Abstract
Background: Family members influence the behaviors and weight loss of adults in weight management programs (WMPs). Less is known about the weight control practices of children who have a parent participating in a WMP. Thus, we aimed to explore weight control practices in children of parents in WMPs.
Methods: We recruited participants who were parents of least one child aged 2–18 living at home from two institution's adult WMPs. Parents reported weight control practices for themselves and their child. We used separate logistic regression models to assess the association of each child weight control practice with parent weight control practice; child age, race, sex, and BMI z-score (BMIz); parent education; and household income.
Results: Parents (N = 300) had a mean age of 41 ± 7 and 85% were female. Children (N = 295) had a mean age of 9.3 ± 4.9; 20% had overweight or obesity. Parents reported their child used the following weight control practices in the past year: 12% dieted, 12% ate very little food, 7% used food substitutes, 10% skipped meals, 29% increased fruit and vegetables, 25% reduced calories, 22% reduced snacking, 21% reduced fat intake, and 45% exercised. Children were more likely to utilize weight control practices if their parent utilized the same weight control practice and if children had obesity and were older.
Conclusions: Children of parents attending WMPs commonly utilize weight control practices, especially older children with higher BMIz. Adult WMPs should offer guidance to parents on ways to incorporate new healthy dietary practices into their family.
Keywords: children, dieting, obesity, overweight, weight, weight control
Introduction
Childhood obesity rates have increased substantially in the past few decades1 with recent reports showing continued upward trends in severe obesity.2 Half of all children aged 8–15 years report that they attempted to lose weight in the previous year; these rates are even higher among children with overweight and obesity.3 Children and adolescents attempting to lose weight practice both healthy and unhealthy weight control behaviors, including exercising (92%), dieting (44%), skipping meals (35%), and starving (18%).3 Children may be more likely to adopt healthy weight control practices when their parents model healthy behaviors, such as increased fruit and vegetable intake4–6 and increased physical activity.7,8
More than 65% of American adults are advised to lose weight by their physician9 and nearly half are attempting weight loss.10 Parental obesity is a strong risk factor for child overweight and obesity.11 Parents who participate in family-based pediatric weight management programs (WMPs) often lose weight with their child, and increased parental weight loss in these programs is associated with increased child weight loss.12,13 When parents of children with obesity are targeted exclusively as the agent of change in a parent-only interventions, children have similar rates of weight loss and health behavior improvements as child-only or family-based interventions.14–17
Yet, very little is known about the effects of parental participation in adult WMPs on the health behaviors of their children. A recent feasibility study by Song and colleagues examined children's BMI percentile and health behaviors in 20 parent–child dyads in which both members had overweight or obesity, and the parent was participating in a commercial WMP.29 Parental and child weight changes over 8 weeks were positively correlated (r = 0.24, p = 0.31), and reduction in fat intake was associated between parents and children (r = 0.47, p < 0.05). However, this work was limited in its sample size and inclusion criteria of only children with overweight or obesity. In fact, 28 dyads were excluded from this study because the child was of healthy weight, though the authors noted that there is future potential to “prevent childhood obesity by improving health behaviors and BMI in children before they develop weight issues” (page 9).29 Therefore, we aimed (1) to explore the weight control practices in children of parents participating in a WMP, and (2) to examine the association of these weight control practices with parental weight control practices, children's weight status, and with other sociodemographic characteristics.
Methods
Study Design and Participants
This was a cross-sectional study performed between May 2017 and July 2017 at two tertiary care adult WMPs in the United States located in North Carolina and Ohio. Adults attending a visit were included if they were over the age of 18 years, had at least one child aged 2–18 living at home, and could read and speak English. Participants were excluded if they were attending an initial intake visit or if they had a terminal illness (e.g., cancer). Participants were recruited from both the bariatric surgery programs and the medical weight loss program (in which lifestyle, pharmacological, and meal replacement interventions are used). At the beginning of their visit, participants consented when approached by a trained research assistant and completed questionnaires on paper during or after their visit. The Institutional Review Boards of Wake Forest University and The Ohio State University approved the study protocol.
