Halo or horn? A qualitative study of mothers’ experiences with feeding children during the first year following bariatric surgery

Abstract

Background:

Obesity is a chronic condition that has an intergenerational effect. The aims of the study were to better understand the impact of maternal bariatric surgery on obesogenic risks to child offspring in the home via documenting mothers’ thoughts, behaviors, and experiences around child feeding, family meals, and the home food environment during her first year postsurgery.

Method:

Utilizing a mixed-method cross-sectional design, 20 mothers (M_age = 39.6 ± 5.7 years, 75% White, M_BMI = 33.6 ± 4.3 kg/m², M_time = 7.7 ± 3.1 months post-surgery) of children ages 6–12 years completed validated self-report measures and participated in a focus group. Mother and child heights/weights were measured.

Results:

The majority of children (N = 20; M_age = 9.2 ± 2.3 years, 65% White, 60% female) were overweight (N = 12; BMI≥85th percentile) and were not meeting the American Academy of Pediatrics healthy eating and activity recommendations to treat/reduce obesity risk. As child zBMI increased, mothers expressed significantly more weight concern (r = 0.59, p = 0.01) and lower obesity-specific quality of life (r = −0.56, p = 0.01), yet assumed less responsibility for child eating choices (r = −0.47, p = 0.04). Qualitative data demonstrated disconnects between mothers’ changes to achieve her own healthier weight and applying this knowledge to feeding her child/family.

Conclusions:

While bariatric surgery and requisite lifestyle change are effective tools for weight loss at the individual level, there is a great need for innovative family-based solutions. Pediatric obesity is preventable or risk-diminished if addressed early. Maternal bariatric surgery may be a unique (yet missed) opportunity to intervene.

1. Introduction

Among youth today in the United States, a majority (57.3%) will have obesity by age 35, with approximately half having carried their excess weight status forward from childhood (Ward et al., 2017). Obesity is costly, burdensome to health and quality of life (Finkelstein, Graham, & Malhotra, 2014; Wang, McPherson, Marsh, Gortmaker, & Brown, 2011), and difficult to effectively treat with lifestyle change alone once children age into adolescence and at higher levels of severity (Danielsson, Kowalski, Ekblom, & Marcus, 2012; Knop et al., 2015). Targeted prevention and intervention strategies for youth at highest risk and before adolescence are an urgent public health priority.

Parents, particularly mothers, play a unique and powerful role in the intergenerational transmission of obesity risk (Schrempft et al., 2018). This risk heightens when parental obesity reaches the severe level (body mass index or BMI ≥ 40 kg/m²) (Whitaker, Jarvis, Beeken, Boniface, & Wardle, 2010). Current estimates indicate approximately 1 in 10 women in the United States meet criteria for severe obesity (Hales, Fryar, Carroll, Freedman, & Ogden, 2018) for whom bariatric surgery remains the most effective treatment. The typical adult patient who undergoes surgery is female (75–79%), approximately 40 years of age (Adams et al., 2017; Bhogal et al., 2015; Courcoulas et al., 2018), and a mother (72.5% prior-to-surgery live birth rate) (Gosman et al., 2010). Not surprisingly, reported rates of overweight/obesity in her residing child offspring (BMI ≥ 85th percentile; age < 18 years) range from 45 to 74% (Bao, Desai, Christoffel, Smith-Ray, & Nagle, 2009; Hirsch et al., 2014; Kral et al., 2006; Lent et al., 2016; Willmer et al., 2015; Woodard, Encarnacion, Peraza, Hernandez-Boussard, & Morton, 2011).

Bariatric nutrition guidelines outline the following (Allied Health Sciences Section Ad Hoc Nutrition et al., 2008). The initial perioperative period (6–8 weeks) begins with a focus on safe texture progression and protein supplementation. Subsequently, the new postsurgery eating plan places emphasis on meal planning/spacing (e.g., 5 small meals per day) and adequate (lean) protein intake while balancing carbohydrates, fats, and fluids. Patients are to avoid sugar sweetened beverages (SSB); foods high in sugar and/or saturated fats; and fried foods, with grains only as tolerated. In addition, patients are advised to adopt a more active lifestyle to optimize weight loss outcomes (King & Bond, 2013). Weight loss is most dramatic during the first 6 months postsurgery, with maximum weight loss at approximately 1 year (≈30%) and weight maintenance requiring sustained lifestyle change (Adams et al., 2017; Courcoulas et al., 2018; Sjostrom, 2013).

Parents are the primary influence on the development of children’s eating and physical activity behaviors. They act as gatekeepers of the home food environment and shape eating behaviors via food parenting practices and modelling, all key drivers in the development and prevention of childhood obesity (Couch, Glanz, Zhou, Sallis, & Saelens, 2014; Dickens & Ogden, 2014; Maitland, Stratton, Foster, Braham, & Rosenberg, 2013; Pyper, Harrington, & Manson, 2016; Vaughn et al., 2016). It is conceivable that postsurgical changes in maternal eating and activity following bariatric surgery would have a positive impact on the home food environment, family meal patterns, her food parenting practices, and subsequently, weight outcomes of her dependent children. At face value, this is a promising perspective, yet empirical support is lacking.

