Investigating the effect of the family-centered empowerment model on the weight and self-concept of obese boys

Abstract

Background

Obesity in children is a chronic problem that can lead to physical and psychological complications, including changes in self-concept. Since the family plays an important role in children’s physical and mental health, it should be considered the central point in all healthcare interventions. This study was conducted to determine the effect of the family-centered empowerment model on the weight and self-concept of obese boys.

Methods

This research was a semi-experimental study with a pretest-posttest design and control group. The sample size consisted of 30 male students between the ages of 9 and 12, with a BMI greater than the 95th percentile in each group (test-control). The family empowerment program was implemented in 4 steps (perceived threat, self-efficacy, self-esteem, evaluation) and during 8 sessions (45 min for each). The data collection tools were a demographic profile questionnaire, a Pirez and Harris standardized self-concept questionnaire, and a digital weight scale. Data were analyzed using SPSS version 22 software. The significance level was considered P ≤ 0.05.

Results

The results of the study showed that the average score of self-concept in the control group did not change significantly over time(P = 0.762), while in the test group, the average score of self-concept immediately after the intervention and after 1.5 months compared to before the intervention showed a significant increase (P = 0.038). There were no significant changes in the mean weight (P = 0.780) and BMI (P = 0.867) before and after the intervention in the control group, but statistically significant changes were seen in the mean weight (P = 0.040) and BMI (P = 0.039) in the test group.

Conclusions

Implementing a Family-Centered Empowerment Model improved self-concept and weight management in obese primary school boys. These outcomes may contribute to positive lifestyle changes, such as increased physical activity, healthier eating habits, and maintaining a normal weight.

Trial registration

Not applicable.

Introduction

Obesity is a growing health problem around the world, and one of the main causes of various non-communicable diseases [1]. According to the Global Burden of Disease (GBD), approximately 30% of the world’s population is overweight or obese [2]. According to the Centers for Disease Control and Prevention (CDC), the prevalence of obesity in children is about 19.3%, and it is higher in boys than in girls [3]. According to statistics in Iran, about 15% of boys are overweight and obese [4]. Children whose body mass index (BMI) is between the 85th and 95th percentile are considered overweight and obese, and those with fat tissue and body mass above the 95th percentile in the growth chart are considered obese [5]. Childhood obesity, a major global health issue, can lead to obesity in adulthood and physical and mental health consequences [6]. Blood pressure, cardiovascular diseases, liver and gall bladder disease, diabetes, premature death, and respiratory diseases are among the physical complications of obesity [1].

Although obesity affects both men and women equally, it can have a particularly serious impact on men [7]. Kidney stones affect men twice as often as women, and obesity increases their risk [8]. Obesity has a particularly detrimental effect on male hormones, male sexual function, and prostate health. Several studies have shown that increased body fat in men increases their risk of prostate cancer [9, 10]. Being overweight increases a man’s risk of developing erectile dysfunction by more than 90% [11]. Men with larger bellies are more likely to have benign prostatic hyperplasia. Obesity in men may also be associated with testicular shrinkage, leading to an increased risk of infertility in young men [12]. The result of studies showed that the testicular volume of boys with normal insulin levels was twice as large as that of boys with increased weight [13, 14]. In addition to physical problems, the risk of mental disorders is also high in obese people. The results of the studies also indicate that mental and social health in overweight children and adolescents can have a lower score compared to peers with normal weight [15, 16]. Obese and overweight people struggle with mental health disorders and changes in self-concept, which in the long run can even lead to more serious illnesses such as anxiety and depression [17].

