Community and Family Perspectives on Addressing Overweight in Urban, African-American Youth

Abstract

Objective

To assess weight-related beliefs and concerns of overweight urban, African-American children, their parents, and community leaders before developing a family-based intervention to reduce childhood overweight and diabetes risk.

Design

We conducted 13 focus groups with overweight children and their parents and eight semistructured interviews with community leaders.

Participants and Setting

Focus group participants (N = 67) from Chicago’s South Side were recruited through flyers in community sites. Interview participants (N = 9) were recruited to sample perspectives from health, fitness, education, civics, and faith leaders.

Results

Community leaders felt awareness was higher for acute health conditions than for obesity. Parents were concerned about their children’s health, but felt stressed by competing priorities and constrained by lack of knowledge, parenting skills, time, and financial resources. Parents defined overweight in functional terms, whereas children relied upon physical appearances. Children perceived negative social consequences of overweight. Parents and children expressed interest in family-based interventions to improve nutrition and physical activity and offered suggestions for making programs interesting.

Conclusions

This study provides insights into the perspectives of urban, African-American overweight children, their parents, and community leaders regarding nutrition and physical activity. The specific beliefs of these respondents can become potential leverage points in interventions.

Electronic supplementary material

The online version of this article (doi: 10.1007/s11606-007-0469-9) contains supplementary material, which is available to authorized users.

INTRODUCTION

Type 2 diabetes is rising among adolescents, paralleling obesity. It is imperative to develop effective, culturally grounded approaches to adolescent overweight.¹ Some studies have found greater tolerance for overweight among African-American girls.^2,3 We aimed to understand practices and beliefs regarding nutrition and weight among overweight African-American youth ages 9–13 years and their parents preparatory to developing a family-based diabetes prevention intervention.

METHODS

Design A multidisciplinary group developed scripts (Table 1) addressing key issues identified through literature and prior studies from this community.⁴ The University of Chicago Institutional Review Board (IRB) approved this study.

Table 1.

Key Prompts for Focus Groups and Interviews

Focus Group Prompts
1. Parents’ Group Prompts:
Physical activity
In some families we’ve talked to, kids play outside a lot; in others, kids stay inside more often—tell me about your children.
How much TV do your children watch/video games do they play?
What types of activities would you like your child to do more often?
What would help them be more physically active?
Eating
On a typical day, from breakfast to dinner, including snacks, what does your child eat?
Would you like to make any changes in your family’s diet?
What would make it difficult to change your family’s diet? / What would help to change their diet?
Body Image
What makes a person healthy?
How do you determine if someone is overweight?
What are your concerns about your weight? Your child’s weight?
What kinds of problems can a person/a child have if s/he is overweight?
Programmatic questions (regarding a proposed program for children and parents to work on healthy nutrition and exercise behaviors)
What kinds of things would you like to learn from this kind of a program?
What would make changing your children’s/family’s diet difficult? What would make it easy?
What kinds of things would make changing your children’s/family’s activity patterns difficult? What would make it easy?
What kinds of things would make it difficult to attend a program like this? What would make it easy?
Do you think your kids would enjoy participating in the program with their parents?
Would you like participating in such a program with your kids?
2. Children’s Group Prompts:
Physical activity
What kinds of things do you like to do after school?
What do you like to play with your friends?
When friends come over, do you like to play inside or outside more?
What kind of activities do you not like to do?
Tell me about recess/gym class in your school.
Eating
What are your favorite foods to eat?
What do you like to eat for snacks or after school?
What don’t you like to eat?
Tell me about the fruits and vegetables that you eat.
Who chooses the foods that you eat?
Lots of families have rules about eating, like “no desert until you finish your plate.” Does your family have any rules like that?
Do you go grocery shopping with your mom or dad?
How much attention do you pay to what your friends eat?
How comfortable are you eating different foods from what your friends eat?
How do you feel about trying new foods?
Body Image (showing body shape line drawings* and saying “Let’s talk about what makes people attractive to you and what makes them look healthy.”)
Which person would you most like to look like?
Which person looks healthiest?
What kind of things would make you think a person was overweight?
Programmatic questions (prefaced by: “We want to create a health program for kids who are interested in learning new exercises, recipes, and eating habits.”)
If you wanted to change the way you eat, what would make if hard?
What kinds of things would help you change the way you eat?
If you wanted to exercise more, what would make it hard?
What kinds of things would help you exercise more?
Can you think of any physical activities that you would like to learn or try?
What are the top three things we could do to make our program fun for kids like you?