In their 2011 publication, Woodard and colleagues first suggested that bariatric surgery has an additional “halo effect” on the family. Specifically, adult family members of patients experienced collateral weight loss 1-year post-surgery, with a similar trend for child offspring with obesity (n = 11) (Woodard et al., 2011). Yet, findings in two subsequent follow-up studies tracking BMI trajectories in child off-spring have been limited to trends and/or unique subgroups. In a retrospective study, 3-year BMI trajectories in child offspring with a parent who had/had not undergone bariatric surgery only differed for boys with overweight (BMI 85-94th percentile), with BMI outcomes lower than expected for the surgical group and higher for the non-surgical group (Hirsch et al., 2014). In a prospective series from Sweden (Sellberg, Ghaderi, Willmer, Tynelius, & Berglind, 2018; Willmer et al., 2015, 2016), mother/child dyads (child: 56% overweight, 18.5% obese) were tracked from 3-months prior to mothers’ bariatric surgery, and again at 9-months, 12-months, and 4-years postsurgery. After adjusting for child sex and age, there was an initial decreased risk for overweight (not obesity) at 1-year. However, by 4-years, although representing only 53% of their original sample, there were no significant changes in prevalence of overweight or obesity, with a trend toward greater rates of obesity. This occurred even as mothers lost weight and maintained a reduction of approximately 32.5 kg. Furthermore, quantitative assessments indicated there were no changes in child offspring fruit, vegetable, or “soft drink” intake pre/post at 9-months (Willmer et al., 2016), with sedentary behavior increasing and physical activity decreasing (Berglind et al., 2015).

Additional quantitative cross-sectional studies comparing home food availability, meal patterns, child feeding, and lifestyle behaviors of child offspring of parents who did/did not undergo bariatric surgery (Walters-Bugbee, McClure, Kral, & Sarwer, 2012; Watowicz, Taylor, & Eneli, 2013) have shown a greater presence of discouraged foods (e.g., breaded poultry or seafood, chips) in a bariatric home, with child offspring more likely to engage in unhealthy lifestyle behaviors (e.g., second helpings, fast food and SSB consumption). In addition, when comparing a group of mothers who were presurgery to those who were postsurgery, groups did not differ in the number of family meals, or mothers’ self-reported child feeding practices, with one exception. Mothers in the postsurgery group reported more frequent modelling of healthy eating for her child (Walters-Bugbee et al., 2012).

Hence, mothers may experience impressive weight loss and make their own significant lifestyle changes following bariatric surgery yet may not be changing the obesogenic nature of the household and diminishing the known risk to her children. To further underscore this point, among adolescents who underwent bariatric surgery and participated in the Teen Longitudinal Assessment of Bariatric Surgery consortium studies, 1 in 4 had a primary caregiver with their own prior history of bariatric surgery (Zeller et al., 2016). Arguably, these findings may speak to a missed opportunity for prevention and intervention. However, questions remain. Currently, we lack depth and a contextually-embedded understanding of how mothers may navigate this postsurgical process as a parent. While extant quantitative studies have provided some knowledge regarding offspring eating behaviors and the home food environment, what are mothers’ thoughts, feelings, and motivations behind these types of empirical findings and where critical gaps and needs lie? Absent are the voices of mothers themselves, sharing their perceptions regarding what it is like being a patient and parent during the first year postsurgery. Personal perspectives gleaned through the additional use of qualitative methods have the potential to inform the design of prevention and intervention models.

To address these questions and gaps and utilizing a mixed method cross-sectional design, the primary aim of this study was to use qualitative methods to document thoughts, behaviors, and experiences around child feeding, family meals, and the home food environment from mothers who have undergone bariatric surgery during their first year postsurgery. We targeted offspring between 6 and 12-years of age, given empirical support for effectiveness of family-based weight loss treatment in this specific age range (Wilfley et al., 2017). Quantitative data characterizing child eating, mother’s feeding practices, and her concerns regarding child weight and quality of life served as descriptive context to understand and interpret these qualitative data.

2. Materials and methods

2.1. Participants

During a brief study window (September–November 2015), study flyers were emailed by the host pediatric medical center to 1) female patients of three collaborating bariatric programs and 2) all employees of the host pediatric medical center. The flyer invited mothers who recently had bariatric surgery to contact study personnel if interested in participating in a research study with aims to “learn about your perceptions about being a mom and what is like to feed your school-age child” during the first year postsurgery.