Self-concept, as one of the important aspects of social development, is not formed at birth but is acquired through social experiences and communication with other members of society. Its formation continues during childhood and becomes almost stable during adolescence [13]. A positive self-concept can be created by successfully engaging in cognitive, social, and motor activities. On the other hand, the development of a positive self-concept through self-efficacious behaviors and successful experiences will also lead to a positive feeling about self [14]. Rao et al. (2020) state that obesity has a two-way relationship with mental health, so mental pressure is also a known risk factor for obesity [15]. In this regard, Kang and Kwack (2020) and Robinson et al. (2020) also showed that the mental health of overweight and obese boys is at an unfavorable level [17, 18]. Given the global increase in the prevalence of obesity in children and adolescents, the development of weight loss interventions and the prevention of secondary problems in this age group is a public health priority [19]. On the other hand, specific interventions for obese and overweight boys are limited in the country. There is convincing evidence about the effective role of family environment and lifestyle on obesity-related behaviors of children and adolescents [20, 21]. Therefore, by involving parents in care, it is possible to prevent the occurrence of irreparable problems and their complications in children. Since one of the goals of therapeutic and educational care is to increase the awareness, attitude, and self-efficacy of patients and their families, the use of nursing theories and models in this field can be helpful [22, 23]. One of the most widely used models in Iranian society is the family-centered empowerment model (FCEM), which was designed by Alhani in 2003. This model was the result of a mixed research study, the first stage of which was a qualitative grounded theory study, which, after going through the stages of forming concepts, developing concepts, identifying the psychosocial process of the problem, and deriving the central variable, went through the modeling stages to create an applied model, and then was implemented in a semi-experimental quantitative study [24, 25]. The FCEM is known as an innovative approach to improving children’s health, especially in the field of chronic diseases [26, 27].

This model is designed based on the principles of family participation and enhancing its capabilities. Empowerment involves the client and his/her family in making decisions and choosing the best way to reduce health problems. Empowering the family can be an important mechanism in providing the best possible care services, and it requires having the power or ability to make decisions [28].

The concepts of the FCEM include: perceived threat, self-efficacy, self-esteem, and evaluation [29]. The perceived threat includes two concepts: perceived severity and perceived sensitivity. Perceived severity, as the first concept, means that a person, by recognizing the risks or complications of a disease, understands the seriousness of that disease and feels at risk for that disease. Perceived sensitivity means that a person, by recognizing his/her situation and a correct definition of health concerning the disease process, feels at risk for contracting that disease and considers the possibility of contracting that disease [29, 30]. As mentioned earlier, being overweight and obese may increase the risk of developing potentially serious physical and mental health problems. However, many adolescents are unaware of the health threat of obesity and are not even aware that they are overweight or obese [31]. On the other hand, many parents even deny that their children are obese, which can make the adolescent’s condition worse [32]. Accordingly, the first step of the model can be used to solve these challenges.

Self-efficacy, as the second concept, means that an individual believes that he or she can do a specific task to solve his or her problem. In the family-centered empowerment model, the goal of this step is to clarify individual expectations and increase the feeling of being capable of acquiring the skills to perform a specific task regarding his or her health [29, 30]. The level of self-efficacy of individuals in the field of weight control plays an important role in preventing and controlling obesity [33]. Weight control self-efficacy refers to an individual’s belief in their ability to resist inactivity or eating in situations with a high probability of overeating. In fact, in the context of weight control, it is self-efficacy that determines whether an individual will initiate a weight change program, how much effort they will put into it, and how long they will continue with it [34].

Self-confidence or self-esteem as the third concept refers to the degree of approval, approval, acceptance, and worth that a person feels towards him/herself. People with low self-esteem have an external locus of control, and people with high self-esteem have an internal locus of control [29, 30]. It should be noted that although the original Family-Centered Empowerment Model (FCEM) uses the term self-esteem to refer to an individual’s internal locus of control, in the present study, the term self-control is considered more conceptually accurate. This is because the focus is on the individual’s perceived ability to regulate and manage their responses and outcomes, rather than on self-worth or self-evaluation. Therefore, the term ‘self-control’ is used throughout this article to better reflect the intended construct.

Overweight and obese children have lower levels of self-control compared to normal-weight children. Moreover, the low level of self-control in children, which correlates with a high level of BMI, is similar to the level of self-control in mothers. Dissatisfaction with body shape due to weight gain, humiliation at school, and bullying leads to changes in adolescent behavior in the form of irritability, restlessness, anxiety, aggression, decreased self-control, and defective self-concept. These conditions can leave lasting psychological problems in the adolescent in the long run. Therefore, in the third step of the model, our goal is to improve the self-control of the obese adolescent [35]. Evaluation, as the fourth concept of the FCEM, is a process that is carried out during the implementation of the model, and evaluation is an outcome that is carried out at the end of the work [29, 30]. The FCEM structure is shown in Diagrams 1 & 2.

Fig. 1.

The family-centered empowerment model structure (Alhani, 2003)

Fig. 2.

