Parental perceptions regarding lifestyle interventions for obese children and adolescents with nonalcoholic fatty liver disease

Abstract

BACKGROUND:

Nonalcoholic fatty liver disease (NAFLD) affects 30% of obese children globally. The main treatment for NAFLD is to promote gradual weight loss through lifestyle modification. Very little is known regarding parental perspectives about the barriers and facilitators that influence the ability to promote healthy lifestyle behaviours in children with NAFLD.

OBJECTIVES:

To explore and describe parental perspectives regarding barriers to and facilitators of implementing lifestyle modification in children with NAFLD.

METHODS:

A mixed-methods approach, including qualitative methodology (focus groups) and validated questionnaires (Lifestyle Behaviour Checklist), was used to assess parental perceptions regarding barriers to and facilitators of lifestyle change in parents of children with healthy body weights (control parents) and in parents of children with NAFLD (NAFLD parents).

RESULTS:

NAFLD parents identified more problem behaviours related to food portion size and time spent in nonsedentary physical activity, and lower parental self-efficacy than parents of controls (P<0.05). Major barriers to lifestyle change cited by NAFLD parents were lack of time, self-motivation and role modelling of healthy lifestyle behaviours. In contrast, control parents used a variety of strategies to elicit healthy lifestyle behaviours in their children including positive role modelling, and inclusion of the child in food preparation and meal purchasing decisions, and perceived few barriers to promoting healthy lifestyles. Internet sources were the main form of nutrition information used by parents.

CONCLUSIONS:

Lifestyle modification strategies focused on promoting increased parental self-efficacy and parental motivation to promote healthy lifestyle behaviour are important components in the treatment of obese children with NAFLD.

Nonalcoholic fatty liver disease (NAFLD) occurs in approximately 30% of obese children (1). The etiology of NAFLD is related to lifestyles characterized by sedentary behaviours and high intakes of simple sugars/saturated fat (2–4). The mainstay of treatment in childhood NAFLD is weight loss through lifestyle modification (3,5,6). However, there is still no consensus regarding the best way to achieve and sustain long-term weight loss in children with NAFLD. The major challenges in evoking sustained lifestyle changes in obese children include poor adherence to health care professional recommendations by the family and child, high rates of nonreturn to treatment centres due to parental and child dissatisfaction with treatment interventions, and lack of family involvement in lifestyle changes (7–12). Preliminary evidence suggests that obese children with NAFLD experience higher rates of depression than obese children without NAFLD, and that this does not improve with standard approaches to lifestyle modification (13).

Very little is known about parental perspectives regarding the current strategies used to promote lifestyle modification in childhood NAFLD and what impact this may have on treatment outcomes (14,15). Given that parental perspectives have been shown to contribute to adherence to treatment in the obese child (12), understanding the perspectives of the family is important. The present pilot study examined the perceptions of parents of obese children with NAFLD regarding barriers and facilitators that influence the parent and child’s ability to incorporate and sustain lifestyle modification.

METHODS

An explorative study incorporating qualitative (focus groups) and quantitative measures (Lifestyle Behaviour Checklist [LBC]) was conducted involving parents of obese children diagnosed with NAFLD (NAFLD parents) and parents of children with healthy body weights (control parents) (16). A cohort of parents with children who had body weights within healthy weight ranges was included to ensure a comprehensive comparison of parental perceptions regarding lifestyle change because very little information is known about how perceptions of NAFLD parents may differ from the general population. A major determinant of child body mass index (BMI) is parental BMI; thus, comparison of parental perceptions among parental groups of varying BMIs provides unique insight into the potential barriers and facilitators to initiate and maintain healthy lifestyle behaviours in the child.

Parents/caregivers who were <18 years of age, with children <4 years of age and/or who were unable to provide informed consent were excluded. Parents of children with NAFLD were recruited from the Liver Clinic at the Stollery Children’s Hospital, Edmonton, Alberta. Control parents were recruited from the community through the use of local advertisements. Informed consent was obtained from all participants before study entry. The study was approved by the Human Research Ethics Board at the University of Alberta (Edmonton, Alberta).

Demographic and anthropometric variables

Demographic information collected included parental/child age, number of children/parents in each household, and the child’s body weight (parent self-report/home measurement and/or clinic measurement) and diagnosis (NAFLD). Parental weight was measured (without shoes and wearing minimal clothing) to the nearest 0.5 kg (Pelstar Scale, model 752KL; O’Meter Professional, USA) at the Clinical Research Unit at the University of Alberta. Parental height was measured without shoes to the nearest 0.5 cm using a stadiometer (Charder HM200PW, Medical Supplies, USA). BMI was calculated as weight (kg)/height (m)² (9). Body weights of children were classified according to WHO criteria (17).