Study Instruments and Measurements
Parents responded yes or no to weight control practices for themselves and their child by answering the question, “Have you [or has your child] done any of the following things in order to lose weight or keep from gaining weight during the past year?” Weight control practices came from questions from Project EAT Weight Control Behaviors, Project EAT questions were developed based on focus groups, literature reviews, and expert content reviews. These items were pilot tested and found to have a test–retest agreement of 88% for healthy behaviors, 85% for unhealthy behaviors, and 96% for extreme behaviors.18 Multiple weight control practices could be selected, including: dieted, fasted, ate very little food, used a food substitute, skipped meals, smoked more cigarettes, took diet pills, made myself vomit, used laxatives, used diuretics, increased fruits and vegetables, reduced caloric intake, cut out between meal snacking, decreased fat intake, and exercised.
Participants reported demographics including age, sex, height, weight, race (categorized in this analysis as white or other), highest level of completed education (some middle school, some high school, high school graduate, some college, associate degree, bachelor's degree, or master's degree or higher), and household income (categorized in this analysis as <$60,000 or $60,000 or more). Participants also reported the demographics of their youngest child living in the home between the ages of 2 and 18, including the child's age, sex, race, height, weight, and perceived weight status (very underweight, underweight, healthy weight, overweight, or obese). For the purposes of these analyses, we used patients' reports of their child's weight status as a dichotomous variable by collapsing under weight and healthy weight (under/healthy weight) and overweight and obese (overweight/obese). The child's BMI was calculated and weight status was categorized according to standardized CDC age- and sex-specific percentiles.19 We categorized child weight status as underweight (BMI <5th percentile), healthy weight (BMI 5th to <85th percentile), overweight (BMI 85th to <95th percentile), or obese (BMI ≥95th percentile).
Statistical Analysis
We used Pearson's chi-square tests and T-tests to examine the association of weight control behaviors with children, parental, and family sociodemographics. Variables that were significant in the bivariate analysis with a p < 0.2 were included in the multivariate analysis. Separate logistic regression analyses were performed for each weight control practice, examining correlates of parent report of child weight control practices including child age, sex, race/ethnicity, weight status, and household income. In our primary analyses we considered child weight status as calculated from parent report of their child's height and weight (categorized as overweight/obesity vs. healthy weight/underweight). We performed sensitivity analyses also examining child's weight status by parent perception of their child's weight status.
Results
Study Sample and Characteristics
Parents predominantly identified as White (75%) and female (85%) and had an average age of 41.2 [standard deviation (SD) = 7.1] years. The majority of parents (89%) completed at least some college, and 66% had an annual household income of at least $60,000. Most parents had an obese weight status, (13% overweight, 22% Class 1 obesity, 20% Class 2 obesity, and 43% Class 3 obesity), the mean BMI of the sample was 39.6 ± 10.6. Approximately half of children were female (48%); all were between the ages of 2–18 years with an average age of 9.3 years (SD = 4.9). By parent reported height and weight, children had a weight status of underweight (6%), healthy weight (47%), and overweight or obesity (46%); children's mean BMI z-score was 18.4 (SD = 9.1). Parents mostly perceived that their children were a healthy weight (80%) with only 20% perceiving overweight or obesity (Table 1).
Table 1.