The family-centered empowerment model structure used in this study

The effectiveness of this model in improving the health of people with chronic diseases such as iron deficiency anemia, asthma, multiple sclerosis, thalassemia, diabetes, etc., at different ages has been tested many times [29] and is likely to be effective in controlling and preventing obesity and its physical and mental complications. Considering what has been said, self-concept and body perception in obese and overweight people are not at an appropriate level. Self-concept in children and adolescents constitutes an important part of their psychological world and is one of the prerequisites for the development of a healthy personality, and the family can play a constructive role in its development. Considering the prevalence of obesity among Iranian boys and the inattention of this group to receiving physical and mental health services, the researchers of the present study decided to conduct a study aimed at the effect of FCEM on the weight and self-concept of obese boys.

Methods

This research was a semi-experimental study with a pretest-posttest design and control group in Tehran/Iran, from February 2024 to September 2024. The sample size was 30 male students having a BMI greater than the 95th percentile in each group (test-control).

The inclusion criteria included

Being a male student, studying in primary schools, between the ages of 9 and 12, having a BMI greater than the 95th percentile, not on a special diet, not suffering from mental disorders, not having thyroid gland disorders and diabetes, not consuming hormonal drugs such as corticosteroids and gonadotropins, not having restrictions for physical activity, parents’ ability to read and write, non-participation in similar educational programs, and being of Iranian origin.

The exclusion criteria included

Incomplete questionnaire completion, distorted information, withdrawal from the study for any reason, not attending more than one training session, getting sick, migrating to another city, and changing the study area during the research period.

Sample size

The sample size was determined using the following formula and based on similar studies, taking into account the confidence level of the test of 95%, the power of the test of 80%, and the attrition rate of 10%, 30 students in each group (test-control) [36].

1

Sampling method

The samples were selected by the cluster sampling method. For this purpose, among the four districts of Tehran (North, South, East, and West), the West district, and then an area were randomly selected by writing names on paper. Then, two schools out of 16 boys’ primary schools in that district were selected, and using a random coin toss, one school was assigned to the test group and another to the control group.

To reduce the possibility of bias in the study, it was very important for us that the students in the control group, due to their curiosity, could not obtain information during the intervention from the students in the test group participating in empowerment sessions. Therefore, one of the two schools was assigned to the test group and the other to the control group.

The health records of all students were checked. With the cooperation of the school administrator and the health teacher, 500 students (250 in both schools) who were likely to be overweight were asked to attend school on a certain day and time (in the morning) while they were fasting, along with their parents. After introducing himself and explaining the objectives and steps of the work, the researcher obtained informed consent from the parents and the students.

Then each student was given a gown to wear to measure their weight. They were asked to stand with bare feet on a digital scale (Seca, Hamburg, Germany; accurate to 100 g).

Also, the height of the students was measured using a meter (Stadiometer SECA 213 with an accuracy of one millimeter) while standing with bare feet, hips, and heels in contact with the wall and looking straight ahead. In this way, the BMI of all samples was calculated. Finally, out of 100 students with a BMI above the 95th percentile, 30 students in the experimental school and 30 students in the control school were randomly included in the study.

The research tools included

The data collection tools included two parts.

1. Demographic characteristics questionnaire (age, educational level, number of family members, father’s education level, mother’s education level, parents’ occupation, family life status).

2. The standardized self-concept questionnaire (Piers and Harris Children’s Self-Concept Scale).

This questionnaire was developed by Piers and Harris in 1969, which contains 80 questions to measure the attitudes and feelings of children and adolescents about themselves, with a range of yes and no answers.

This scale has 6 dimensions: 1- behavior; 2- School status and cognitive and mental status; 3- appearance and physical characteristics; 4- Anxiety; 5- Sociability (popularity); and 6- Happiness and satisfaction. The total score of self-concept is obtained from the sum of the scores. A higher score on this scale indicates a positive self-concept, and a lower score indicates a negative self-concept. Moteqayer and Torkan (2020) have reported the reliability of this questionnaire using Cronbach’s alpha equal to 0.87 [37].

Intervention steps

With the coordination of the school principal, one of the school’s classes was used to hold meetings. In the test school, students were divided into 5 groups of 6 people. The FCEM was implemented in 4 stages during 8 sessions (each session 45 min) and according to the pre-test results in the test group.