LBC questionnaire

The LBC is a 25-item, validated questionnaire that assesses both parental identification of problem behaviours (cut-off >50) and parental confidence (self-efficacy; cut off <204) in dealing with perceived child problems related to child lifestyle behaviours (16). The questionnaire asks parents to rate whether the behaviour represents a problem for them (7-point Likert scale; 1 = not at all, 7 = very much) and to rate how confident they are in dealing with the stated behaviour of their child (10-point Likert scale; 1 = ‘Certain I can do it’ to 10 = ‘I cannot do it’). Results were expressed as mean ± SD. Potential inter-relationships between demographic and anthropometric variables (child/parental age and BMI) and the LBC scales were assessed using multivariate analysis; P<0.05 was considered to be statistically significant. All statistical analyses were performed using SAS version 9.0 (SAS Institute Inc, USA).

Focus groups

Focus groups were conducted by trained moderators using an interview guide. The interview guide consisted of six open-ended questions that addressed concepts related to parental perceptions and attitudes toward nutrition education and lifestyle modification (perceived barriers and facilitators). Interview guide content was vetted for face and content validity by external expert reviewers. All focus groups were recorded (IC recorder ICD PX312, Sony Corporation, USA) and transcribed verbatim line by line by two trained and independent reviewers who cross-verified the transcriptions to ensure accuracy of the transcriptions. Data analysis included the ongoing process of categorizing; sampling continued until theoretical saturation was attained (11). Content was analyzed using both inductive and deductive coding approaches, and data were entered using Excel version 12.3.3 (Microsoft Corporation, USA). Procedures and methods were corroborated and independently verified by senior research team members to ensure coder reliability and validity of identified research themes. This approach is useful because it allows for an in-depth, comprehensive analysis of the underlying meaning of the text (18). Transcribed data were coded according to themes and entered using Excel. Data analysis included the ongoing process of categorizing; sampling continued until theoretical saturation was attained (11). Data are presented according to themes and selected respondent quotations are included for illustrative purposes (Tables 1, 2 and 3).

TABLE 1.

Parental self-efficacy and the Lifestyle Behaviour Checklist

Lifestyle behaviours related to diet	Problem scale		Confident scale
	NAFLD	Control	NAFLD	Control
Eats too quickly	5.0±2.4	2.5±2.1	5.2±4.4	8.2±1.8
Eats too much food	6.0±1.1*	2.3±1.4†	4.7±4.1*	8.2±1.4†
Eats unhealthy snacks	4.5±0.5	3.6±1.8	5.7±4.0	7.0±1.5
Whines or whines about food	3.7±1.8	2.7±1.9	6.7±4.2	8.2±1.1
Yells about food	3.2±1.7	1.7±1.0	6.7±4.2	9.1±1.3
Throws a tantrum about food	2.5±1.0	1.7±1.7	7.2±4.2	8.5±1.5
Refuses to eat certain foods	4.7±0.9	3.3±2.1	6.0±3.9	6.2±1.1
Argues about food (eg, when you say no more)	4.7±1.2*	1.6±0.9†	5.5±4.2*	8.2±1.3†
Demands extra helpings at meals	5.0±1.8*	2.3±1.5†	5.2±4.0*	8.1±1.4†
Requests food continuously between meals	2.5±1.2	1.7±1.3	5.5±4.2	8.7±1.3
Demands food when shopping or on outings	3.7±2.7	2.7±1.6	7.0±4.2	7.7±1.8
Sneaks food when they know they are not supposed to	3.5±2.5	2.5±1.6	5.7±4.9	6.8±2.3
Hides food	1.2±0.5	1.0±0.0	7.7±4.5	8.2±2.1
Steals food (eg, from other children’s lunch boxes)	1.0±0.0	1.1±0.3	7.7±4.5	7.3±2.5
Eats food to comfort themselves when feeling let down or depressed	2.0±1.4	1.5±1.0	5.2±3.7	8.0±1.9
Lifestyle behaviours related to physical activity
Watches too much television	3.5±2.6	3.0±1.7	7.0±3.8	6.6±1.3
Spends too much time playing video or computer games	5.2±2.3*	2.0±0.9†	4.7±3.7*	7.8±1.8†
Complains about doing physical activity	5.5±1.7*	1.2±0.7†	4.5±4.3*	9.0±1.4†
Refuses to do physical activity	3.7±2.6	1.2±0.4	4.5±4.3*	8.6±1.3†
Complains about being unfit or feeling low in energy	3.0±2.8	1.1±0.3	4.2±4.2	9.0±1.4
Complains about being overweight	1.7±0.9	1.6±0.7	4.5±4.3	8.8±1.8
Complains about being teased	2.5±1.7	1.3±0.7	6.7±4.2	8.1±2.9
Complains about not having enough friends	1.0±0.0	1.5±1.0	6.7±4.2	8.0±3.1
Complains about being unattractive	1.0±0.0	1.1±0.3	6.5±4.3	8.3±3.0
Complains about not fitting into clothes	1.5±0.5	1.1±0.3	6.5±4.3	8.7±2.0
Total scores	82±17*	48±17†	148±92	204±38

Data presented as mean ± SD.