Participant Characteristics
| Parent characteristics | N (%) or mean (SD) |
|---|---|
| Age | 41.2 (7.2) |
| Female | 254 (84.7%) |
| Hispanic | 12 (4.0%) |
| Race | |
| Asian | 1 (0.3%) |
| Black or African American | 60 (20.3%) |
| White or Caucasian | 219 (74.0%) |
| Bi-/multiracial | 12 (4.1%) |
| Other | 2 (0.7%) |
| BMI | 39.6 (10.6) |
| Weight category | |
| Healthy weight | 7 (2.4%) |
| Overweight | 37 (12.6%) |
| Class 1 obesity | 65 (22.1%) |
| Class 2 obesity | 58 (19.7%) |
| Class 3 obesity | 127 (43.2%) |
| No. of children under 18 | |
| 1 | 67 (22.4%) |
| 2 | 122 (40.9%) |
| 3+ | 109 (36.6%) |
| Child characteristics | |
|---|---|
| Age | 9.3 (4.9) |
| Mal | 154 (52.0%) |
| Race | |
| Asian | 4 (1.3%) |
| Black or African American | 59 (19.7%) |
| White or Caucasian | 195 (65.0%) |
| Bi-/multiracial | 25 (8.3%) |
| Child weight status calculated from parent reported height and weight | |
| Underweight | 15 (6.4%) |
| Healthy weight | 111 (47.4%) |
| Overweight or obesity | 108 (46.2%) |
| Parent perception of child weight status | |
| Underweight | 23 (7.8%) |
| Healthy weight | 213 (79.7%) |
| Overweight or obesity | 60 (20.3%) |
SD, standard deviation.
Parent Report of Parent Weight Control Practices and Parent Report of Child Weight Control Practices
Parents reported using a wide variety of weight control practices, both healthy and unhealthy (Table 2). Over 92% of parents reported having dieted, more than half skipped meals, 2.7% vomited, 80% increased fruit and vegetable intake, and 89% exercised. Parents also reported that their child utilized healthy and unhealthy weight control practices, although parents less commonly reported that their child utilized more extreme weight control practices (1% smoking, 0.3% took diet pills, 0% vomited, 0.7% used laxatives, and 0% used diuretics). Parents more commonly reported child weight control practices that are considered unhealthy for children and adolescents, but are more commonly accepted among adults, such as dieting (11.7%), eating very little food (11.7%), using a food substitute (7.4%), and skipping meals (10.1%). Many parents reported that their child utilized healthy weight control behaviors (29.1% increased fruit and vegetable intake, 24.8% reduced caloric intake, 21.7% eliminated snacking, 21.4% reduced fat intake, and 45.5% exercised) (Table 2).
Table 2.
Percentage of Parents and Children Practicing Weight Control Behaviors
| Parent N (%) | Child N (%) | pa | |
|---|---|---|---|
| Dieted | 276 (92.6) | 35 (11.7) | 0.3 |
| Ate very little food | 206 (69.1) | 35 (11.7) | 0.008 |
| Used a food substitute (powder or special drink) | 222 (74.8) | 22 (7.4) | 0.02 |
| Skipped meals | 168 (56.4) | 30 (10.1) | 0.1 |
| Smoked more cigarettes | 14 (4.7) | 3 (1.0) | |
| Took diet pills | 124 (41.5) | 1 (0.3) | |
| Made myself vomit | 8 (2.7) | 0 (0.0) | |
| Used laxatives | 21 (7.0) | 2 (0.7) | |
| Used diuretics | 19 (6.4) | 0 (0.0) | |
| Increased intake of fruits and vegetables | 241 (80.6) | 87 (29.1) | 0.001 |
| Reduced the number of calories you eat | 277 (92.6) | 74 (24.8) | 0.5 |
| Cut out between meal snacking | 228 (76.3) | 65 (21.7) | 0.01 |
| Decreased fat intake | 237 (79.3) | 64 (21.4) | <0.001 |
| Exercised | 267 (89.3) | 136 (45.5) | 0.5 |
p-Value represents association of parent and child practicing the weight control practice by Pearson chi-square test.
In bivariate analyses, parents' and children's weight control practices were not associated with dieting, skipping meals, decreased caloric intake, or exercising (Table 2). Eating very little food was associated with parents and children (15.1% of children whose parents reported eating very little vs. 4.3% of children whose parents who did not report eating very little, p = 0.008). Parents' and children's weight control behaviors were also associated with use of a food substitute (9.5% vs. 1.3%, p = 0.02), increased consumption of fruits and vegetables (33.3% vs. 12.1%, p = 0.001), reduced snacking (25.1% vs. 11.3%, p = 0.01), and reduced fat intake (25.9% vs. 4.8%, p < 0.001). Adjusted analyses revealed similar results. Children's and parents' weight control practices were not associated with dieting, eating very little food, using a food substitute, skipping meals, decreased caloric intake, or exercising (Table 3). Parents who increased their consumption of fruits and vegetables had 3.9 times the odds of also reporting that their child increased their consumption of fruits and vegetables (95% confidence interval 1.5–10.1). Parents' and children's weight control practices were also associated with reduced snacking (2.7 [1.1–6.5]) and reduced fat intake (5.4 [1.6–18.8]).