The first stage (perceived threat, including the two concepts of perceived severity and perceived sensitivity)

Threat perception was conducted through lectures and group discussions during 2 weekly sessions. The goal was to answer the two questions “How important is this disease?” and “How likely is it that I will become fatter?“. To increase the perceived severity, physiology, diagnosis, symptoms, complications, prognosis, drug and non-drug treatment were discussed. To increase the perceived sensitivity about vulnerable groups, factors causing obesity and concrete examples of their symptoms were discussed.

Weekly feedback was obtained through question-and-answer sessions and group discussions within the designated virtual space following the conclusion of each session. At the end of each session, a summary was made and their questions were answered, and the date and purpose of the next session were determined. Weekly feedback was obtained through question-and-answer sessions and group discussions on two questions written on educational cards about the topics discussed.

The second stage (enhancement of self-efficacy)

Self-efficacy refers to an individual’s self-perceived ability to act effectively in a variety of situations It is an important factor that influences patients’ ability to self-manage symptoms of their chronic diseases. Self-efficacy plays an important role in determining whether self-care actions are initiated, how much effort is exerted, and how long the effort is sustained in the face of obstacles and failure [33]. In the present study, three additional 45–60 min sessions were conducted by the researcher to improve the self-efficacy of obese boys. Self-efficacy was increased through group problem-solving, practical demonstrations, and practice and repetition, with an emphasis on the statement “I can contribute to losing weight and improving my sense of self-worth (self-concept).” In these meetings, the children got acquainted with their problems and gave concrete examples of their actions regarding the effective management of the disease. They talked about the need to see a specialist in case of overeating or to do blood tests. They discussed how to have a routine of movement and activity, and how to choose a healthy daily diet. The boys shared their experiences related to the content of each session and engaged in problem-solving processes. They proposed solutions to various challenges, and the best solution was chosen.

The third stage (increasing self-control through educational participation)

Self-control is defined in the FCEM as an internal locus of control, that is, an individual’s perception of control over their own outcomes [29]. In all sessions, the boys were encouraged to participate in the training and transfer the topics raised in the sessions, along with the educational cards, to their active family members. The boys, as health liaisons, had the role of trainers for other family members to participate in understanding issues related to obesity and ways to prevent its complications. Feedback on the educational subjects was also evaluated weekly. The feeling of recognition and empowerment in the child’s mind, and receiving encouragement from the researcher, increased self-control, a sense of responsibility, and consequently improved self-control. At this stage, the boys were able to tell their families about their problems and, by increasing their self-control, share training issues with them. On the other hand, the family member has the role of a reminder or follow-up for the patient and helps the patient to implement and follow the educational tips. Given the possibility that the active family member would not be empowered through the boys’ education and the study of the educational card, all the active family members were invited to discuss the information that the patients had taught them and what they had learned from the educational card together under the supervision of the researcher during two sessions. In these sessions, the information was presented by the active family member, and the researcher played a central role. Based on the group discussion of the active family members, the researcher found out: 1- To what extent were the boys successful in transferring the educational information? 2- Points that the boys did not transfer to the active family member were discussed. 3- The questions of the active family member were answered. At this stage, the boys and the family came to believe, mentally and practically, that they were able to prevent the complications of obesity and its consequences through self-control and the adoption of preventive behaviors.

The fourth stage (evaluation)

It comprises two parts (Process evaluation and final evaluation). Verbal questions were used in each session to ensure that boys had learned the material from the previous sessions. The final evaluation and assessment of the model’s impact were conducted immediately after the end of the intervention and 1.5 months later in both groups.

Data analysis

In this study, data analysis was performed in SPSS 22 software. Descriptive statistics (mean, standard deviation, frequency, and frequency percentage) were used to describe demographic information. The chi-square test was used to examine the homogeneity of qualitative data. The independent t-test was used to compare the mean data of two groups in two stages, before and after the intervention. The ANOVA was used to compare the mean data of groups at different times. The significance level was considered P ≤ 0.05.

Results

The results showed that most of the students in the two groups of control (56.67%) and test (53.33%) were in the age group of 11–12 years.

Most of the students in the control group (33.67%) and in the test group (40%) were in the fifth grade.

