentioning
appearance or body size. A mother shared that emphasizing the child’s health rather than appearance or size madeweight-related conversations easier:I believe that it’s easier as a parent to talk about
health from within and not, I mean, that’s what one
should strive for. Instead of how it looks on the scaleor how it looks in clothes and waist measurements.
(code M12)

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This mother tried to convey the message that people
look different and that this is fine. Several parents further encouraged their children to focus on what the bodycan do rather than fixating on their looks, thereby downplaying the significance of weight and appearance as theprimary indicators of a person’s value or self-esteem.
Additionally, some parents tried to communicate thatbeing thin does not equal happiness or good health.
Parents tried to promote this self-acceptance throughacting as role models and fostering a positive and nonjudgmental familial environment. For example, a few
parents mentioned avoiding discussions and stigmatizing
comments related to people’s body sizes or appearances.
Others tried to boost their children’s self-confidence bysetting an example for their children, consciously avoiding making negative comments about their own weight
and appearance but rather complementing themselves.
A mother shared an example of how she and the child’s
father had boosted their son’s self-confidence by making
positive comments about themselves in front of the child.
Both me and [the son’s father] are role models…. [My son] can look in the mirror and say ‘God,
I’m handsome’ because [the father] does that too[laughs]. Maybe I don’t do it as often, but I still try
to remember to avoid talking negatively about mybody in front of the kids. I try to avoid that when I
talk to myself too. To stand in front of the mirror andthink negatively about yourself or that some part ofyour body looks bad. Definitely not in front of thechildren, I want them to feel good about themselves
regardless of how they look. (code M70)

Recognizing and coping with stigmatizing acts
Fostering self-acceptanceParents who engaged in weight-related discussions that
focused on health, rather than size or appearance, often
said they wanted their children to accept themselves as
they were regardless of weight status. Several parents
emphasized the importance of fostering confidence
and self-acceptance by alluding to diversity, such as thismother:He’s well aware that he’s a bit bigger than the others and… Yes, for a while he wanted to wear a t-shirt
in the public swimming pool. Because he thought he
had like big boobs. Eh, but then I kept telling himthat ‘We all look different and there are thin ones,
there are chubby ones, there are dark-skinned ones…’
and I sort of tried to give him that overall picturethat everyone doesn’t look the same. And he has sortof accepted that. (code M7)

Almost all parents recalled situations when their children
had encountered weight-based stigmatizing acts, that is“specific negative behaviors or communications involvedin stigmatizing actions or events” [34]. One example
was weight-based teasing or bullying from school peers.
Such incidents often left their children feeling distressed.
In response, parents sought to comfort their children,emphasizing that those engaging in such behavior might
have their own insecurities, and encouraged their children to consult the school staff. Some parents took proactive steps by scheduling meetings with their children’s
school teachers to address the issue.
According to several parents, weight stigma extended
beyond the school setting. Some parents recounted situations where other family members, such as siblings andgrandparents, made well-intended but thoughtless comments about the child’s weight. For example, one motherrecalled her daughter’s older brother noticing his little
sister’s weight when they had to be weighed when renting

Sjunnestrand et al. BMC Public Health(2024) 24:1695

skis during a trip, commenting: “’Oh, you really weigh alot!’” (code M22). A common strategy parents employed
to cope with these situations was to talk to their family members, conveying that such comments were notappropriate or acceptable.
A few parents also described distressing encounters in clinical settings, where healthcare professionals
expressed negative attitudes towards the parent and thechild due to the child’s weight, effectively stigmatizing
both the “bad” parenting and the weight itself. These incidents sometimes occurred in the presence of the child:“We encountered a terrible doctor,” a mother told theinterviewer, “who said to her something like, ‘If you continue like this, you’ll weigh 130 kilos by the time you’rea teenager, and you wouldn’t want that’” (code M88).
Such incidents could lead the parents to cancel followup healthcare appointments in an attempt to protect
their children from stigmatizing acts. According to theparents, these experiences increased their children’s distress, with children becoming self-conscious about theirappearance and not wanting to eat too much to avoid
gaining weight.

Discussion
Our study is the first to explore how parents discussweight-related issues with their children, several years
after participation in a childhood obesity treatment program. While parents emphasized the importance of discussing weight and health related behaviors with theirchildren, they found it challenging due to uncertainties
about how to approach it safely and sensitively. A few
parents found the conversation manageable, citing theirown experiences of having overweight or their style ofcommunication with their child as facilitating the conversation. Some parents said they engaged in weight-related
conversations with their children more frequently as theymatured, driven by children’s growing self-awareness.
Parents also said that contextual factors, such as genderand the presence of others, shaped the conversation. In
particular, parents perceived boys as more resilient, thus
exposing them to more negative weight talk. Lastly, parents employed strategies such as fostering their children’s
self-confidence, downplaying the significance of appearance and emphasizing health when discussing weightwith their children to shield them from weight stigma.
Below, we discuss three overarching aspects of thesefindings, and their implications.
Our findings highlight that parents balance between
managing their children’s obesity on the one hand, andthe need to protect their well-being on the other. Thisaligns with previous qualitative research showing thatparents find themselves caught in a moral dilemma
between these two objectives [35, 36] and that communication about weight and weight-related behaviors