Table 3.
Results of Individual Logistic Regression Models Reporting Correlates of Parent's Report of Child Weight Control Practices, Including Child's Weight Status as Calculated from Parent Reported Height and Weight
| Model 1: Dieted | Model 2: Ate very little food | Model 3: Used food substitute | Model 4: Skipped meals | Model 5: Increased F&V OR (95% CI) | Model 6: Reduced calories | Model 7: Reduced snacking | Model 8: Reduced fat intake | Model 9: Exercised | |
|---|---|---|---|---|---|---|---|---|---|
| Parent practice | 2.36 (0.27–20.71) | 3.09 (0.99–9.62) | 6.97 (0.86–56.72) | 1.60 (0.66–3.88) | 3.89 (1.51–10.01)** | 2.71 (0.54–13.66) | 2.70 (1.13–6.44)* | 5.25 (1.51–18.22)** | 1.66 (0.68–4.06) |
| Child's calculated weight status overweight/obese | 5.70 (2.06–15.74)** | 2.06 (0.83–5.09)* | 9.02 (1.89–43.10)** | 1.32 (0.55–3.17) | 1.73 (0.94–3.18) | 3.81 (1.91–7.62)*** | 2.86 (1.42–5.76)** | 2.04 (1.02–4.09)* | 1.35 (0.77–2.37) |
| Income ≥$60,000 | 0.41 (0.13–1.26) | 0.77 (0.29–2.06) | 0.42 (0.10–1.81) | 0.43 (0.15–1.21) | 0.67 (0.35–1.31) | 0.98 (0.47–2.06) | 0.94 (0.45–1.99) | 0.73 (0.33–1.58) | 0.50 (0.27–0.92)* |
| Male sex | 0.20 (0.07–0.54)** | 0.44 (0.18–1.07) | 0.52 (0.16–1.68) | 0.94 (0.40–2.21) | 0.98 (0.54–1.79) | 0.87 (0.45–1.69) | 0.55 (0.28–1.09) | 0.56 (0.29–1.10) | 0.78 (0.45–1.36) |
| White race | 0.42 (0.14–1.24) | 1.65 (0.51–5.38) | 0.72 (0.20–2.68) | 2.81 (0.77–10.25) | 0.68 (0.33–1.40) | 0.68 (0.31–1.51) | 0.81 (0.35–1.87) | 0.83 (0.37–1.86) | 0.80 (0.40–1.60) |
| Parent BMI | 0.99 (0.94–1.04) | 1.00 (0.95–1.05) | 0.95 (0.89–1.01) | 1.02 (0.97–1.06) | 0.99 (0.97–1.03) | 1.02 (0.98–1.05) | 1.01 (0.98–1.05) | 0.99 (0.96–1.03) | 0.99 (0.97–1.02) |
| Child age | 1.26 (1.12–1.42)*** | 1.13 (1.02–1.25)* | 1.11 (0.98–1.27) | 1.12 (1.01–1.24)* | 1.08 (1.01–1.15)* | 1.16 (1.08–1.26)*** | 1.12 (1.04–1.21)** | 1.08 (1.01–1.17)* | 1.09 (1.03–1.16)** |
p < 0.05, **p < 0.01, ***p < 0.001.
CI, confidence interval; OR, odds ratio.
Child Weight Status and Parent Report of Child Weight Control Practices
In bivariate analyses, children were much more likely to utilize most weight control practices if they had overweight or obesity (Fig. 1) by calculated BMI. In adjusted analyses, children with overweight or obesity had increased odds of using most weight control practices. Results of the sensitivity analyses considering parent's perception of their child's weight status were similar (Table 4).