Interview Prompts
3. Prompts for Interviews with Community Leaders:
Needs, values, beliefs, practices
What kinds of health problems do you observe in your community facing young people?
How does the family fit into those health issues?
How aware do you think community members are of these problems?
What health concerns do you perceive to be of interest to community members?
Given all these priorities, where do obesity, nutrition, and exercise fit?
What are the barriers to healthy nutrition in this community?
What are the barriers to physical activity for children and families?
Solutions/Approach
What kinds of resources do community members have for healthy lifestyles?
(Community organizations/exercise/recreational facilities...)
What kinds of programs do you have in your community to address the health problems that you have identified? Where are the ‘holes’?
What kinds of programs would you like to see in your community to address the problems that you have identified?
Where does the proposed intervention (brief description given) fit into the community?
What would be barriers to program effectiveness?
How could we best engage members of your facility/community?

*Figure rating scale adapted from: Stevens J, Story M, Becenti A, et al. Weight-related attitudes and behaviors in fourth grade American Indian children. Obes Res. 1999;7:34–42.

Participants Urban, African-American focus group participants were recruited through flyers in community sites (YMCA, grocery market, neighborhood organizations, clinics) asking “Are you concerned about your child’s weight?” Median household income in this community is approximately $28,000.⁵ Families were screened by telephone for inclusion criteria: African-American family with a 9- to 13-year old child (chosen to inform development of a program for youth this age). Families whose child’s reported weight exceeded the 85th percentile for age and gender were included. At least 1 parent had to accompany the child to the focus group session in a community room at a local grocery store. Parents provided written informed consent; children assented. Each family received $50.From 12/01 through 6/02 we conducted 13 focus groups with children and parents. Of 43 families agreeing to participate, 32 families comprising 32 children and 35 adults came to focus group sessions. Nearly all children were above the 95th percentile of weight for age. Six focus groups comprised 2–6 same-sex children (four girls’ and two boys’ groups); 6 comprised these children’s parents. Thirty-two mothers and 3 fathers participated in parents’ groups, run separately but concurrently with children’s groups. One group comprising both parents and children together was less successful at eliciting frank discussion and was not repeated.Semistructured interviews with 9 community leaders complemented family perspectives. We identified potential interviewees by contacting community leaders with whom we had prior relationships and through referrals from other leaders. All leaders contacted agreed to participate (YMCA director, fitness coach, parish nurse, social service worker, elementary school vice-principal, school outreach worker, dietitian, health educator, and alderman). A semistructured interview format (Table 1) facilitated in-depth probing of each leader’s perspective.

Analysis Transcripts from audiotaped focus groups and interviews were analyzed using grounded theory.⁶ Readers independently identified recurring themes that were discussed at meetings, modified by consensus, and arranged into major domains. Further description of methods is available in an online Appendix.

RESULTS

We observed theme saturation after 6 child and 6 parent focus groups. Sixteen themes emerged, clustering into 4 domains (Domains 1–4, Table 2). We report in this paper the most prominent themes; additional quotations are available in an online Appendix.

1. Barriers to Healthy Nutrition and Exercise ranged from environmental and socioeconomic barriers to preferences for sedentary activities and high-fat foods. Time pressures presented significant barriers to physical activity and healthy nutritional habits; fast food was convenient. Parents often could not prepare meals, especially breakfast; children grabbed snacks on their own. Neighborhood safety issues presented barriers to physical activity. Financial pressures made healthy nutrition and weight lower priorities. Healthy foods were perceived as expensive and affordable recreation opportunities limited. Children preferred sedentary activities (movies, telephone calls, computers) and high-fat foods (pizza, cheeseburgers, French fries, chips, ice cream). Children liked fruit; some reported limited availability. Vegetables were not favored, unless served with cheese sauce, dip, or butter. Time pressures and preferences for sedentary activities and high-fat foods dominated discussion of barriers to healthy nutrition and exercise, and appeared most salient to families.

2. Parental Challenges and Concerns described limits in parents’ knowledge and skills, parent/child interactions, and ability to create a healthy family environment. Parents wanted information about healthy nutrition and weight. Parents felt confused; many felt doctors did not advise enough about children’s weight and nutrition. Children often got sweets/junk foods outside the home. Children accessed snack foods at vending machines, stores, and from friends. Parents said children often received unhealthy foods from grandparents and others. Parents reported difficulty setting limits on television time and food intake. Limiting children’s food intake felt challenging because of parents’ desires not to “deprive” children. Parents worried about psychosocial effects of overweight on children and hesitated to address weight issues for fear of damaging children’s self-esteem. Limiting television and self-esteem concerns appeared to present the most serious challenges for parents.