The greatest number of families in the control (60%) and test (66.67%) groups had 3 members.

The highest level of education of mothers in the control group was related to diploma and university education (33.33%) and in the test group, diploma education (33.33%).

Most of the fathers in the control and test groups had a diploma, respectively 33.33% and 36.66%.

More than half of the mothers in both groups were housewives, and most of the fathers in the control (43.33%) and test (50%) groups had free jobs. The results of the chi-square test showed that the two groups were homogeneous in terms of demographic characteristics and had no statistically significant difference (P ≤ 0.05) (Table 1).

Table 1.

Individual characteristics of research samples in the control and test groups

Variable		Test Group	Control Group	*P-Value
Student’s age	9–10 10–12	14(46.67%) 16(53.33%)	13(43.33%) 17(56.67%)	p = 0.795
Educational grade	Third Fourth Fifth Sixth	3(10.0%) 11(36.67%) 12(40.0%) 4(13.33%)	3(10.0%) 10(33.33%) 11(36.67%) 6(20.00%)	p = 0.920
Number of family members	3 4 5 ≤	20(66.6%) 4(13.33%) 6(20.00%)	18 (60.0%) 5(16.7%) 7(23.3%)	p = 0.795
Mother’s education	Elementary degree Secondary degree High school degree Academic degree	7(23.3%) 6(20.00%) 10(33.3%) 7(23.3%)	5(16.7%) 5(16.7%) 10(33.3%) 10(33.3%)	p = 0.780
Mother’s job	Housewife Employed	18 (60.0%) 12(40.0%)	20(66.6%) 10(33.33%)	p = 0.650
Father’s education	Elementary degree Secondary degree High school degree Academic degree	5(16.7%) 7(23.3%) 11(36.67%) 7(23.3%)	4(13.33%) 8(26.66%) 10(33.3%) 8(26.66%)	p = 0.762
Father’s job	Unemployed Self-employed Employee	8(26.66%) 15(50.0%) 7(23.3%)	7(23.3%) 13(43.33%) 10(33.3%)	p = 0.720

* χ2: Chi-squared

According to the findings, before the intervention, there was no statistically significant difference between the two test and control groups in any of the dimensions of self-concept and its overall score(P > 0.05), while after the intervention, this difference was significant(P ≤ 0.05).

In the test group, immediately after the intervention and 1.5 months later, there was an increase in all dimensions and the total score compared to before (P ≤ 0.05). In the control group, no significant change was observed in any of the dimensions and the total score of self-concept compared to before (P > 0.05) (Table 2).

Table 2.

Comparison of the Self-concept dimensions score at different times in the control and test groups

Variable	Group	Time			P-value
		Before M∉±∉Sd	Immediately after M∉±∉Sd	1.5 months later M∉±∉Sd
Behavior	Test	11.52∉±∉3.43	14.36∉±∉3.03	14.75∉±∉3.12	**P = 0.023
	Control	11.02∉±∉3.56	11.57∉±∉3.48	11.68∉±∉4.05	**P = 0.358
		*P = 0.471	*P = 0.002	*P = 0.001
Appearance and physical characteristics	Test	12.69∉±∉2.63	16.32∉±∉2.02	16.75∉±∉2.18	**P = 0.032
	Control	12.58∉±∉2.57	12.63∉±∉2.36	12.75∉±∉2.03	**P = 0.557
		*P = 0.484	*P = 0.003	*P = 0.002
Anxiety	Test	11.83∉±∉1.25	7.24∉±∉1.71	7.56∉±∉1.35	**P = 0.036
	Control	11.65∉±∉1.56	11.06∉±∉1.75	11.21∉±∉1.23	**P = 0.759
		*P = 0.684	*P = 0.002	*P = 0.012
Sociability (popularity)	Test	7.65∉±∉1.62	11.83∉±∉1.33	11.53∉±∉1.72	**P = 0.013
	Control	7.75∉±∉1.66	7.63∉±∉1.81	7.85∉±∉1.52	**P = 0.655
		*P = 0.609	*P = 0.032	*P = 0.014
Happiness and satisfaction	Test	6.57∉±∉1.11	8.85∉±∉1.57	8.09∉±∉1.75	**P = 0.035
	Control	6.52∉±∉1.23	6.86∉±∉1.62	6.81∉±∉1.45	**P = 0.532
		*P = 0.747	*P = 0.003	*P = 0.002
School status and cognitive and mental status	Test	12.69∉±∉2.63	16.32∉±∉2.02	16.75∉±∉2.18	**P = 0.032
	Control	12.58∉±∉2.57	12.63∉±∉2.36	12.75∉±∉2.03	**P = 0.557
		*P = 0.852	**P = 0.021	**P = 0.031
Total	Test	57.10∉±∉2.96	73.40∉±∉2.34	74.40∉±∉2.22	**P = 0.038
	Control	57.53∉±∉3.57	56.70∉±∉3.16	56.51∉±∉2.26	**P = 0.762
		*P = 0.611	*P = 0.0001	*P = 0.0001

