Abstract
Objective
We investigated mothers’ possession and display of action competence to counteract or prevent overweight and eventual obesity in their children. Action competence is defined as a personal resource where the most important aspect is the individual’s wish to take action and to believe in its benefit. It unfolds within the room for action as experienced by the individual due to action obstacles and action potentials.
Methods
In a case-control study, mothers of 111 overweight children (MOC) were compared with mothers of 149 nonoverweight children (MNC). They underwent a semistructured interview about action competence, lifestyle, and their 7- to 9-year-old children.
Results
Compared to MNC, MOC considered it more important to change habits, both for themselves (p = 0.003) and their children (p < 0.001). MOC were more motivated to change habits (p < 0.001), assessed their action competence to be higher (p < 0.001), and felt to a greater extent that they supported their children to achieve an appropriate weight (p < 0.001) compared with MNC. No difference was found between MOC and MNC in the assessment of their own room for action and their children’s room for action.
Conclusion
Self-assessed room for action was not limited for either MOC or MNC, and MOC even assessed their action competence to be greater.
Key Words: Case-control study, Mother-child relation, Childhood overweight, Action competence
Introduction
Childhood overweight and obesity are recognised internationally as serious medical and public health issues. These chronic non-communicable diseases require urgent attention [1, 2]. In spite of numerous studies, prevention and treatment of childhood overweight and obesity is characterised by lack of effective intervention [3, 4], and almost all studies emphasised the need for action [3–10].
There is a need to look in new directions with the hope of achieving a more comprehensive understanding of the complex phenomenon of childhood obesity. One direction could be to investigate mothers’ possession of action competence, and how action competence is played out to counteract or prevent overweight in their children. One study examined the strategies used by the parents to prevent unhealthy weight gain in children [10], which were balanced diet/healthy eating, promoting exercise, reducing ‘junk’ food, limiting the amount of fat and sugar in the diet, promoting more fruit consumption, and providing education about healthy lifestyle. We approach the theory behind mothers’ action competence on childhood obesity from the mother’s perspective. Action competence pertains to the individual and is here defined as a personal resource where the most important aspect is the individual’s wish to take action and to believe in its benefit [11, 12]. Action competence is a societal phenomenon which is expressed in the action of the individual to enter, use and change existing practice. Displaying action competence involves the individual to draw up and realise personal aims or intermediate aims. Realisation of the aims is obtained through qualified and motivated action. Action competence always occur along with a specific situation, where action competence will unfold due to action potentials and action obstacles within the room for action [12]. To unfold the specific action competence, general preconditions of the person and environment are demanded. Albertsen and Andersen [13] described the personal preconditions as skills, setting, motivation, and positive self-knowledge to take action, where motivations are influenced by a person’s emotions, expectations and goals [14]. The preconditions could either limit or positively influence the mothers’ capacity to display the specific action competence to the benefit of their children’s weight and health. Societal and local resources, such as work, residence, finances, family and social relations, also provide a basis of support to display action competence [13, 14].
One key issue in being able to play out action competence to combat child obesity is that the parents, as primary care givers, are aware of their children’s weight status. Parents who do not recognise weight problems in their children are less likely to take steps to change their children’s unhealthy lifestyle and prevent obesity [15]. In the article ‘Maternal and Child Awareness and Expectations of Child Overweight’, published in this issue of the journal, our objective was to investigate the mothers’ and children’s perception of body size as a basis for the mothers’ assessment of their children’s weight status and their awareness of weight problems in their children [16]. Uncertainty in assessing the overweight children was found both for these children and their mothers. However, the perception of normal body size was not distorted when compared with non-overweight children and their mothers. The overweight children and their mothers had the same perception of a normal body size, a similar wish for a normal body size, and considered a normal body size to be the most attractive and socially acceptable. In the present article, our aim was to study the mothers’ possession of action competence, both for those who did not recognise, and those who did acknowledge a weight problem in their children. We studied how the specific action competence was assessed and played out with the intention of counteracting or preventing their child’s overweight.
