Associations between Parent Behavior and Adolescent Weight Control

There has been a well-documented increase in the prevalence of pediatric obesity during the last 30 years, with ∼34% of adolescents (ages 12–19 years) now either overweight or obese [body mass index (BMI) ≥85th percentile for age and gender; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010]. Pediatric obesity increases the risk of negative physical consequences, including metabolic, cardiovascular, and respiratory comorbidities (Weiss et al., 2004), and is also associated with increased risk for negative psychosocial outcomes, such as impaired quality of life (Zeller, Roehrig, Modi, Daniels, & Inge, 2006), decreased self-concept and body image (Israel & Ivanova, 2002), and impairments in social functioning (Janssen, Craig, Boyce, & Pickett, 2004). Furthermore, youth who are obese are at increased risk of being obese as adults, with greatest risk for adolescents (Guo et al., 2000). Family-based behavioral weight control (BWC) programs have demonstrated efficacy in the treatment of overweight children (ages 8–12 years), with some promise for long-term outcomes (Oude Luttikhuis et al., 2009; Wilfley et al., 2007; Young, Northern, Lister, Drummond, & O’Brien, 2007). Notably fewer BWC interventions have been conducted with adolescents, and outcomes are variable (Jelalian et al., 2008). A recent review concludes that while comprehensive interventions involving behavioral strategies combined with attention to diet and physical activity show promise in decreasing adolescent obesity, there is a need for further development of effective interventions (Tsiros, Sinn, Coates, Howe, & Buckley, 2008). Variables associated in previous trials with better weight loss outcomes have included male gender and greater attendance at group sessions (Jelalian et al., 2008). However, it is unclear what role parental involvement plays in predicting weight loss success, with a review finding mixed evidence for a positive association between greater parent involvement and greater weight loss outcomes in primarily school-age samples (Kitzmann & Beech, 2006). Relatively few studies have explicitly examined the role of parents in adolescent BWC. In an early study, adolescents demonstrated comparable decreases in percent overweight (∼8%) regardless of whether they participated in a BWC intervention alone or with a parent (Coates, Killen, & Slinkard, 1982). This is consistent with findings from a recent randomized intervention for rural overweight youth that did not find any difference in BMI z-score decrease between parent-only versus family-based interventions, either at posttreatment or at 10-month follow-up (Janicke et al., 2008). In contrast, Brownell, Kelman, and Stunkard (1983) demonstrated superior outcome when adolescents and parents attended separate group sessions, compared to adolescents participating alone or in the same group as parents. However, a replication of this study with 36 African-American adolescent girls showed no significant difference in outcome regardless of whether parents were seen together with adolescents, in separate groups, or not included in treatment (Wadden et al., 1990). Consistent with social learning theory (Bandura, 1977), parents serve as role models for their children and shape their children’s habits, including those contributing to obesity risk. Parents serve as a child’s first model of eating behavior and have the opportunity to present healthy eating and physical activity habits (Golan & Weizman, 2001). Children’s dietary intake patterns (e.g., food preference, intake of fruits and vegetables, etc.) tend to resemble their parents’ patterns (Fisher, Mitchell, Smiciklas-Wright, & Birch, 2002), and parental dietary and physical activity behaviors appear to have a lasting effect on children’s dietary and physical activity patterns and BMI trajectory (Davison, Francis, & Birch, 2005). Although parent modeling has been discussed as an important component for pediatric obesity intervention (Golan & Crow, 2004; Golan & Weizman, 2001), relatively little research has explored how parent modeling may be associated with BWC intervention outcome. We propose that parent adherence to weight control strategies (e.g., self-monitoring of their own dietary intake) and parent weight change are key behaviors through which parent modeling may be associated with adolescent weight loss. The importance of parent self-monitoring is consistent with previous research. Germann and colleagues (2007) found that ethnic minority youth whose parents self-monitored throughout the first 3 months of treatment were more likely to lose weight compared to those whose parents did not self-monitor. Furthermore, in a second study, daughters of mothers with better treatment attendance demonstrated significantly greater weight loss than those whose mothers attended less often (Wadden et al., 1990). Finally, indirect support for parent modeling is provided by research demonstrating positive correlations between child and parent weight loss in the context of BWC for school-age children (e.g., Epstein, McCurley, Wing, & Valoski, 1990; Wrotniak, Epstein, Paluch, & Roemmich, 2004). These associations have not been explored in the context of an adolescent BWC trial. Parent-feeding attitudes and practices have also received attention. Some of the research has focused on controlling feeding practices, such as parent restriction of their children’s eating during meals, inclination to pressure their child to eat more food, and monitoring of their child’s food intake (Birch et al., 2001; Faith, Scanlon, Birch, Francis, & Sherry, 2004). These types of feeding practices may hinder the child’s opportunities for the development of self-control with respect to eating (Birch et al., 2001). Cross-sectional research among school-age children has linked parental restriction of children’s eating with child weight status (Webber, Hill, Cooke, Carnell, & Wardle, 2010) and weight gain (Clark, Goyder, Bissell, Blank, & Peters, 2007). The transition into adolescence is characterized by greater independence in food choices, which may limit the direct impact of parents on their adolescent’s intake at mealtimes, in comparison to younger children. However, parental-feeding attitudes and practices likely continue to exert an important role among adolescents. First, parents typically continue to have involvement in food purchasing and preparation for adolescents and may be present during a portion of adolescent mealtimes. Nearly 50% of adolescents eat at least five meals per week with their family, with younger adolescents reporting more frequent family meals compared to older adolescents (Fulkerson, Neumark-Sztainer, & Story, 2006). Second, parental-feeding attitudes and practices are by no means limited to mealtimes and could consist of critical comments or suggestions made at any time of the day (Kluck, 2008). The objective of the current study was to examine associations between parent behaviors (parent weight change, parent self-monitoring of their own dietary intake, and feeding practices and attitudes) and changes in adolescent BMI and weight following 16 weeks of BWC intervention. We hypothesized that greater parent weight loss and higher levels of parent self-monitoring would be associated with greater teen weight loss. We also sought to explore associations between parent-feeding practices/attitudes and adolescent weight loss. Data for this study were drawn from a randomized adolescent BWC trial, involving 16 weeks of active intervention followed by 4 bi-weekly maintenance sessions, in which parent weight was not an intervention target. See Jelalian et al. (2010) for a detailed description of the treatment conditions and primary outcomes and Hart et al. (2010) for an examination of dietary intake in this sample.