Page 9 of 12

is perceived as sensitive and delicate [27–38]. Consequently, parents may find themselves lacking the necessary knowledge and support required to navigate theseconversations effectively. Similar findings were raised in
our previous qualitative study, in which parents expresseda need for increased guidance and support from healthcare professionals [5]. This absence of support to address
their child’s weight may foster a sense of hopelessness, as
shown in studies with parents of older children with obesity [39, 40]. That is, parents may develop the belief thatchildren will struggle with obesity for the rest of theirlives. While this finding was not present in our study, it
is important to note that the children in our study arestill young. Thus, providing adequate support to parents,
strengthening their self-confidence and instilling hope iscrucial.
Despite parents expressing uncertainties about how
to navigate weight-related conversations effectively, thisstudy provides several good examples of such discussions. For instance, some parents mentioned employing aweight-neutral approach and redirected the conversation
away from size and appearance. This type of approachhas been linked to improved well-being [1, 19] and adecreased risk of eating disorders in adolescents [11].
Other accounts shed light on a more problematic
approach in weight-related discussions with children andreveal noticeably weight-biased attitudes among a few
parents. Specifically, some parents described employing
negative and judgmental language as a means of motivating their children to lose weight. This aligns withprevious research that highlighted parents as a potential
source of weight stigma [2, 41]. Indeed, an earlier study
found that parents may speak about children with obesity
as lazy and lacking self-control [41], implying a belief that
their children’s excess weight stems from personal flaws.
The fundamental starting point in coping with stigmatizing acts, according to Sobal, is recognition [34]. Onceobesity is recognized as stigmatized, it can be countered.
Given that parents are key resources in obesity treatment, providing guidance and support for safe and sensitive weight-related communication is a vital priority.
However, there is a lack of evidence-based guidelines forhow such communication is best carried out.
In all forms of childhood obesity treatment, parents need support to understand that while obesity is achronic disease [26] that may require lifelong treatment,children with obesity can live healthy lives and develop
healthy relationships with their bodies. Living with achronic disease like obesity does not mean that children
will suffer for the rest of their lives. If children receive
obesity treatment which emphasizes improvements inhealth and quality of life, they can develop the lifelong
skills necessary to live well with obesity [42]. In our study,
while some parents understood these messages, others

Sjunnestrand et al. BMC Public Health(2024) 24:1695

did not. The parent support program offered in the ML
study emphasized the children with obesity can leadhealthy lives. However, the participants’ mixed endorsement of this message conveys the importance of reinforcing it throughout obesity treatment and beyond. To
achieve this, it may be helpful to train pediatric healthcare professionals with whom families engage outside thespecialized obesity treatment context.
In a few cases, parents spoke of their children encountering stigmatizing acts from healthcare professionals.
This aligns with research showing that weight bias attitudes are prevalent among healthcare professionals,
including pediatricians [28, 43]. This is concerning, as
parents conveyed that such instances prompted them toavoid future obesity management appointments, posing
a potential risk of delaying or even preventing appropriate treatment – a risk that has been observed in previous research [28, 44]. For example, a study by Puhl et al.
revealed that almost a quarter of parents who perceived
their doctor using stigmatizing language in relation totheir child’s weight reported they would cancel any future
healthcare appointments [45]. In addition, primary
healthcare professionals’ minimization of parents’ concerns poses a barrier to childhood obesity treatment [39].
Given the recognized effectiveness of early treatment[46], providing training and tools for healthcare professionals to communicate with parents in a compassionate, sensitive, and non-judgmental way is of paramountimportance.
Lastly, most parents expressed that girls were more vulnerable to weight-related conversations than boys, and it
appeared that this gendered perception affected the sensitivity with which they approached these conversations.
This finding corroborates existing but limited researchsuggesting that parents seem to be more inclined toengage in negative weight-related conversations with
their sons rather than their daughters [47]. Interestingly,
however, despite an almost equal distribution of parents
with sons and daughters in our sample, the accounts
related to body image in this study tended to focus moreon boys. This was unexpected, as parents in general
expressed more concerns about girls. Crucially, there
is no evidence suggesting that boys are immune to thenegative effects of weight-related conversations [1]. The
perception that boys are more resilient than girls may
inadvertently render boys’ distress invisible and contribute to the internalization of weight stigma. This shouldraise some caution about a potentially gender-biased
misconception of boys not being hurt by weight stigma,
or perhaps even a cultural norm that “a boy should be
able to take it” (hinted in some parents’ stories). It is
important to understand the potential consequences ofsuch attitudes for boys’ body image and self-esteem.