Material and Methods
Material and methods have previously been described [16] and are dealt with only briefly here. The study was based on the Danish National Birth Cohort (DNBC) [17], a longitudinal large-scale study involving data collection when the children were 7 years old, with a follow-up of the mothers’ and the children’s current situation, and based on whether the children had or had not become overweight, regardless of the mothers weight. When recruiting for the present case-control study in autumn 2007, 11,249 children had turned 7, and data from their follow-up questionnaires were registered. After meeting the inclusion and exclusion criteria (described in [16]), 2,846 pairs were potentially eligible, from which 471 pairs were randomly selected within candidate case and control groups. Of these, 241 pairs were invited to participate as cases and 230 as controls [16]. In total, 307 of the 471 pairs participated in the examination (65%). Subsequently, 47 were withdrawn due to a change in body mass index (BMI) status or the onset of puberty, which resulted in 260 (55%) (119 boys and 141 girls) mother-child pairs being finally included in the analysis. Data collection took place between September 2007 and January 2009.
Examination and Interview
Two researchers, who were equally trained and experienced in child and family contact, conducted a 2-hour face-to-face interview and physical examination of the mothers and children (first author 82% and project nurse 18%). To investigate the mothers’ possession of action competence and their ability to display it, a semi-structured interview was constructed. The questions were constructed around, and founded within, the theoretical framework of the study [11–14, 18–20]. Hence, the questions were written from the mother’s perspective and aimed to capture aspects of the mother-child relationship, action competence, and health behaviour. The questions were presented to the mothers under the headings of the children’s weight, the mothers’ attitude to food/meals, physical activity, sleep, and healthy living. There were also questions relating to their assessment of their actual lives, their judgement and readiness to take action to make changes, how the mothers and children got along together, and some supplementary background questions regarding the information the mothers had previously provided in the DNBC study. In the semi-structured interview, the Lickert scale was used with 5 answer possibilities, and the opportunity to elaborate on the answers was provided. It was pre-tested on 4 mothers, resulting in minor adjustments in the order of questions and wording. Interview questions are available on request from the first author. The interview was conducted with the mothers who had a full copy of the questions and answer possibilities in front of them. The questions were read aloud to the mothers by the researcher who orally repeated the mother’s answer when ticking the box relating to the answer. If the mother elaborated on the answer, the researcher also wrote the elaboration down and read it back to the mother aloud for validation.
The mothers’ assessment of their possession of action competence was revealed through questions about their skills and proficiency and the capacity to transfer them from one situation to another, as well as their motivation, including aim, expectation and emotions in relation to habit change. These features were expressed in terms of how prepared the mothers were to live healthily, how healthy they actually lived, how important they thought it would be to change the way they lived, and how willing they were to support their children to make changes in their habits in order to live more healthily. It was also assessed to what extent they tell their child how to avoid weighing too much, and to what extent they are in a position to, and capable of, supporting their children to change habits in order to live healthily.
Questions about whether the mothers mostly assessed their life experience as either providing opportunities or obstacles, how they assessed their own action choices, and to what extent they felt they had influence over their own lives were designed to reveal to what extent the mothers took the opportunities for action presented with regard to their child’s weight issues. The mothers’ assessment of their children’s room for action was revealed through questions about how they brought up their children, to what extent they supported their child’s influence over his/her own life, and the extent to which the child showed meaningful and appropriate behaviour. Questions about the mothers’ first reaction to habit change and to what extent they considered their surroundings as supporting them to lead a healthy life were used to assess if people in their surroundings were conductive and whether they had a positive self-understanding and belief in their capacity to carry out actions.
Statistical Analysis
Descriptive statistics for the variables of interest were calculated for each group. Mean and standard deviations were determined where appropriate, and a threshold for statistical significance was set a priori at 0.05 and with 95% confidence intervals. The Pearson chi-square test was used to test for differences between the categorical variables. A t-test for unpaired data was used to test for differences between cases and controls. Statistical analyses were performed in SPSS software version 16.0/17.0 (SPSS Inc., Chicago, IL, USA), except for marginal homogeneity which was tested using the Stuart-Maxwell test in Stata (StataCorp LP, College Station, TX, USA).
Ethics
The study was approved by the DNBC (ref. no. 2007-05), the Danish Data Protection Agency (j. no. 2007–41–1435), and the Danish National Committee on Biomedical Research Ethics (j. no. H-D-2007-0015), and carried out according to the Helsinki Declaration. All children and mothers were informed about the purpose and procedure, and provided oral and written informed consent.