* Independent t-test

** Repeated Measures ANOVA

The results showed that the average weight and BMI in the control group did not change significantly over time, while in the test group, the average weight and BMI decreased significantly in the second and third rounds compared to the first round (P ≤ 0.05) (Table 3).

Table 3.

Comparison of weight and BMI at three different times in the control and test groups

Variable	Group	Time			P-value
		Before M∉±∉Sd	Immediately after M∉±∉Sd	1.5 months later M∉±∉Sd
BMI	Test	32.23∉±∉3.41	31.51∉±∉3.43	30.81∉±∉3.32	**P = 0.039
	Control	33.74∉±∉3.12	33.06∉±∉1.60	32.47∉±∉3.19	**P = 0.867
		*P = 0.080	*P = 0.010	*P = 0.002
Weight	Test	60.16∉±∉6.27	59.01∉±∉4.50	58.60∉±∉6.02	**P = 0.040
	Control	61.60∉±∉5.80	61.80∉±∉5.70	61.10∉±∉5.81	**P = 0.780
		*P = 0.380	*P = 0.010	*P = 0.040

* Independent t-test

** Repeated Measures ANOVA

Discussion

As the findings showed, over time, the self-concept score increased, and the average weight and BMI of obese boys decreased in the test group compared to the control group. Therefore, it can be concluded that the intervention based on FCEM has been effective in improving the self-concept and weight control of obese boys. Other studies have also investigated the effect of implementing the FCEM on other chronic diseases in children, such as asthma, hemophilia, thalassemia, iron deficiency anemia, chronic kidney failure, type 1 diabetes, etc [38–44]. Although the above studies have mostly focused on the quality of life, since obesity, self-concept, and quality of life are directly related to each other [45]. It can be said that the results of the above studies confirm the findings of the present study. In addition, a quasi-experimental study by Mulyana et al. (2024) demonstrated that FCEM implementation significantly reduced anxiety and improved quality of life in children with chronic disorders, highlighting the model’s potential across multiple psychosocial dimensions [46]. Similarly, Nemati et al. (2021) found that FCEM-based interventions improved both treatment adherence and emotional functioning in children with epilepsy, supporting the model’s relevance in both behavioral and emotional outcomes [47].

In the field of improving self-concept in obese children and adolescents, several interventions have been carried out, the results of which are in line with the present study. Ginis et al. (2017) showed in a study that weight loss in obese people through exercise and diet control has caused a significant increase in self-concept and body image perception [46]. In the above study, although the samples were in a higher age range, the mean baseline BMI was higher in the boys in the present study, despite their younger age (approximately M_BMI = 32.23 ± 3.41 compared to 31.6 ± 3.5). In the Ginis study, only the main sample (women) was given 8 weeks of exercise training, but in the present study, the active family member was also involved in the educational intervention, and thus it is expected that the reciprocal effect of improving self-perception in boys will also occur in the active family member.

These results are consistent with the findings of the studies of Asadian and Yu et al. (2016) and McIntyre et al. (2015) [48, 49]. In their study, they showed that the effect of free weight and resistance training on adolescents’ self-concept has an effect. In analyzing these findings, it can be stated that physical activity improves physical appearance and brings them closer to social ideals. In this regard, according to the feedback that an individual receives about his or her competencies, his or her self-concept increases. In a way, being present in sports and social environments may be a reason for increasing social interaction and, subsequently, improving self-concept. In the present study, an attempt was also made to hold group training sessions so that adolescents could be more in a social environment and express themselves.