Interested mothers were phone screened for eligibility. These criteria included that the mother was (a) 3–12 months post a single, non-device-based bariatric procedure (i.e., gastric bypass, sleeve gastrectomy), (b) ≥ 30 years of age, (c) English-speaking, and with a (d) child 6–12 years of age living in their home with no chronic illness or developmental disability. In homes with multiple eligible offspring, the younger child was enrolled. Device-based procedures were excluded based on unique treatment demands (i.e., periodic adjustments). A maternal age ≥30 years ensured no offspring were the result of teen child-bearing, a known risk to both mother and child (Hoffman, 2013).

Of the initial 41 female respondents, 14 were ineligible (e.g., n = 13: child and/or mother was outside of targeted age or postsurgery window; n = 1: child reported to have a developmental disability). Of the 27 eligible, 3 were unable to attend any scheduled focus group, and 4 did not attend as scheduled and were unable to reschedule. Recruitment stopped when focus group content demonstrated thematic saturation (Saunders et al., 2018). Twenty mothers participated in one of the five focus groups with 1 group having 3 mothers, 3 groups having 4 mothers, and 1 group having 5 mothers, respectively.

2.2. Procedures

Study visits were held on Saturdays at a non-clinic affiliated hospital conference room lasting a duration of approximately 2–2.5 h. Mother/child dyad’s written consent/assent were obtained. As part of informed consent, it was explained that their responses would remain confidential. Specifically, through responses to written questionnaires and their verbal comments via participation in the focus group would be deidentified, with personal names and program affiliations removed to maintain privacy. In addition, as part of focus group instructions, participants were directed to respect the privacy of the group members and to not share information learned with those outside of the group. Heights and weights were measured by trained study personnel. Child participants were provided with supervised activities in an adjacent room. Mothers completed self-report questionnaires independently. Upon completion, mothers engaged in a focus group, which ranged from 62 to 82 min in length.

Focus group questions and associated probes were developed a priori by experts in pediatric nutrition (SR), psychology (MZ), and the conduct of focus groups (LC), based on study aims and using guidelines as outlined by Krueger and Casey (Krueger and Casey, 2015). An interview guide was created and tailored to the specific stakeholder group. The question pathway was structured to first generate discussion regarding mother’s experiences and changes since surgery with regard to a specific topic (e.g., family meals) and ending with a question regarding how/if these changes had impacted her family/child (See Table 1). Questions were initially pilot-tested in a mock focus group to ensure they were understandable. Trained female doctoral (MZ) and masters level (SC) clinicians moderated each focus group. Neither moderator was known to participants prior to the study nor were they affiliated with the participants’ bariatric centers. Moderators used a structured interview guide with probes to elicit responses, as needed. Only one change was made to the question pathway during the course of the study. After the first focus group, it was determined that mothers often spoke of a period of time when things were “harder” versus “easier”. A follow-up probe (“Was there a period of time since your surgery when it was harder or easier to … [i.e., cook, shop, have family meals]?“) was added for all subsequent focus groups.

Table 1.

Focus group questioning route.

1. How do know what to eat each day?

2. How do you know what foods to serve your child, and how much food?

3. When you think about what people call a “family meal”, what does that look like at your house?

4. How have family meals changed since your surgery?

5. What is the hardest part about family meals with your child?

6. Describe what “cooking dinner” means to you.

7. How has cooking foods changed since your surgery?

8. How has food shopping changed since your surgery?

9. What is the hardest part about cooking a meal at home for your child?

10. What are some reasons your family eats out?

11. How has eating out changed since your surgery for you? For your child?

12. What is your biggest concern for your child’s health, now and in their future?

13. Is there anything else we should know about being a mom who has had bariatric surgery?

Focus group discussions were audio-taped and transcribed verbatim by an outside vendor (GMR Transcription). Families were compensated $75 for their time and contribution to the study. Institutional Review Boards at all participating institutions approved the study protocol.

2.3. Quantitative measures

Demographics.

Mothers completed a demographics form, providing child and mother age, sex, race, ethnicity, as well as mother’s marital status and highest level of education.

Anthropometrics and Perceived Weight Status.

Heights and weights were measured by trained study personnel using a portable scale (Seca 770 Digital Floor Scale) and stadiometer (Charder HM-200P). Height and weight data were used to calculate BMI (kg/m²) for mothers, and BMI percentiles and zBMI for children (Kuczmarski et al., 2002). Mothers responded to the following question to assess her perceptions of child weight: “Would you consider your child to be underweight, healthy weight, overweight, obese or severely obese?“.

Child Obesity-specific Quality of Life.

Mothers completed Sizing Them Up (STU [Modi & Zeller, 2008]) to assess caregiver perspective of youth obesity-specific quality of life. This 22-item measure has been demonstrated to be reliable and valid (youth ages 5–18 years). The total score, used in the present analyses, was calculated by summing all items and converting this raw score to a scaled score from 0 to 100, with higher scores indicative of better quality of life.