Results
Detailed characteristics of the participants are described in an accompanying article [16]. The children’s mean age was 8.1 years, and the case children’s mean BMI was 4.37 kg/m2 greater than that of the control children (p < 0.001). There were no significant differences between MOC and MNC with regards to age and height, but a significant difference was found for weight, BMI, waist (all p values < 0.001), and hip circumferences (p = 0.001), where MOC had higher measurements for all parameters. MOC had a lower socio-occupational status than MNC (p < 0.001).
The Mothers’ Possession of Action Competence
We found no significant difference between MOC and MNC as about 60% of both MOC and MNC were very willing to live healthily (table 1). In contrast, only 16% MOC and 20% MNC assessed their children to be very willing to live healthily – again no significant difference between the 2 groups. Even though about 60% of MOC and MNC were willing to live healthily, only 13% of MOC and 18% MNC answered they actually lived healthily (all p values < 0.001). For MOC as opposed to the MNC, the most important action was to change habits, both for themselves (p = 0.003) (table 1) and their children (p < 0.001). MOC were also more motivated than MNC to change habits (p < 0.001). Yet, MOC did not talk very much with their children about weight, although they talked significantly more about weight with their children than MNC did (p < 0.001). Mothers from both groups mentioned risk and fear of anorexia if they talked about and focused too much on their children’s weight. No significant difference was found, as about half of both MOC and MNC assessed themselves to have high competence to change their children’s habits towards a healthier lifestyle (table 1).
The Mothers’ Competence to Take Action
Regarding the mothers’ first reaction to habit change, we found no significant difference between the groups: 51% of MOC and 59% of MNC assessed it to be easy, and 50% and 41%, respectively, assessed it to be hard, to change lifestyle habits (table 2). When mothers assessed their own room for action, about 80% of both MOC and MNC found more potential opportunities than obstacles in their lives. This was supported by 87% from both groups who felt they had a high level of influence over both their own and their children’s lives. When mothers assessed their children’s room for action, the majority of both MOC and MNC stated that they brought up their children using a combination of assisting the children and letting the children solve problems themselves. More than 2 out of 3 mothers from both groups found that they highly supported their children to have influence over their own lives. Neither was a significant difference seen between MOC and MNC when they assessed their children’s appropriate behaviour. A total of 79% of MOC assessed that they had taken specific action to avoid obesity in their children, which was significantly different from the MNC of whom 64% stated they had taken no specific action towards prevention of overweight among their children (p < 0.001) (table 2). Besides, MOC felt more than MNC that they supported their children to achieve a normal weight (p < 0.001). Furthermore, MOC assessed that their children were harder to guide towards healthy habits while MNC to a higher extent felt their children were easy to guide into healthy habits (p < 0.001). In addition, MOC more often than MNC answered that they were not well supported in living healthily by the people in their surroundings, such as grandparents, schoolteachers, playmates and friends (p = 0.003).
Discussion
The main findings from this study were that both MOC and MNC were highly motivated to live healthily, but a difference was found between the 2 groups in how willing they were to live healthily and what they actually achieved. Despite the fact that the MOC, compared to the MNC, assessed that they were very willing to change habits and they were in possession of action competence, it was not always enough for them to display action competence in everyday life to prevent or treat overweight in their children.
Even though half of MOC and MNC answered that they had the competence to change habits and lifestyle, some found it hard and others easy. Those who found it hard may already consider their lifestyle quite healthy and not find many possibilities for further changes. Alternatively, they were influenced by the fact that they did not really wish to take action or did not believe in the benefit of it. Both are personal conditions that can inhibit habit changes [11, 12]. They may also have been aware that all behavioural and lifestyle changes are complex, this is in agreement with findings in other studies [1, 3, 4, 14].
Even when the MOC were highly motivated to take action and their emotions, expectations and goals were pointing in the same positive direction, the reality of their self-perception could inhibit them from taking action [14], even though they considered it important to change habits both for themselves and their children. In contrast to this, there are parents who are unaware and unconcerned about their children’s weight [21]. Those mothers from both groups who found it easy to change lifestyle are likely to have good memories from earlier experiences with behavioural change for themselves and their children. This is consistent with studies that designate the parents as the central agent of change in their children’s environment [10, 22]. Thus, through their parenting and feeding style, they can influence and foster a healthy lifestyle for their children.