^*†Values with different superscripts were significantly different at P<0.05

TABLE 2.

Perceived barriers and facilitators of parents regarding lifestyle modification

Perceptions	Themes	Representative quotation
		Lean control group	NAFLD
Barriers	Children’s food preferences	“My kids are very picky…sometimes I have to mask the vegetables.”	“My son doesn’t like fruit... I still don’t find a fruit that he eats.”
	High cost of healthy foods	“The challenge is that you can buy those big litres of soda, and fast foods, cookies and chips, they’re so much less expensive than the healthy options.”	“Because healthy is more expensive.”
	Time constrains	“The lack of time, I mean for me time is a big barrier, I don’t have a lot of time to figure out different things.”	“I just can’t do day time. It is very annoying when people get cranky because they think is too much time for health visits”
	Fast-food exposure	“Advertising, I mean it’s because they want to have hamburgers all the time, cause their friends have hamburgers all the time and they see just all the advertising for all different foods, restaurants and whatever.”
	Cravings	Not discussed	“I don’t have sweet cravings, but my son does.”
	Lack of motivation	Not discussed	“My son lack’s of motivation”, “A poor social life.”
Facilitators	Role modelling	“Children copy us, it is important to show them how to eat, how does it taste and everything comes with the time and consistency.”	“I know that I should be his role model and you know, I mean I don’t exercise either, I don’t have time to exercise.”
	Provide healthy foods	“It is keeping with a big variety, available foods at home.”	“As long as we have a lot of fruits and vegetables all times, there is always something to please them.”
	Portion control	“I have to keep reminding my nineteen-year-old that if he grabs something and starts eating out of it. I will say to him: use a bowl… you have no idea how much of that are you eating.”	“Usually it’s a negotiation.”
	Food preparation and preplanning	“Most of the time it is homemade food. So it involves a lot of preplanning, at least a day a head of time. Sometimes I’m cooking supper at four in the afternoon so that we can bag it and take it”	“If we are out and we know we’re going to be out for the whole entire day, we usually pack snacks”
	Family environment	“I’ve always tried as much as possible, that all of us eat supper together”

NAFLD Nonalcoholic fatty liver disease

TABLE 3.

Parental perceptions regarding nutrition education provided in standard of care

	Themes	Representative quotation
		Lean control group	NAFLD group
Attitudes and perceptions	Lack of practical recommendations	“Things like: have so many grams of such and such per day, but they do not show on a plate what the portion looks like.”	“The information is out there but it is not simplified and therefore, it is just not been followed.”
	Online information is not trusted	“We have to think about the kind of information we’re reading and see if it make sense or not.”	“So, different sites say different things so it is almost like a try and error”
	Lack of support from health professionals	“Some pediatricians say: as long as they’re healthy weight it does not matter what they’re eating.”	“You don’t want to go see a nutritionist and be just completely discouraged, I get that already”
Needs	Recipes and snack ideas	“Recipes, because everybody knows like fruit and vegetables are good, everybody knows that we are not supposed to eat too much fat and too much carbohydrates, but not everybody knows how to combine those.”	“Different ideas for what to pack for snack ideas, those types of things.”
	Practical tools	“Something that kids get to know themselves, that they can go online and tape what they ate that day and know the things they should or not eat”	“Something that we can work when we go shopping, like a list, so then you are not kind of side-track by everything else.”
	Motivation techniques	Not discussed	“Motivation techniques, anything that gives hope”

NAFLD Nonalcoholic fatty liver disease

RESULTS

Demographic and anthropometric data

A total of 12 parents (n=4 NAFLD [three female, one male] and n=8 control [seven female, one male]) participated in the present study. No significant differences in mean (± SD) parental age (NAFLD 43.5±9.6 years versus controls 41.9±8.4 years; P=0.5), child age (NAFLD 13.0±4.5 years versus controls 10.2±5.7 years; P=0.4) and/or in the number of children per household (NAFLD 1.6±0.7 versus controls 1.3±0.5; P=0.3) were present between the groups. However, parental/child BMI was significantly greater in the NAFLD group (parent 30.4±5.6 kg/m²; child 32.6±5.2 kg/m²) compared with parental/child BMI (parent 21.9±2.5 kg/m²; child 16.4±3.1 kg/m²) in the control group (P<0.005). Parental BMI was positively associated with child BMI (r²=0.4; P=0.03).