Page 10 of 12

Strengths and limitations

One of the strengths of this study is the relatively large
sample size (for a qualitative study) and the diversity ofparticipants in terms of both the parents’ and children’scharacteristics. However, as with all qualitative studies,
this study represents the subjective narratives of parents and may not be representative in other contexts
which limits the generalizability of the findings. Furthermore, it is important to note that this study focuses onparental accounts of their conversations, not the conversations as such. Interview situations can influence parental responses through impression management, whereindividuals shape their answers to align with perceived
expectations [48]. In this context, parents may believethat a specific approach to discussing their child’s weightaligns with the interviewer’s expectations, creating an
uncertainty about the accuracy of their responses.
The previous interviews with parents conducted immediately after treatment mainly focused on parents’ experiences of the study [22]. If those interviews included thesame set of questions used in this study, we would havebeen able to capture their longitudinal experiences ofraising a child in the context of obesity treatment. Furthermore, how the children themselves perceived weightrelated conversations remains unexplored, which we
acknowledge as an additional limitation. Importantly,
however, the children in the study have been interviewed
about food and meals in their everyday lives. For ethicalreasons, the interview questions did not raise the topic ofweight, but the findings suggested the children had positive and joyful relationships to food and eating in company with others [49]. Lastly, as the interviews included
parents from both treatment groups, no comparison
between the two treatment arms was possible.
Implications and future research

Future studies should consider including observations
to analyze weight-related conversations between parents and their children. This may be extended to examine
the role gender has in shaping these discussions. As thisstudy suggests, boys may be subjected to negative weightrelated discussions as their parents may perceive them as
more resilient. Going forward, this emphasizes the needto further investigate how weight-related discussions
can impact children, irrespective of gender. In addition,
future studies should investigate whether parents employ
different approaches when discussing weight with theirsons compared to their daughters in larger samples ofgirls and boys.
Furthermore, this study reveals that children may bebullied, teased, or experience discrimination because of
their weight in several social settings, including within
their own family. These findings align with our previous
interview study, conducted immediately after treatment,

Sjunnestrand et al. BMC Public Health(2024) 24:1695

in which parents articulated feelings of blame, guilt, andjudgement by healthcare professionals [5]. This underscores the pervasiveness of weight stigma and the need toaddress this issue on a societal level. In the United States,
proposals have been made to legislate against weight
stigma and discrimination [29]. Although the progress ofthese proposals has been slow [29], states with anti-bullying laws that specifically include weight as a protectedclass have witnessed a decrease in weight-based bullying among youths [30]. Therefore, extending comparable
legislation to a Swedish context may potentially reduceweight-based bullying.
To ensure that the healthcare settings remain free of
prejudice and discrimination, countering weight bias
among healthcare professionals is critical. However, current initiatives to reduce weight stigma have shown, at
best, moderate effectiveness [31]. This underscores theneed to develop more effective interventions targeting
healthcare settings, as also emphasized in recent recommendations from the World Obesity Federation [25].
Notably, interventions directed at students in healthrelated professionals show more promising results in
reducing weight bias [50]. Therefore, implementing comprehensive interventions early and throughout healthcare
education may be beneficial.

Conclusion
In this unique study, we conducted interviews with parents to explore their long-term experiences of navigating weight-related conversations with their growing
children post-obesity treatment. We found that many
parents need support to navigate weight-related discussions as they express uncertainties regarding how such
communication can be done in a safe and sensitive manner. In general, parents perceived boys as more resilient,potentially placing boys at a greater risk of exposure tonegative weight-related discussions. Lastly, addressing
weight stigma is part of children’s obesity management
process, as children may be bullied, teased, or experience discrimination in different social settings. Moreresearch is needed to explore how young children undergoing obesity treatment experience weight stigma and tounderstand gendered differences in these experiences.
Our findings underscore the importance of developing
impactful interventions to address weight stigma within
the healthcare system and society at large.
Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12889-024-19195-1.
Supplementary Material 1
Supplementary Material 2

Page 11 of 12

Acknowledgements
We want to thank all parents who took part in the interviews, generously
dedicating their time and sharing their experiences.
Author contributions
MS analysed the data and wrote a first draft of the manuscript. NN contributed
to the analysis of the transcripts and the drafting of the manuscript. KN
contributed to the development of the interview guide, conducted all theinterviews and co-edited the manuscript. XRS, KJ and KE contributed to theanalysis and to writing the manuscript. AE contributed to the developmentof the interview guide and co-edited the manuscript. PN designed theMore and Less Study, contributed to the development of the interview
guide, supervised the analysis of the transcriptions and the drafting of themanuscript. All authors approved of the final version of the manuscript.
Funding
No funding to report.
Open access funding provided by Uppsala University.
Data availability
The transcripts/data of this qualitative study are not publicly available due toconfidentiality agreements with the participants but are available from thecorresponding author on reasonable request.

Declarations
Ethical approval and consent to participate
This study was conducted in accordance with the Declaration of Helsinki andwas approved by the Regional Ethical Board in Stockholm (ID: 2011/132931/4). Informed consent was obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Department of Food Studies, Nutrition and Dietetics, Uppsala University,
Uppsala, Sweden
2
Department of Psychology, Lund University, Lund, Sweden
3
Department of Clinical Science, Intervention and Technology (CLINTEC),
Karolinska Institutet, Stockholm, Sweden
4
European Association for the Study of Obesity, United Kingdom and Bias
180, Ottawa, Canada
5
Warwick Medical School, University of Warwick, Coventry, UK
Received: 3 January 2024 / Accepted: 19 June 2024

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