When the mothers assessed their own room for action and their children’s room for action, the opportunities were the same for both MOC and MNC. For MOC compared to MNC, their room for action seemed not to be limited. In addition, they all felt they had a high degree of influence over their own and their children’s lives. This is opposed to finding’s by Grønbæk [23] who reported that in nearly 10% of the families the children’s obesity was considered to be caused exclusively by factors not in control of the parents. The MOC took different strategies of action in supporting their children to prevent unhealthy weight gain, which is in agreement with findings by Crawford et al. [10]. This emphasizes the motivation of the MOC to take action. Based on the frame of reference [13, 14], it was expected that MOC would report less action competence compared with MNC. However, MOC assessed higher levels of action competence than MNC. This result could be biased because data were obtained through interview, where the mothers might not want to admit face-to-face to the researcher that they had done nothing to avoid overweight in their children. On the other hand, MNC might not have been conscious of displaying action competence with the particular purpose of preventing an increase in their children’s BMI. If they have a basically healthy lifestyle that may prevent overweight, then there may be nothing to draw specific attention to such actions.
Compared to MNC, MOC to a greater degree reported that they supported their children to achieve a normal weight, but also that the children were harder to guide towards healthy habits. This could be due to the fact that they had tried to avoid overweight in their children – but without success since their children at the time of the examination were overweight. The MOC reported they had less support from those in their surroundings, which could be another barrier to displaying action competence, since several studies emphasise the importance of a supportive network for successful change of behaviour and lifestyle [4, 24]. Other factors in the local environment or society could also be inhibitors for the mothers to be able to play out their action competence towards child overweight [13, 14]. Action competence pertains to the individual [13, 14], but as stated by Lobstein et al. [1], the society provides a framework which could inhibit or facilitate healthy choices for mothers and their children.
Another interesting finding was that mothers from both groups expressed that they feared their children could develop anorexia if they talked about and focused too much on their children’s weight. This could be because parents are overly concerned about their children being underweight but not about them being overweight [15]. The same fear has also been reported in a review by Butryn and Wadden among health professionals, teachers and parents, who fear dieting may lead to eating disorders [25]. Anorexia is seen in prepubescent children in Westerns cultures where food is in abundance [26], but fear of anorexia should not impede efforts to counteract child obesity [25], especially in the absence of the children avoiding food, performing extensive exercising, or being preoccupied with body weight or energy intake, which are some of the criteria for anorexia nervosa [27]. On the other hand, the mothers’ fear must be acknowledged and accomodated with information and explanations about the development of anorexia nervosa. This is a challenge for health professionals who are in contact with those families.
Limitations and strengths pertaining to the study design are described in detail in the accompanying paper [16]. The particular strength of this part of the study is the use of semi-structured interview questions focusing on and founded within acknowledged theories about action competence. On the other hand, the contrast between MOC and MNC in terms of action competence may appear weaker in the present setting than in real life in the underlying populations because of the selection processes for both the DNBC study and the present study. Therefore, it would be necessary to replicate our study in different settings where the selection processes are different. Furthermore, studies of action competence in other cultures and countries and in other age groups of children may be helpful. Also, research is needed on how to address the problem within the family and which interventions they prefer and find successful. Further research on barriers and possibilities to take action by both families and health professionals to help children to prevent overweight and eventual obesity is necessary. One possible approach to this problem is to conduct in-depth qualitative interviews with mothers and children.
In conclusion, we have shown that both MOC and MNC felt they had a high influence on their own and their children’s lives, and that the room for action was not limited. Surprisingly, MOC found their action competence to be greater than MNC, which may be due to fewer concerns about their children’s weight. Yet, the MOCs’ action competence towards child obesity was not always played out or had not been sufficient to prevent overweight among their children.
Disclosure Statement
The authors declare no conflict of interest and are solely responsible for the content and writing of this paper.
Table 1.