Parental self-efficacy and lifestyle behaviours of the child

Control parents had significantly lower total scores for lifestyle factors (diet, physical activity) assessed to be a ‘problem’ by NAFLD parents (Table 1). Significant problems identified by NAFLD parents included pace of eating, the amount of food consumed and issues related to sedentary physical activity (length of time devoted to watching television or playing video games, and child refusal to participate in nonsedentary activities). There were no significant differences noted between groups for total scores related to parental confidence to cope with these issues (P>0.05). However, NAFLD parents had lower confidence scores (self-efficacy) related to coping with specific lifestyle behaviours, particularly with regard to food portion sizes consumed, food binging and reductions in sedentary behaviours (time spent playing video games), than control parents (P<0.05). This was particularly evident in the parents with higher BMI who had significantly reduced confidence related to dealing with food-related behaviours, such as “eats too much” (P=0.007), or refusing to participate in nonsedentary physical activities (P=0.02).

Parental perceived barriers to and facilitators of lifestyle modification in the child

Data regarding identified themes related to parental perceptions of barriers and facilitators to promote lifestyle modification are presented in Table 2. A total of four focus groups were conducted (NAFLD parents, n=2 parents per focus group; control parents, n=4 parents per focus group). The major themes related to potential barriers to promoting lifestyle behavioural change in the child that emerged from both groups were environmental factors such as exposure of children to ‘fast foods’ through the media and school, the high cost of healthy foods verses less expensive fast foods, children’s food preferences and overall lack of time (Figure 1). One noteworthy difference in NAFLD parents, however, were the cited struggles with role modelling of healthy lifestyle behaviours by the parents themselves and a lack of overall self-motivation to make lifestyle changes. In contrast, control parents cited positive role modelling of healthy lifestyle behaviours as an important facilitator to promote overall healthy lifestyle behaviours in their child. This included involving the child in food purchasing decisions and meal planning, encouraging the child to try new foods, monitoring food choices in terms of nutritional quality rather than portion size and participating in nonsedentary recreational activities with their child. All of these approaches created a family environment in which children were encouraged to talk about healthy food options, rather than simply focusing on portion size control. A stronger emphasis by control parents was placed on prioritizing meal planning and food selection as part of daily routines. NAFLD parents did not use these strategies to the same extent. For example, although role modelling was cited as one potential strategy to elicit changes in child lifestyle behaviours, this approach was applied inconsistently and was rarely used to support healthier food choices and alterations in physical activity in the child with NAFLD. NAFLD parents perceived the ‘art of negotiation’ to be a more feasible approach to promote healthier food choices in their child and to elicit changes in nonsedentary activities. Less focus was devoted to meal preparation and/or integrating the child into this process, or prioritizing time spent by the parent and child in meal planning, food selection and/or in changes in physical activity.

Figure 1).

Factors influencing parental self-efficacy related to promoting lifestyle modification in the child and adolescent with nonalcoholic fatty liver disease. BMI Body mass index

Parental perceptions related to nutrition education

The major sources of nutrition education were health care professional (paediatrician/family physician, nurse, dietitian) and Internet sources (Table 3). The focus of this education was related to infant feeding/child development and general healthy eating for both groups; however, for the NAFLD parents, more emphasis was placed on lifestyle modification when seen by health professionals for treatment of NAFLD. Both groups expressed concern about access to trained health professionals in nutrition and cited this as the major reason for continued reliance on Internet sources for nutrition information. Another major concern expressed by NAFLD parents was the lack of practical nutrition resources provided by health professionals. Parents emphasized the need to increase the practicality of nutrition resources (eg, recipes, snack ideas, shopping lists) provided by health care providers to ensure incorporation of lifestyle changes into daily life. Interestingly, these parents also asked for ‘anything that provides hope’ and/or prevents the parent and child from ‘being completely discouraged’.