Figure 1.
Percent of parents reporting child weight control practices, by child weight status. *p < 0.05, **p < 0.01, ***p < 0.001.
Table 4.
Results of Individual Logistic Regression Models Reporting Correlates of Parent's Report of Child Weight Control Practices, Including Parent Perception of Their Child's Weight Status
| Model 1: Dieted | Model 2: Ate very little food | Model 3: Used food substitute | Model 4: Skipped meals | Model 5: Increased F&V OR (95% CI) | Model 6: Reduced calories | Model 7: Reduced snacking | Model 8: Reduced fat intake | Model 9: Exercised | |
|---|---|---|---|---|---|---|---|---|---|
| Parent practice | 2.83 (0.33–24.09) | 4.19 (1.37–12.80)* | 9.37 (1.17–74.94)* | 2.15 (0.88–5.26) | 4.44 (1.80–11.01)** | 2.60 (0.66–10.26) | 3.14 (1.34–7.38)** | 7.66 (2.19–26.76)** | 1.53 (0.66–3.56) |
| Parent perceives child weight status overweight/obese | 4.66 (1.91–11.35)*** | 3.06 (1.22–7.70)* | 9.25 (2.94–29.11)*** | 3.28 (1.30–8.28)* | 4.45 (2.18–9.09)*** | 6.52 (3.11–13.68)*** | 3.32 (1.59–6.92)** | 3.39 (1.57–7.30)** | 2.44 (1.23–4.85)** |
| Income ≥$60,000 | 0.30 (0.10–0.88)* | 0.65 (0.27–1.57) | 0.36 (0.10–1.38) | 0.44 (0.16–1.20) | 0.84 (0.46–1.55) | 0.93 (0.48–1.82) | 0.96 (0.50–1.85) | 0.84 (0.42–1.69) | 0.61 (0.35–1.05) |
| Male sex | 0.33 (0.14–0.81)* | 0.45 (0.20–0.98)* | 0.92 (0.33–2.53) | 1.29 (0.56–3.00) | 0.97 (0.55–1.70) | 0.88 (0.48–1.61) | 0.63 (0.34–1.15) | 0.63 (0.34–1.17) | 0.83 (0.50–1.36) |
| White race | 0.58 (0.22–1.53) | 1.50 (0.59–3.83) | 0.41 (0.14–1.20) | 1.94 (0.66–5.65) | 0.52 (0.28–0.99)* | 0.58 (0.29–1.14) | 0.81 (0.40–1.63) | 0.89 (0.44–1.82) | 0.68 (0.38–1.22) |
| Parent BMI | 1.00 (0.96–1.05) | 1.02 (0.99–1.06) | 1.00 (0.95–1.05) | 1.03 (0.99–1.07) | 1.00 (0.98–1.03) | 1.04 (1.01–1.07)* | 1.02 (1.00–1.14) | 1.02 (0.99–1.05) | 1.01 (0.99–1.04) |
| Child age | 1.16 (1.05–1.28)** | 1.03 (0.95–1.12) | 1.01 (0.90–1.13) | 1.10 (1.00–1.21)* | 1.05 (0.99–1.12) | 1.07 (1.01–1.15)* | 1.07 (1.00–1.14)* | 1.04 (0.97–1.11) | 1.08 (1.03–1.14)** |
p < 0.05, **p < 0.01, ***p < 0.001.
Sociodemographics and Parent Report of Child Weight Control Practices
Increased child age was associated with increased odds of reporting most child weight control practices (Table 3). Children's weight control practices were not consistently associated with their race or sex, parental BMI, or household income (Table 3).
Discussion
Parents in WMPs commonly reported that their children utilize weight control practices, including healthy behaviors (e.g., exercising and increasing fruit and vegetable intake) and unhealthy behaviors (e.g., dieting, skipping meals, and using a food substitute). Children were more likely to utilize most weight control practices if their parent utilized the same weight control practice and if children had overweight or obesity and were older.