Maternal possession of action competence regarding their children – assessed by the mothers (MOC n = 111, MNC n = 149; children’s BMI categories determined as per Cole cut-off points [28])
| Lickert scale, n (%) |
p valuea | ||||
|---|---|---|---|---|---|
| high | some | less or low | not or none | ||
| How willing to live healthily | |||||
| Mothers regarding themselves | 0.586 | ||||
| MOC | 70 (63) | 40 (36) | 1 (1) | 0 (0) | |
| MNC | 89 (60) | 60 (43) | 0 (0) | 0 (0) | |
| Mothers regarding their children | 0.522 | ||||
| MOCb | 18 (16) | 63 (57) | 25 (23) | 4 (4) | |
| MNC | 29 (20) | 78 (52) | 36 (24) | 6 (4) | |
| How healthily they actually live | |||||
| Mothers regarding themselves | 0.228 | ||||
| MOC | 14 (13) | 78 (70) | 18 (16) | 1 (1) | |
| MNC | 27 (18) | 108 (73) | 14 (9) | 0 (0) | |
| Mothers regarding their children | 0.562 | ||||
| MOC | 15 (14) | 82 (74) | 14 (13) | 0 (0) | |
| MNC | 24 (16) | 108 (73) | 16 (11) | 1 (1) | |
| Consider it important to change habits | |||||
| Mothers regarding themselves | 0.003c | ||||
| MOC | 29 (26) | 41 (37) | 27 (24) | 14 (13) | |
| MNC | 22 (15) | 38 (26) | 61 (41) | 28 (19) | |
| Mothers regarding their children | < 0.001c | ||||
| MOC | 35 (32) | 35 (32) | 24 (22) | 17 (15) | |
| MNC | 8 (5) | 29 (20) | 55 (37) | 57 (38) | |
| Mothers’ motivation for habit change | < 0.001c | ||||
| MOC | 103 (93) | 7 (6) | 1 (1) | 0 (0) | |
| MNC | 113 (76) | 32 (22) | 4 (3) | 0 (0) | |
| Talk about weight with their children | < 0.001c | ||||
| MOC | 19 (17) | 47 (42) | 29 (26) | 16 (14) | |
| MNC | 12 (8) | 31 (21) | 53 (36) | 53 (36) | |
| Mothers’ competence to change children’s habits | 0.393 | ||||
| MOC | 58 (52) | 48 (43) | 5 (5) | 0 (0) | |
| MNC | 73 (49) | 73 (49) | 3 (2) | 0 (0) | |
p value when computed into categories with more than 5 in each cell.
The Lickert scale also had a ‘do not know’ answer possibility which was chosen by 1 mother only.
Significant. MOC = Mothers of overweight children; MNC = mothers of non-overweight children.
Table 2.
Maternal action competence played out towards their children – assessed by the mothers (MOC n = 111, MNC n = 149; children’s BMI categories determined as per Cole cut-off points [28])
| Lickert scalea, n (%) |
p valueb | ||
|---|---|---|---|
| MNC | MOC | ||
| Mothers’ first reaction to habit change | 0.167 | ||
| Easy | 88 (59) | 56 (51) | |
| Hard | 61 (41) | 55 (50) | |
| Mothers’ room for action | |||
| Mothers’ experiences of opportunities or obstaclesc | 0.412 | ||
| Opportunities | 123 (83) | 87 (79) | |
| Obstacles | 25 (17) | 23 (21) | |
| Do not know | 1 (1) | 1 (1) | |
| Mothers’ impact on own life and children’s life | 0.973 | ||
| High | 130 (87) | 97 (87) | |
| Some | 19 (13) | 14 (13) | |
| Children’s room for action | |||
| Children’s upbringing | 0.945 | ||
| Children mainly solving problems alone | 1 (1) | 1 (1) | |
| Children mainly assisted in problem-solving | 7 (5) | 6 (5) | |
| Combination of the above two | 141 (95) | 104 (94) | |
| Support children’s influence on own life | 0.147 | ||
| High | 99 (66) | 83 (75) | |
| Some | 50 (34) | 25 (23) | |
| Less | 0 (0) | 3 (3) | |
| Children’s appropriate behaviour | 0.985 | ||
| High | 27 (18) | 21 (19) | |
| Some | 104 (70) | 77 (69) | |
| Less | 18 (12) | 13 (12) | |
| Mothers felt they had taken specific action | < 0.001d | ||
| Yes | 54 (36) | 88 (79) | |
| No | 95 (64) | 23 (21) | |
| Support children to achieve a normal weight | < 0.001d | ||
| High | 66 (44) | 57 (51) | |
| Some | 43 (29) | 46 (41) | |
| Less | 12 (8) | 7 (6.3) | |
| None | 27 (18) | 1 (1) | |
| Do not know | 1 (1) | 0 (0) | |
| Children easy to guide to healthy habits | 0.001d | ||
| High | 56 (38) | 30 (27) | |
| Some | 84 (56) | 58 (52) | |
| Less | 9 (6) | 23 (21) | |
| Support from people in their surroundingse to live a healthy lifestyle | 0.003d | ||
| High | 26 (17) | 15 (14) | |
| Some | 104 (70) | 63 (57) | |
| Low | 17 (11) | 26 (23) | |
| None | 2 (1) | 7 (6) | |
The Lickert scale was used with 5 answer possibilities (high, some, less, none, do not know); in some of the questions, only categories with answers are shown.
p value when computed into categories with more than 5 in each cell.