3. Definitions of Overweight: Parents expressed that bigger people are just built differently; charts do not always apply. Parents did not define overweight as problematic, perse. Many said larger-framed individuals would not look healthy if their weight conformed to standardized body mass index (BMI) charts. Children were more apt than parents to use size and appearance to determine overweight, defining healthy weight as “medium-sized,” or “not too skinny, not too thick.” Children reported that peers considered overweight were teased, depressed, socially isolated, and perceived as greedy and lazy. Parents perceived overweight as problematic when functional limitations resulted. Physical limitations, aches and pains, breathing troubles, and clothes not fitting provided defining points for overweight. Participants perceived health risks of overweight, mentioning high blood pressure, diabetes, and heart attacks. Children cited Big Pun, a severely obese rap artist who died prematurely, but also associated excessive thinness with poor health.

4. Program Recommendations comprised ideas regarding a proposed family-based intervention for overweight children. Parents expressed strong interest in learning general skills like time-management and goal setting, as well as nutrition-related skills such as healthy food preparation, and children suggested activities they would like to try.

Table 2.

Selected Themes and Sample Quotes**

Themes and Quotes
Domain 1: Barriers to Healthy Nutrition and Exercise Behaviors
Theme 1: Awareness is higher for other, acute health conditions such as asthma.
Families deal with things that are very immediate. We’re basically crisis management creatures... (Community leader)
Theme 2: Time pressures are a barrier to physical activity and to healthy eating.
Kids have 20 minutes—by the time they get in line, get their tray, sit down and eat till the time they line up, that’s 20 minutes. So they’re like eating whatever they can get in their stomach. You don’t have time to peel an orange or eat a whole apple. Time is gone. (Community leader)
McDonald’s, Burger King, anything fast—because you don’t have the time...I’ll stop at the restaurants, even though I really can’t afford it. (Parent)
Theme 3: Financial pressures make healthy nutrition and weight a lower priority.
Priorities are paying the bills, having a place to stay, having food, having your lights on, and clothes on your back. Working to pay the rent. (Community leader)
My daughter, she would like to enroll in karate classes and ...a ballet class...but I just couldn’t afford it. I couldn’t afford it. (Parent)
Theme 4: Safety issues present a barrier to physical activity.
Nothing is the way it was when we were coming up...I mean you got crime that’s going on where we’re leery of letting them go out down the street. (Parent)
The really safe place is just as far as the parent can see them. No—as far as the parent can reach out and touch them. (Community leader)
Theme 5: Kids express preferences for sedentary activities and for foods high in fat.
As she gets older she finds things that she is more interested in that aren’t really physical, like hanging out with her friends, movies, that type of stuff. (Parent)
I eat McDonald’s every day—a double cheeseburger. Sometimes I think it’s not healthy. (Child)
Domain 2: Parental Challenges and Concerns Regarding Overweight Children
Theme 6: Parents want information about healthy nutrition and healthy weight for kids.
To learn what really is healthy, cause if I were asked the question, I couldn’t even lie and say I know what healthy is, but would love to learn that. And learn that really healthy lifestyle for my daughter and myself. (Parent)
Theme 7: Kids get sweets/junk foods from sources other than home, including school and other family members.
I don’t buy candy. But when I do laundry, I find candy wrappers in her pockets. (Parent)
And we go shopping and if I want something and I don’t get it, the next day if I go over to my grandma’s house, she’ll have it. (Child)
Theme 8: Parents have difficulty setting limits on screen time (TV/computer) and food intake.
Sometimes I’m glad she got a lot of homework so she doesn’t have time for TV. (Parent)
They stay up all night playing video games, watching TV; they don’t get enough sleep. (Parent)
You could be trying to get ready for work and the TV’s there...you can’t get around the TV. (Parent)
When do you say, “This is enough?...You can’t have anymore [food].” (Parent)
Theme 9: Parents worry about the psychosocial effects of overweight on their kids.
I don’t want her to feel that...because she’s big she’s not supposed to love herself. (Parent)
And then [as kids get older] they’ll be trying to date, and that’s when it really gets tough. (Parent)
One little girl told my daughter, ‘For your birthday, I’m buying you some Slim Fast®.’ And it really hurt her feelings. I told her, ‘Everybody is different.’ (Parent)
Domain 3: Definitions of Overweight and Societal Norms
Theme 10: Bigger kids and adults are just built differently (charts don’t always apply).
My sister—I wouldn’t say she’s overweight. She’s real thick. She’s been big-boned all her life—she’s been thick from a little girl. (Parent)
According to my height I should weigh 115 pounds. I would not look like I was well if I weighed 115 pounds. Now I weigh 190 pounds. (Parent)
Theme 11: Children were more apt than parents to use size and appearance to determine if someone is overweight. (Children were looking at a figure rating scale* during discussion)
She is medium-sized. Like a girl’s supposed to look. (Child)
Theme 12: Overweight is a problem when people have functional limitations as a result.
If you see a person and...they can’t be as mobile as everyone else, that they complain of a lot of aches and pains and, you know, that’s what I...think of as overweight. (Parent)
When you can’t do what everybody else can do you won’t be ever do like your other friends could...If somebody was trying to have a swinging contest, you try to have a swing...and maybe even break the swing. (Child)
Now, when you get obesity and you can’t tie your shoe or whatever, then, yes, you have a weight problem, sure. (Parent)