Parental Child Feeding Attitudes and Practices.

Mothers completed the Child Feeding Questionnaire (CFQ [Birch et al., 2001]) to assess her level of concern regarding child weight (Concern), how responsible she feels for the quantity and quality of their child’s diet (Perceived Responsibility), as well as parenting behaviors related to child eating (Pressure to Eat, Monitoring, Restriction) shown to increase obesity risk. All item responses were obtained using a 5-point Likert scale from 1 to 5, with each scale calculated as an average score. This measure has been demonstrated to be reliable and valid.

Child Eating and Activity Behaviors.

Mothers answered questions regarding child eating and activity behaviors. At time of data analysis, these were used to approximate whether her child was meeting American Academy of Pediatrics (AAP) target behaviors for healthy eating and activity habits to treat/reduce obesity risk (Barlow & and the Expert, 2007). For fruits and vegetables, mothers were asked “how many servings of fruits and vegetables (combined) does your child eat on a typical day?” (dichotomized as 0 = 3 or more, 1 = 2 or fewer). For SSB, mothers were asked to endorse (yes or no) “what beverages does your child drink on a typical day” from a provided list. SSB was dichotomized as 0 = if no SSB were endorsed or 1 = if at least one was endorsed. For eating out, mothers were asked “how often your child eats a meal at or from a restaurant, including take out” for breakfast, lunch, and dinner. Response options ranged from “never” to “5 or more times per week” and were summed across meals and dichotomized (0 = 2 or fewer times per week, 1 = 3 or more times per week). Similarly, mothers were asked how often their child gets food from fast food restaurants (“never” to “5 or more times per week”), with responses dichotomized as 0 = never or 1 = any. For number of family meals in the past week, mothers were asked “during the past 7 days, how many times did all or most of your family living in your house eat a meal together” (dichotomized as 0 = 5 or more times, 1 = less than 5 times). Finally, with regard to time spent on a “typical weekday” in leisure-based screen time, response options ranged from “none” to “4 or more hours per day” and were summed across activities such as watching TV/DVDs, computer/video games, and internet/electronic media. Responses were dichotomized as 0 = 2 h or less or 1 = more than 2 h.

2.4. Data analysis

Quantitative measures with continuous scales were scored based on published instrument guidelines. Responses regarding AAP recommendations were dichotomized as described above. Analyses for these measures were completed using SPSS Version 23. Descriptive statistics regarding maternal, child, and family demographics were calculated. Spearman’s correlations assessed the association of child zBMI with CFQ and STU continuous scales. For AAP recommendations, Fisher’s exact tests were completed to examine the association of child weight status group, dichotomized based on BMI-for-age-percentile for overweight (BMI≥85th percentile: “C-OV”) and healthy weight (BMI≤85th percentile; “C-HW”), with each eating and activity habit. Logistic regressions, with weight status group as the independent variable and each eating/activity as the dependent variable, were used to provide an indication of the magnitude of the effect (i.e., odds ratio).

The key concepts analytic framework (Krueger and Casey, 2015) was used as a guide to analyze focus group data. Specifically, by choosing this approach, investigators create a new structure for the qualitative data focused on the emergent key central themes that support research aims, that cut across questions, participants, and groups. An a priori codebook was developed by study leads (MZ, SR) based upon study aims and transcript review. Next, study leads independently coded two transcripts and generated additional coding categories and labels. The remaining transcripts were then reviewed, with several modifications generated until no additional codes emerged. The final coding framework had 28 coding node options, each with a clear definition. An “other” code was created for statements that did not fit within the coding framework.

Transcripts and the final coding framework were subsequently uploaded to NVivo software (QSR International©) for coding and data organization. Coding of the 5 focus group transcripts was independently completed by three trained coders, including the study co-lead/registered dietitian (SR), a pediatrician (RK), as well as a pediatric psychologist (MM) who served as the reliability coder. The primary study team (MZ, SR, RK, MM, SC) and the qualitative expert (LC) met two times to compare themes and achieved consensus around final key themes (major, minor) and representative quotes. Themes generated from the focus groups are assumed to be representative of the thoughts, behaviors, and experiences of mothers who have undergone bariatric surgery.

3. Results

3.1. Participant and family characteristics

Participant demographics are presented in Table 2. Mothers were approximately 40 years of age with the majority White, married and/or living with a partner, and having two dependent children in the home. Mothers underwent either the sleeve gastrectomy (n = 16) or gastric bypass (n = 4) and were a mean of 7.7 ± 3.1 months post-surgery. The majority of child participants were White and female, with 12 (60%) children classified as overweight (“C-OV”) and 8 (40%) as healthy weight (“C-HW”).

Table 2.

Demographic and family characteristics by child weight status.