Controls n = 148, cases n = 110.
Significant.
Grandparents, schoolteachers, playmates, friends. MOC = Mothers of overweight children; MNC = mothers of non-overweight children.
Acknowledgments
We thank the children and their mothers who participated in the study, paediatric project nurse Karina Larsen for her contributions to data collection and data keying, statistician Claus Holst for supervising the analysis, Lorna Campbell, M.A., PGCE, for careful and competent text-editing of the manuscript. Financial support: Lundbeck foundation/UCSF, Åse and Ejnar Danielsens Foundation, Nurses Research Foundation, Hvidovre Hospital Research foundation, Rosalie Petersens Foundation, Beckett-Foundation, King Christian × Foundation, Else Poulsens memorial award. Books donated for the children: Egmont Comics Publisher, Carlsen A/S, Klematis A/S, Banner and Korch. This study is part of the activities of the Danish Obesity Research Centre, DanORC (www.danorc.dk/).
References
- 1.Lobstein T, Baur L, Unuy R. Obesity in children and young people: a crisis in public health. Obes Rev. 2004;5:4–84. doi: 10.1111/j.1467-789X.2004.00133.x. [DOI] [PubMed] [Google Scholar]
- 2.WHO: European Ministerial Conference on Counteracting Obesity Diet and Physical Activity for Health. Istanbul, Turkey. 2006 European Charter on Counteraction Obesity, WHO, 2006, pp. 1–5. [Google Scholar]
- 3.Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O’Malley C, Stolk RP, Summerbell CD. Interventions for treating obesity in children. Cochrane Database Syst Rev. 2009;((1)):CD001872. doi: 10.1002/14651858.CD001872.pub2. [DOI] [PubMed] [Google Scholar]
- 4.Summerbell CD, Waters E, Edmunds L, Kelly SAM, Brown T, Campbell KJ. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2005;((3)):CD001871. doi: 10.1002/14651858.CD001871.pub2. [DOI] [PubMed] [Google Scholar]
- 5.British Medical Association Board of Science: Preventing Childhood Obesity 2005:pp. 1–61. [Google Scholar]
- 6.Jackson-Leach R, Lobstein T. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 1. The increase in the prevalence of child obesity in Europe is itself increasing. Int J Pediatr Obes. 2006;1:26–32. doi: 10.1080/17477160600586614. [DOI] [PubMed] [Google Scholar]
- 7.Lobstein T, Jackson-Leach R. Estimated burden of paediatric obesity and co-morbidities in Europe. Part 2. Numbers of children with indicators of obesity-related disease. Int J Pediatr Obes. 2006;1:33–41. doi: 10.1080/17477160600586689. [DOI] [PubMed] [Google Scholar]
- 8.Schwartz MB, Brownell KD, Actions necessary to prevent childhood obesity. creating the climate for change. J Law Med Ethics. 2007;35:78–89. doi: 10.1111/j.1748-720X.2007.00114.x. [DOI] [PubMed] [Google Scholar]
- 9.Doolen J, Alpert PT, Miller SK, Parental disconnect between perceived and actual weight status of children. a metasynthesis of the current research. J Am Acad Nurse Pract. 2009;21:160–166. doi: 10.1111/j.1745-7599.2008.00382.x. [DOI] [PubMed] [Google Scholar]
- 10.Crawford D, Timperio A, Telford A, Salmon J. Parental concerns about childhood obesity and the strategies employed to prevent unhealthy weight gain in children. Public Health Nutr. 2006;9:889–895. doi: 10.1017/phn2005917. [DOI] [PubMed] [Google Scholar]
- 11.Jensen BB. A case of two paradigms within health education. Health Educ Res. 1997;12:419–428. [Google Scholar]
- 12.Saugstad T, Sundhedspædagogiske overvejelser (Health educational theory and practice considerations) Sundhedspædagogik for praktikere (Health Educational Theory and Practice for Practitioners) In: Mach-Zagal R, editor. Copenhagen: Munksgaard; 1997. pp. pp. 33–44. [Google Scholar]