**Additional quotations are available in an online appendix.

DISCUSSION

This study of attitudes and beliefs among overweight African-American children, their parents, and community leaders corroborates previous findings and offers new insights. Parents defined overweight in functional terms rather than by measurement or charts. Similar results were noted in qualitative studies of African-American women^7,8 and among low-income families.⁹ In the presence of limited resources and confusing messages about nutrition, parents often feel overwhelmed. One study of low-income mothers suggested the best approach to childhood obesity may be to focus on improving parenting skills.⁹ Time pressures, competing priorities, and financial constraints are commonly cited barriers to physical activity and healthy nutrition.^8,9

Children, parents, and community leaders agreed about many topics, but some significant tensions also appeared. Community leaders portrayed families as living chaotic, “crisis management” lifestyles that precluded action on health and nutrition concerns expressed in our focus groups. Nonetheless, parents’ concerns about their children’s diet and the social and health consequences of overweight suggests readiness to change,¹⁰ which can be leveraged in a family-based intervention.

Another divergence occurred between children and parents defining overweight. Parents chose a functional definition and appeared more lenient than children, who relied more on physical appearance. Children’s experience is grounded in schoolyard reality; they see and openly suffer the social consequences of overweight, whereas overweight adults may become resigned or face more subtle discrimination. In an intervention, parents may respond to motivation around functional outcomes, whereas children’s preferences for medium build can be engaged, as long as self-esteem is bolstered and healthy nutrition practices are emphasized.

Children expressed preferences for peer-related activities, whereas parents enjoyed working with their kids. The bonding that developed among peers even during brief focus groups could provide significant reinforcement for participants in a group intervention. Parents expressed catharsis after sharing experiences and airing frustrations; many exchanged contact information after focus groups. Some children who had never met before hugged after the focus groups.

Limitations Focus group participants were self-selected, and the sample size was relatively small. Children’s weight was self-reported by parents in phone screening. We did not collect income information. Results may not generalize beyond our urban African-American population.

IMPLICATIONS

We have identified family and community strengths and challenges as targets for intervention. Most research aimed at reducing childhood overweight and related risk factors has not focused on specific ethnic groups. Few culturally sensitive interventions have been developed for African-American women,^4,11–13 children,^14–17 or families.¹⁸ Weight control interventions for youth work best when they involve both children and parents.¹⁹ Our first 3 domains enrich program development on a deeper cultural level by suggesting which beliefs, knowledge, and skills should be targeted, and what strengths augmented, in this community to increase healthy nutrition and exercise behaviors in families.²⁰ For example, program leaders will incorporate motivational interviewing techniques to engage parents’ concerns about functional status associated with overweight. Families will practice shopping for and preparing lower-fat and lower-calorie alternatives to preferred foods, identified from focus groups.

Community leaders expressed significant interest about focus group findings and wanted to continue involvement in the developing project. We have built a Community Advisory Board for our family-based intervention project. A local grocery store and YMCA were identified for nutrition and exercise sessions. As researchers gain access to community sites, local institutions benefit from educational and financial resources associated with the project and increased community recognition. Such community-based participatory research techniques have significant promise for dispelling mistrust while developing a sense of community ownership for practical, culturally grounded programs.^12,15,16