	Total N = 20	C-HWa N = 8	C-OVa N = 12	p b
Mother
BMI	33.6 ± 4.3 R = 27.3–41.4	33.2 ± 4.4	33.8 ± 4.4	0.76
Age (years)	39.6 ± 5.7 R = 32-50	39.0 ± 5.1	39.9 ± 6.2	0.73
Race: White	75.0%	100.0%	58.3%	0.06
Married/Living with Partner	60.0%	37.5%	66.7%	0.36
Education: Earned College Degree	60%	75%	50%	0.37
Employed	89.5%c	100.0%	81.8% c	0.49
Number of  Children in  Home	2.15 ± 0.93 R = 1-4	2.5 ± 0.9	1.9 ± 0.9	0.18
Child
zBMI	0.92 ± 1.14 R= −0.86–2.55	−0.24 ± 1.70	1.70 ± 0.66	< 0.001
Age (years)	9.15 ± 2.3 R = 6-12	8.0 ± 1.8	9.9 ± 2.4	0.07
Sex: Female	60.0%	37.5%	75%	0.17
Race: White	65.0%	87.5%	50.0%	0.16

Note: BMI = body mass index.

^aC-HW = children of healthy weight status (BMI < 85th percentile); C-OV = children of overweight status (BMI≥ 85th percentile).

^bp-values are based on two-tailed independent t-tests when examining mean values and on Fisher’s exact tests when examining percentages.

^cMissing for n = 1.

All 8 mothers of C-HW correctly perceived their child’s weight status to be of “healthy weight”. Of the 12 mothers in the C-OV group, 7 (58.3%) reported their child was of “healthy weight” despite measured values indicating that 2 met overweight status and 5 met obese status. Mothers’ perception of their children’s’ obesity-specific quality of life was significantly associated with child zBMI (r = −0.55, p = 0.012), with quality of life decreasing as degree of excess weight increased.

When examining child feeding practices (Table 3-CFQ Scales), greater concern about child weight and lower perceived responsibility for the quantity and quality of their child’s diet were significantly associated with increasing child zBMI. Most children, whether in the C- HW or C-OV group, were not meeting estimates of AAP recommendations for healthy eating and activity habits to treat/reduce obesity risk (Table 4). There were no significant group effects (C-HW vs. C-OV) for fruit/vegetable, SSB, or fast food consumption, nor for frequency of eating out or family mealtimes. There was also no significant group difference in hours of screen time, although the odds ratio (OR) indicated a large effect.

Table 3.

Mother-reported child feeding practices from Child Feeding Questionnaire.

Measures	M ± SD N = 20	ra with child zBMI	p a
Concern about child weight	2.08 ± 1.32	0.65	0.002
Perceived Responsibility for Child Feeding	4.38 ± 0.54	−0.45	0.047
Pressure to Eat	2.00 ± 0.97	−0.43	0.06
Restriction	3.00 ± 1.07	−0.01	0.97
Monitoring	3.83 ± 1.05	−0.23	0.33

Note: BMI = body mass index; M = mean; SD = standard deviation.

^aZero order Spearman’s correlations and two-tailed p-values with child zBMI.

Table 4.

Mother report of child offspring behaviors based on American Academy of Pediatrics (AAP) recommendations for healthy eating and activity habits to treat/reduce obesity risk.

	C-HWa (N = 8)	C-OVa (N = 12)	p b	OR b	AAP Guidelines
Fruits & vegetables	50.0% ≤ 2 serv/day M (SD) = 2.63 (.74)	33.3% ≤ 2 serv/day M (SD) = 2.58 (.67)	0.65	0.50	5 + serv/day
SSB	50.0% ≥ 1/day	58.3% ≥ 1/day	1.00	1.40	None
Fast food	75.0% weekly	66.7% weekly	1.00	0.67	None
Eating outc	25.0% ≥ 3x/week	25.0% ≥ 3x/week	1.00	1.00	≤2x/week
Family meals	62.5% < 5x/week	50.0% < 5x/week	0.67	0.60	5–6x/week
Screen timed	50.0% > 2 h/day	91.7% > 2 h/day	0.11	11.00	≤2 h/day

Note: OR = odds ratio; serv/day = servings per day; SSB = sugar sweetened beverage; x/week = times per week.

^aC-HW = children of healthy weight status (BMI < 85th percentile); C-OV = children of overweight status (BMI≥ 85th percentile).

^bTwo-tailed p-values were based on Fisher’s exact tests. Odds ratios were based on logistic regressions, completed with child weight status (C-HW = 0 and C-OV = 1) as the independent variable and each eating and activity habit as the dependent variable.

^cEating food prepared away from home summed across all meals.

^dUsing computer, video games, and electronic media for leisure.

3.2. Focus group themes

Analyses of qualitative data identified three central themes regarding maternal thoughts, behaviors, and experiences around child feeding, family meals, and the home food environment during the first year postsurgery.

Theme 1. Bariatric surgery is mothers’ personal journey.