- 13.Albertsen K, Andersen H. Handlekomptence som begreb i sundhedspædagogik og – forskning (Action competence as a concept in health education in theory and practice) Psyke and Logos. 2001;22:751–770. [Google Scholar]
- 14.Christensen U, Albertsen K. Teorier om dannelse og forandring af livsstil (Theories of forming and changing lifestyle) In: Iversen L, Kristensen T, Holstein B, Due P, Medicinsk Sociologi – samfund, sundhed og sygdom, editors. Copenhagen: Munksgaard Denmark; 2003. pp. pp. 207–224. [Google Scholar]
- 15.He M, Evans A. Are parents aware that their children are overweight or obese? Do they care? Can Fam Physician. 2007;53:1493–1499. [PMC free article] [PubMed] [Google Scholar]
- 16.Brødsgaard A, Wagner L, Poulsen I, Peitersen B, Sørensen T. Maternal and child awareness and expectations of child overweight. Obes Facts. 2011;4((4)):297–304. doi: 10.1159/000331012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Olsen J, Melbye M, Olsen SF, Sorensen TI, Aaby P, Andersen AM, Taxbol D, Hansen KD, Juhl M, Schow TB, Sorensen HT, Andresen J, Mortensen EL, Olesen AW, Sondergaard C. The Danish National Birth Cohort – its background, structure and aim. Scand J Public Health. 2001;29:300–307. doi: 10.1177/14034948010290040201. [DOI] [PubMed] [Google Scholar]
- 18.Cocherham WC. Health lifestyles in Russia. Social Soc Med. 2000;51:1313–1324. doi: 10.1016/s0277-9536(00)00094-0. [DOI] [PubMed] [Google Scholar]
- 19.Due P, Holstein BE, Sundhedsadfærd (Health behaviour) Forebyggende sundhedsarbejde (Disease-preventive health activities) In: Kamper-Jørgensen F, Almind G, editors. Copenhagen: Munksgaard Denmark; 2003. pp. pp. 181–191. [Google Scholar]
- 20.Wold B, Øygard L, Eder A, Smith C. Social reproduction of physical activity. Implications for health promotion in young people. Eur J Public Health. 1994;4:163–168. [Google Scholar]
- 21.Jeffery AN, Voss LD, Metcalf BS, Alba S, Wilkin TJ, Parents’ awareness of overweight in themselves and their children. cross sectional study within a cohort (EarlyBird 21) BMJ. 2005;330:23–24. doi: 10.1136/bmj.38315.451539.F7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Golan M, Crow S. Parents are key players in the prevention and treatment of weight-related problems. Nutr Rev. 2004;62:39–50. doi: 10.1111/j.1753-4887.2004.tb00005.x. [DOI] [PubMed] [Google Scholar]
- 23.Grønbæk HN. ‘We’ve always eaten healthily’. Family narratives about causes of their child’s obesity and their motivation for taking action. Nordic Psychol. 2008;60:183–208. [Google Scholar]
- 24.Verheijden MW, Bakx JC, van WC, Koelen MA, van Staveren WA. Role of social support in lifestyle-focused weight management interventions. Eur J Clin Nutr. 2005;59((suppl 1)):S179–S186. doi: 10.1038/sj.ejcn.1602194. [DOI] [PubMed] [Google Scholar]
- 25.Butryn ML, Wadden TA. Treatment of overweight in children and adolescents does dieting increase the risk of eating disorders? Int J Eat Disord. 2005;37:285–293. doi: 10.1002/eat.20098. [DOI] [PubMed] [Google Scholar]
- 26.Patel DR, Phillips EL, Pratt HD. Eating disorders. Indian J Pediatr. 1998;65:487–494. doi: 10.1007/BF02730877. [DOI] [PubMed] [Google Scholar]
- 27.Fosson A, Knibbs J, Bryant-Waugh R, Lask B. Early onset anorexia nervosa. Arch Dis Child. 1987;62:114–118. doi: 10.1136/adc.62.2.114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and Obesity worldwide international survey. BMJ. 2000;320:1240–1243. doi: 10.1136/bmj.320.7244.1240. [DOI] [PMC free article] [PubMed] [Google Scholar]