Shoja et al. (2019) also showed in a semi-experimental study on 50 overweight children aged 8–10 years that 12 weeks of play-based physical exercises for an average of 40 min resulted in students’ physical self-concept, which is in line with the findings of the present study [50]. On the other hand, as is clear, the age range of children in Shoja et al.‘s study is almost at the same level as the age range of boys in the present study, but the intervention was carried out without parental participation.

Utesch et al. (2018) also showed that the self-concept of overweight and obese children improved after 6 weeks of exercise and nutritional modification. They summarize that there are reciprocal effects between self-concept and an individual’s motivation to engage in physical activity, which in turn can affect an individual’s obesity [47]. In the present study, the boys were in early adolescence, aged 9 to 12, which is why parental participation and support were required, while in the study by Utesch et al., the age range was higher (11 to 17), which may be the reason for the lack of parental participation in the intervention process. Also, in the Utesch study, only a predetermined exercise and physical activity training session was provided, while in the present study, after providing valid initial information, the adolescents themselves participated in choosing an appropriate diet and regular physical activity type, and they were encouraged to choose the appropriate solution by themselves. Furthermore, a randomized trial by Amiri et al. (2022) involving children with metabolic syndrome showed that motivational interviewing combined with parental involvement led to significant changes in children’s self-esteem and weight outcomes [51]. These findings provide additional support for the notion that empowering families leads to more sustainable behavior change.

Self-concept is a network of positive and negative ideas and beliefs about oneself. Feedback from others, especially parents, communication with the environment, and social interactions are among the factors that affect self-concept [51]. Considering the importance of family influence, in none of the studies, the role of family members, especially parents, was not considered, and the interventions were only on obese people, which is the difference between the present study and other studies. The family is a natural and social system that people are willingly or unwillingly dependent on [20]. Family is the first center where a person feels safe, accepted, and supported [52]. The structure and psychological environment of the family, which is the general combination of relationships between its members, affect the performance and behavior of a person in the face of problems, psychological pressures, anxieties, fears, and other unpleasant stimuli [26]. Parents are the most powerful factors affecting children’s physical and mental health. Just as parents influence family members, children also influence their parents’ behavior with their personality and behavioral characteristics [41]. The present study clearly showed that obese boys play an active role in transferring educational materials to their families. On the other hand, warm family relationships and their participation in the intervention process can increase self-concept and, in other words, positive emotions in obese boys. In this regard, Bahrami and colleagues showed in a study that family communication in the form of dialogue has a positive and significant effect on the self-concept of male students [53].

The results of the present study also showed that there was a significant difference in the average weight and BMI score between the two test and control groups, so that at the end of the study, the average weight and BMI score of obese boys in the intervention group decreased significantly, while there was no change in the control group.

Although the authors did not refer to behavior change models directly, the structure and mechanisms of the Family-Centered Empowerment Model (FCEM) show clear parallels with key components of established behavior change theories. For example, the first step of FCEM, which aims to increase the perceived threat of obesity and its consequences among children and their families, aligns with the ‘perceived severity’ and ‘perceived susceptibility’ constructs in the Health Belief Model (HBM). Similarly, the model’s emphasis on enabling children and families to choose healthy behaviors and participate in decision-making reflects the concept of ‘self-efficacy’, a core element not only of HBM but also of Social Cognitive Theory (SCT). SCT particularly emphasizes the role of social influence, family modeling, and reciprocal determinism—concepts evident in the present study’s involvement of active family members. Recognizing these similarities strengthens the theoretical underpinnings of FCEM and supports its application in behavior change interventions.

According to the first step of the model, family empowerment increases the perceived threat of the disease in affected individuals and their families. It can be explained that the intervention in this research had been able to increase the awareness of the child and the active members of the family about the factors that cause obesity and its possible complications. On the other hand, according to the second step of the model, the intervention has been able to make the child and the family efficient in choosing the best diet and performing their routine physical activities. An effort was made to make children more responsible for their health status and gain the ability to control matters related to improving their health situation. In addition, children were empowered in teaching their families, and thus, according to the third step of the model, their self-control was also improved. In the end, not only did the self-control improve, but the children also lost weight, albeit slightly.