Across focus groups, there was strong consensus that bariatric surgery was a solo journey, often commenting, “It’s all about you.” Mothers related that the first 3–4 months postsurgery were overwhelming with the “most barriers and hurdles” to family life. For example, one mother stated, “It was awful. And I just pretty much opted out of any mealtime with my family,” and another said, “I can’t watch you guys eat that.” Their lack of/decreased hunger following surgery impacted not only their own intake (as expected), but also their desire to grocery shop, cook, and eat with family. One mother shared “I did not shop enough because I was never hungry,” while another stated, “There are days that the kids are like, are you ever gonna make dinner? – because I am not hungry. I forgot.” Nonetheless, mothers felt their postsurgery eating process was well-defined by their clinical program, often indicating there were “a lot of rules.” They spoke of pre-planning meals and needing to prepare new foods and in new ways, with the primary focus on protein intake. Mothers also detailed their strategies to meet their daily protein, water, and fitness goals, with many using smartphone apps to self-monitor and set reminders. “I try to surround myself with good choices for high protein, so that way I can grab, but I have to be thinking about it as well as remind myself to eat and drink.”

Theme 2. Family eating is a parallel versus integrated process.

As the focus group question pathway transitioned to her child and family, it was consistently evident that while on this personal journey, mothers’ new eating behaviors were perceived as hers alone. For many mothers, this proved challenging. One mom highlighted this challenge by saying, “… trying to figure out what my kids will eat and then trying to figure out a healthier option for me.” Another stated, “It’s kind of like - here’s what you can eat - but there is not really anyone telling you how to deal with your family or your kids.” Mothers directly stated that in the context of changes to her eating behavior, her families’ eating remained unchanged. For example, “the only thing that has changed for me is the food that I buy for myself. I still buy normal stuff for my family.” For many, these patterns also were seen when eating foods prepared away from home: “I’ll still take them to the drive thru and get them something like that if they want it. But I just won’t eat anything from there.” With consensus across groups that eating family meals were a challenge in general (i.e., scheduling due to child/parent commitments outside the home), many mothers additionally reported eating at different times than their family, whether due to her meal-spacing needs or her eating differently. One mom explained, “My son and daughter will eat at the same time …. but I eat at a different time,” and another stated, “I sometimes don’t even put out a plate for me if I know what they are eating is junk.”

Theme 3. Influences on child eating during mother’s personal journey.

The third major theme characterized mothers’ perceptions of influential factors that encouraged or impeded changes to her feeding behaviors, her child’s eating, and family meals during the first year postsurgery.

Emotions, Cognitions, and Beliefs.

For many mothers, emotions tied to food and weight impacted her food-based parenting. Mothers viewed that imposing their new and more healthy eating patterns would cause “suffering” and they did not want to take away the “joy” of eating from their children. “I feel like they did not put me in this situation. I put myself in the situation I was in. I don’t feel like I should punish them for my situation.” In addition, mothers also spoke of being fearful of transmitting their “baggage” on to their children. For instance, one mother stated, “Whatever hang-ups and self-esteem things I have, I’m just trying really hard not to give that to them, regardless of fat or thin, or how they look.” Another mother “… noticed she’s [her child] been gaining weight. And I am afraid to talk to her about it. I’m afraid to address it because I don’t want to get to her like the way my mom did it.”

Mothers also described new cognitions or beliefs about what food means to them, which included the removal of the social context around eating. For example, “food is fuel” was a frequent phrase used. One mother said, “I do not look at food like – yeah, I want it to taste good – but basically it’s serving a purpose.” In turn, there was a focus on “just feeding your kid” as opposed to thinking about their child’s eating behaviors, the foods their children are eating and how their eating behaviors will impact their weight. An exemplar quote from one mother was, “It’s just more mechanical.” Similarly, one mother shared, “Whether I can get something that all three-well two of them will like, and the protein I can tolerate. That’s pretty much it …“.

Disconnect between knowledge and skills.

Mothers’ comments often alluded to a disconnect between her new knowledge and skills regarding her own healthy eating and her skills or expectations in how or whether to enact changes with her child’s eating. Comments included: “I changed the way I eat and I do not know how to change his …“; “It’s hard to make stuff that you can’t eat and know that you’re eating something that’s good that they won’t eat”; or “I am usually making something else for them because, depending on what I am making, I don’t really expect them to try everything”.

When mothers recognized changes in their childs’ behavior, they perceived this as the result of the childs’ observation of mothers’ behavior change, versus mothers’ change in food-based parenting practices. An exemplar comment from one mother was: “I have noticed the girls say that they’re ‘all about protein’ – they’re more conscious of what they put in their mouths and what the nutrients are in it, because I must mention it a lot.” Another said, “Because I watch what I eat and what I drink she’s just more aware of what she is eating and drinking …. but it’s not really changed what she eats, it just she seems to be thinking about it more just because it is a part of our life.” Taken to an extreme, one mother shared, “I just want to model good eating habits, but I don’t want to talk about diets, and I don’t want to talk about calories.”