DISCUSSION

Clinical guidelines for childhood NAFLD treatment recommend gradual weight loss through lifestyle modification (5,6). Recent evidence suggests supporting effective parenting styles and direct involvement of the parent in lifestyle change, particularly in younger children, may result in sustained healthy lifestyle changes (9,12,19). While the perceptions of parents with obese children have been well described in the literature (7,9), there is no information regarding parental perceptions in obese children with chronic liver disease. This is important to understand to ensure effective programming can be developed to promote healthy lifestyle behaviours in childhood NAFLD. The present pilot study describes and explores parental perceptions regarding the barriers and facilitators to elicit healthy lifestyle behavioural changes in children with NAFLD and the factors that may influence this (parental self-efficacy/motivation, nutrition education).

Parental perceptions related to barriers to and facilitators of lifestyle modification

The major barriers to incorporating healthy lifestyle patterns cited by NAFLD parents included lack of time, higher costs of healthy foods, differences in prioritization of time spent in meal preparation and lower parental self-efficacy related to promoting healthier lifestyle behaviours in the child. Interestingly, while both groups of parents cited common problems related to food intake and increasing time spent in sedentary activities, control parents cited a higher sense of self-efficacy and a greater diversity of parenting approaches to address these concerns. For example, control parents cited role modelling of healthy behaviours as the primary method for inducing healthy lifestyle patterning of the child. A number of different strategies were used to do this, including increased prioritization of time spent in meal preparation, inclusion of the child in food purchase and meal preparation decisions, and less emphasis on food portion size. This also included increasing emphasis on communication with the child at an early age about healthy food choices, ensuring that a variety of healthy food choices were available within the home and parental participation in nonsedentary activities with their child.

In contrast, NAFLD parents cited a lack of motivation to make personal healthy lifestyle choices or to participate in nonsedentary activities, and a substantially lower sense of self-efficacy to promote lifestyle change in the child compared with control parents. The use of negotiation regarding food selection, food portion size and/or increasing nonsedentary physical activity was a major strategy used. This included the potential for the use of ‘food rewards’ to compensate or motivate short-term healthy behaviours in their child. Food negotiation has been identified as a strategy among parents with different socioeconomic backgrounds such as lower-income mothers (20), parents of children in kindergarten (21), and parents of obese children and adolescents (9). However, this strategy is often associated with weight gain because the ability to establish limits can be compromised and the use of food as a reward can send conflicting messages to the child (22). Both permissive and/or authoritarian parenting styles regarding fast food consumption have been associated with increased rates of childhood overweight (12,22,23). While NAFLD parents did not report using permissive parenting approaches, the combined use of lower parental self-efficacy/motivation and use of negotiation may be an important factor influencing adherence to lifestyle recommendations. NAFLD parents cited lack of time as the major reason for the paucity of family-based meals and nonreturn to treatment centres, factors that are known to be associated with an increased paediatric obesity and diminished sustainability of lifestyle change (7,8,12,22).

Parental perceptions related to nutrition education

Both groups reported that they received previous nutrition education during routine health visits. However, both groups stated that this information often did not satisfy a specific need to promote healthy lifestyle behaviours, particular with regard to dietary modification. Parental behaviours regarding food intake may be more dependent on individual parenting style, personal food preferences and parental peers rather than dietary guidelines (24,25). Preliminary evidence suggests that children with NAFLD and their families are aware of dietary guidelines promoting healthy lifestyle behaviours, but still struggle to translate and sustain these changes (13–15,26). All of this suggests that both content-focused education and behavioural/psychological interventions are needed to promote lifestyle change. The need for motivational techniques to promote parental self-efficacy, in addition to practical and easy to apply techniques, were also cited as a key strategy to assist parents and children with positive lifestyle behavioural changes.

Study limitations include the relatively small sample size. While theoretical saturation of all key themes were reached within the focus groups for each concept presented, it is possible that additional themes may have emerged with a larger sample size. No new themes emerged from either group after the first focus group was conducted, indicating that the current sample size was sufficient to assess primary outcomes. While the sample size precludes the ability to determine the other potential sociodemographic factors (eg, parental education, household income, ethnicity) that may influence perceived parental perceptions about barriers and facilitators related to lifestyle interventions, the current pilot study presents novel and compelling differences related to parental perceptions about lifestyle modification that may influence treatment outcomes for the obese child with liver disease.

CONCLUSION

Despite medical evidence of end-organ injury consequent to obesity, parents of children with NAFLD struggle to encourage their children to follow a healthy lifestyle. Barriers to successful incorporation of lifestyle modification include lower parental self-efficacy and lack of parental motivation to incorporate and role model healthy lifestyle behaviours to the child. All of these factors may contribute to increased nonadherence to lifestyle advice in children with NAFLD. The present pilot study highlighted compelling differences in parental perceptions, self-efficacy and motivation to promote healthy lifestyle behaviours in the child – factors that may directly influence overall effectiveness of lifestyle treatment for the child with chronic liver disease.