In this regard, Soltani et al. (2017) conducted a study to investigate the effect of family-oriented educational intervention on reducing the BMI of obese and overweight children [27]. Although in the above study, the samples were mothers, with the implementation of educational sessions, the BMI in children decreased. Therefore, it can be explained that parents, especially mothers, have a great role in following a healthy lifestyle in the family and maintaining the health of all family members. The results of a study by Heydari et al. (2022) also showed that sports training and routine aerobic activities significantly reduce the weight of overweight and obese boys [54]. In this study, children were encouraged to exercise for at least half an hour a day instead of sitting in front of the TV and spending time on social media. Parents were also encouraged to participate in this activity so that, according to social learning theory and the role model effect, children would also be encouraged to be physically active.

The results of the studies by Di Figlia-Peck et al. (2020) and Kim et al. (2020) also indicated that family-based cognitive-behavioral therapy leads to a decrease in BMI and average weight in obese boys [55, 56]. Thus, it can be explained that any educational intervention, if accompanied by the participation of parents and family members, in addition to its effect on warm family relationships, creates a good and intimate feeling between family members, and increases the willingness and motivation to follow treatment, also has desirable effects on physical health. Similarly, Sadeghzadeh et al. (2023) highlighted that family-based emotional regulation training not only improved self-concept in overweight adolescents but also decreased emotional eating patterns—a key contributor to obesity [52].

The primary environment of the child is the family. Even when the child becomes an adult, the family remains an influential factor in their life [57]. Children’s motor development and lifestyle choices, especially during the period known as the golden age of development, are greatly influenced by parents [58]. Therefore, it is important to choose a healthy lifestyle, including balanced and quality meals and routine activities in the family, because it affects the control of children’s weight and obesity [59]. Therefore, the health team can teach positive parenting skills and healthy lifestyles to parents by carrying out interventions based on empowerment, so that changes in health behaviors and improvement of children’s physical and mental health are also established. On the other hand, students are the ones who convey health messages to the family, so by providing appropriate health education in schools, many diseases caused by unhealthy lifestyles can be prevented in the whole family.

Conclusion

This study demonstrated that an educational program focused on increasing awareness of obesity risks and enhancing self-efficacy and self-control effectively improved self-concept and weight management in obese male students. The intervention, involving both students and their families, led to significant positive changes in psychological and physical outcomes. These findings highlight the importance of family-centered empowerment approaches in addressing childhood obesity. The current research also faced some limitations, the most important of which include only one gender (boys), and the lack of participation of all family members in the intervention process, which limits the generalization of the results. Differences in psychological characteristics, interpersonal interactions, and differences in people’s motivations and personalities are factors that cannot be controlled by the researcher but may affect the results.

Abbreviations

%

Percentage

ANOVA

Analysis of Variance

BMI

Body Mass Index

CDC

Disease Control and Prevention

FCEM

Family-Centered Empowerment Model

GBD

Global Burden of Disease

HBM

Health Belief Model

M ± Sd

Mean ± Standard deviation

N

Frequency (number)

P

P-value

SCT

Social Cognitive Theory

Author contributions

Seyed Hossein Hosseini Motlagh conducted sampling, did the intervention, collected information, analyzed data, and drafted the work. FatemehSadat SeyedNematollah Roshan supervised the research process, checked the analysis process, and reviewed the manuscript. Farnaz Shishehgar gave intellectual advice to the student and reviewed the entire article.

Funding

None.

Data availability

Due to the privacy of the samples, the data set analyzed in this study is not publicly available. But they are available upon reasonable request from the corresponding author (FSSNR).

Declarations

Study approval statement

The study protocol was reviewed and approved by the ethics committee of Tehran Azad University of Medical Sciences with the number REC.TMU.IAU.IR.1402.299 dated 2/20/2024. The study adhered to strict ethical guidelines to ensure the protection and well-being of all participants.

Ethical considerations

This study was approved by the Research Council and Ethics Committee of the Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran (Code REC.TMU.IAU.IR.1402.299, Date 20/02/2024). Participation in the study was completely voluntary for the participants, and non-participation did not affect their treatment process. The participants in the study were assured that the information would be confidential. Also, considering that the participants in the study were between the ages of 9 and 12, according to the ethical guidelines for research on vulnerable groups, written informed consent was obtained from the legal guardian. Finally, since the control group did not receive any intervention, they were given all educational materials in the form of a booklet to comply with research ethics.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.