Concern about child obesity risk.

Mothers expressed concerned about her child “ending up like” her. For some, it was a foregone conclusion, with no apparent solution she could implement. For example, one mother stated, “With two overweight parents, obese parents, they are probably gonna be obese … this is the reality. I don’t think I can change that barring surgery. I mean, that’s what I had to do … so I sort of feel fatalistic about things.” Others shared, “It’s just her DNA, and it’s not going to change …” or “I see my son in 20 years getting the same surgery and I don’t like that.” For others, their worry and concern were expressed as a motivator for making healthy changes in the home. One mother stated, “I don’t want them to be heavy. I don’t want them to deal with the health issues I’ve dealt with. I can try to do something preventative.” Similarly, another mother stated, “I want them to make those choices, to be able to make the healthy choices now, so I want to instill that in them so she doesn’t have these issues.”

Minor theme: Mothers desired additional information and support.

While a more minor theme relative to the aims of the study (i.e., child/family), it is noteworthy that the mothers’ comments reflected a desire for additional information and support regarding their own eating. There was general consensus that the postsurgery eating plan was well-defined by their clinical program guidelines and early nutrition support (i.e., prescribed daily intake of grams of protein and ounces of water). Yet mothers consistently described a heavy reliance on online support via social media platforms during this first year postsurgery. Specifically, mother’s spoke of gaining informational support with regard to “alternate protein sources”, recipes, and cookbooks. More personally, mothers related they gained significant social support and connection, as one mother stated, “I am in two different groups on Facebook, and I would be lost without either of those two groups,” and others noted “… it’s kind of like a family, honestly,” or “… it gives you hope.”

4. Discussion

Using a mixed method approach, we provide new insights into mothers’ thoughts, feelings, and motivations regarding food parenting practices, family meals, and the home food environment during her first year following bariatric surgery. Specifically, qualitative data demonstrated a critical disconnect between mothers’ descriptions of changes she made to her own behaviors to achieve a healthier weight postsurgery and directly applying these new healthier strategies to feeding her children. Moreover, these data shed an explanatory light on potential contributing factors for this disconnect.

Quantitative findings align with the broader pediatric and extant bariatric literatures and provide a descriptive backdrop for mothers’ narrative gleaned from the qualitative data. For example, it was unsurprising to find that many mothers did not accurately identify their child as having overweight/obesity even though subsequent measured values indicated this clinical status in 60% (Lydecker & Grilo, 2016). Despite these inaccurate perceptions and similar to the literature, as child zBMI increased, mothers endorsed a greater negative impact of weight on their child’s day to day life (i.e., lower obesity-specific quality of life) (Modi & Zeller, 2008), as well as greater child weight concern (Birch et al., 2001), yet less responsibility in the management of their child’s eating choices. Similar to the majority of youth in the United States, regardless of weight status (Kim et al., 2014; Knell, Durand, Kohl, Wu, & Pettee Gabriel, 2019; Watowicz, Anderson, Kaye, & Taylor, 2015), many child offspring did not appear to be meeting recommended dietary and activity guidelines. Direct comparisons of these data to the aforementioned bariatric offspring literature is challenging due to differences in measures used and study designs (Berglind et al., 2015; Sellberg et al., 2018; Willmer et al., 2015, 2016). Nonetheless, these data confirm previously reported mother and/or child behaviors postsurgery, underscoring obesogenic risks remain even in the context of mothers’ active engagement in lifestyle change.

Several key themes and supporting influential factors emerged from qualitative data analyses. Specifically, mothers described being on a personal journey postsurgery where lifestyle changes were hers alone. Child/family eating occurred in a separate and often, unchanged parallel process. For instance, postsurgery food/eating had become more mechanical for mothers as she was less hungry, and thus, child feeding became a more perfunctory task. Indeed, for some families no changes in eating had occurred (“I still buy normal stuff for them”). In other families, changes were not expected to occur due to new cognitions and emotions tied to food and weight influencing mothers’ approach to food-based parenting. Powerful comments suggested implementing healthier eating would cause her child to “suffer”. She spoke of fear she might transfer her “baggage” onto her children. As such, many mothers described a hands-off approach to food-parenting. In addition, mothers also directly acknowledged low knowledge or skills to implement health-promoting parenting practices (“I do not know how”). Most poignant were comments indicating obesity, and the potential necessity of future surgical intervention, were assumed outcomes for her child. That said, concern for her child’s health and obesity risk were palpable when directly asked.

Family meals were also directly impacted. Beyond typical challenges of a “busy family” schedule as reported in the general population (Fulkerson et al., 2011), mothers spoke of additional barriers, including her lack of hunger early in her postsurgery course, her desire to avoid watching others eating, and her differing meal-spacing needs. It is well established that family meals are associated with better dietary intake in youth (Fulkerson, Larson, Horning, & Neumark-Sztainer, 2014). In addition to providing important opportunities for parents to model healthy eating behaviors (Pearson, Biddle, & Gorely, 2009), family meals are also associated with healthier family functioning (Moens, Braet, & Soetens, 2007). Accordingly, this lack of shared mealtime experience postsurgery may limit these potential positive impacts.

Rare were comments suggesting mother and family food/eating were integrated, or where the mother had been the agent of change. To further highlight this point, one mother shared, “Since my surgery, it has been like a total change for all of us, so I have been very lucky.” Another mother stated, “I cook more now, and it’s a lot healthier …. I think I cook better for the kids, too.” And finally, “I feel like they’ve gotten onboard, but it’s just because I’ve been really strict about it. I don’t want to hear whining. They know that whatever mommy makes is what I make. Eat it or don’t eat it.”

Taken together, the clinical implications of these findings are clear, yet currently difficult to implement in the real world. The practice of adult bariatric medicine is driven by a “patient-centered” approach. It has been suggested that the transition to a “family-centered” approach has the potential for a much broader impact (Bylund, Benzein, & Sandgren, 2017; Lent et al., 2016; Pratt et al., 2018). For example, a recent qualitative study with adult patients and adult family members suggested that bariatric surgery is an “individual decision with a family impact” (Bylund et al., 2017). Yet within these “family-centered” approaches, the primary aims are to further improve (adult) patient outcomes via increased support, with benefits to family health more secondary.

The current data suggest a very different pathway is needed for bariatric homes with school-aged children. Mothers lack insight, knowledge, skills, and emotional readiness to address the known obesity risk her children carry. Greater support, education, and innovation are needed if change at the parent-child level is to occur. Family-based weight loss treatment (FBT) is the gold-standard for effective pediatric obesity treatment for school-age youth (6–12 years) in which parents are also targeted to lose weight and taught positive behavioral parent training skills and healthy food-parenting practices (Wilfley et al., 2017). Far from straightforward, it may be possible to incorporate many of these principles into adult bariatric care when patients are also parents of school-age children. As with any supplemental behavioral intervention, requisite efficacy testing as well as consideration of implementation science methodology are indicated to establish feasibility from a provider (and payor) perspective.

At a minimum, bariatric care models should incorporate discussions with adult patients who are also parents regarding weight concern for child offspring. Subsequent referrals back to primary care or tertiary pediatric weight management programs could be made when indicated. In addition, given mothers described reliance on online resources for information and support, supplemental content could be provided by clinical program staff that specifically addresses family-based concerns.

This study provides an important step in understanding why maternal bariatric surgery may not diminish risk to children in her home. We utilized systematic strategies to ensure rigor in our study design and methods, analysis, and presentation of findings as outlined by experts in the field (Krueger and Casey, 2015; Sciences, 2018; Wu, Thompson, Aroian, McQuaid, & Deatrick, 2016). However, findings should be interpreted within the context of the study’s limitations. First, we utilized a cross-sectional design. “Change” was based on mother’s perceptions versus measured change in any outcomes. Second, we chose to recruit mothers within a wide range across the first postsurgery year (i.e., 3–12 months) to capture the breadth of experiences during what is consistently demonstrated as the most active phase of weight loss (Adams et al., 2017; Ahmed et al., 2018; Courcoulas et al., 2018). Prospectively understanding mothers’ perspectives and experiences across the longer-term, particularly as weight loss trajectories diverge (i.e., weight regain [Ahmed et al., 2018]) may prove additionally informative. Third, while our broad recruitment strategy (i.e., multiple programs) reduced risks of potential program bias, it is unknown whether mothers who were experiencing greater/fewer challenges postsurgery were more likely to volunteer for a study with aims to “learn about your perceptions about being a mom and what is like to feed your school-age child”. Fourth, although the number of women participating in each focus group was lower than recommended (Krueger and Casey, 2015), qualitative thematic saturation was achieved with the present sample size. Moreover, the smaller group size provided opportunities for in-depth insights into their experiences (Krueger and Casey, 2015). While themes are assumed to be representative of the thoughts, behaviors, and experiences of mothers who have undergone bariatric surgery, participants could have altered the amount or type of information shared due to lack of familiarity with other participants. Finally, child eating and activity behaviors were based on mother-report, which is limited by her understanding (i.e., “serving size”) and knowledge regarding child intake and activity in a given day/week.

5. Conclusions

For millions of families today, obesity will be a chronic condition likely passed on to the next generation without successful intervention. While bariatric surgery and requisite lifestyle change are effective tools at the individual level, based on these qualitative results, the spread of impact to children present in the home will not happen without innovative family-based solutions. Pediatric obesity is preventable or risk-diminished if addressed early. Maternal bariatric surgery may be a unique (yet missed) opportunity to intervene.