While very little is known about children of parents attending medical WMPs, previous studies investigating weight change among children living with a parent having undergone bariatric surgery have produced mixed results. A retrospective case–control study found that BMI trajectories of children living with a parent with obesity did not differ based on whether the parent had bariatric surgery.20 In a prospective 1-year study of 15 children living with a parent who had bariatric surgery, the child's baseline BMI was used to predict their 1-year expected BMI, and researchers found that postsurgery children with obesity were found to have a lower BMI than expected for their growth curve.21 Watowicz et al. examined the lifestyle behaviors of children following parental bariatric surgery compared to age- and sex-matched controls. They found that children whose parents underwent bariatric surgery were more likely to exhibit unhealthy behaviors such as eating two or more helpings of food at each sitting, eating fast food, consuming soda several times a week, reporting no vegetable intake, and less playing outside for an hour each day.22 Woodard et al. reported that children of parents who received bariatric surgery had improved physical activity behaviors but had no change in dietary behaviors.21 Yet, there is virtually no literature about the behaviors and weight status of children with parents attending nonsurgical WMPs. Further research is needed among children of parents participating in both WMPs and bariatric surgery to assess its effect on the child's weight status and health behaviors. Additionally, future research should assess for multiple children in the home to discern if effects are similar between siblings, or may be more pronounced for children with certain roles in the family (i.e., eldest child, youngest child, etc.).
This study had some limitations. All child weight control practices were reported by the parents, which likely resulted in an under-reporting of child weight control practices, especially unhealthy weight control practices.3 Child height and weight were not measured and were reported by parents as well and may have resulted in misclassification of weight status. Previous research has indicated that parents typically underestimate their child's weight and that height accuracy is gender dependent, with parents most likely to underestimate their girl's height and overestimate their boy's height.23 When asked about their perception of their child's weight status, parents commonly underestimate their child's weight status.24,25 This likely resulted in a under classification of overweight/obesity in our study for both calculated BMI and parental weight perception. Parents included in this study were primarily mothers, which while reflective of many WMPs could limit generalizability to all parent–child dyads. Additionally, the high percentage of white participants from higher income levels also limits generalizability. The cross-sectional nature of this study prevents causal inferences, and further prospective longitudinal studies are needed to investigate the effect of parental participation in WMPs on children's weight, weight control behaviors, and health behaviors.
Parental modeling of healthy physical activity and dietary behaviors is associated with healthier physical activity and dietary behaviors in their children.26 However, this is more complex in adults participating in WMPs, where parents are significantly restricting caloric intake, using meal replacements, taking weight loss medications, and/or receiving bariatric surgery. Many of the weight control practices that are encouraged in adult WMPs may be unhealthy for children and adolescents. Given the high rates of disordered eating behaviors in children and adolescents with obesity,27,28 it is crucial that parents in WMPs are counseled on how to discuss their participation with their child, are discouraged from modeling unhealthy weight control practices, and are encouraged to model and practice healthy dietary and physical activity behaviors as a family.
Acknowledgments
Research assistant support for the project described was provided by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR001420. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Author Disclosure Statement
No competing financial interests exist.
References
- 1. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988–1994 through 2013–2014. JAMA 2016;315:2292–2299 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US children, 1999–2016. Pediatrics 2018;141. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Brown CL, Skelton JA, Perrin EM, Skinner AC. Behaviors and motivations for weight loss in children and adolescents. Obesity (Silver Spring) 2016;24:446–452 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Tibbs T, Haire-Joshu D, Schechtman KB, et al. The relationship between parental modeling, eating patterns, and dietary intake among African-American parents. J Am Diet Assoc 2001;101:535–541 [DOI] [PubMed] [Google Scholar]
- 5. Goldman RL, Radnitz CL, McGrath RE. The role of family variables in fruit and vegetable consumption in pre-school children. J. Public Health Res 2012;1:143. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Natale RA, Messiah SE, Asfour L, et al. Role modeling as an early childhood obesity prevention strategy: Effect of parents and teachers on Preschool Children's Healthy Lifestyle Habits. J Dev Behav Pediatr 2014;35:378–387 [DOI] [PubMed] [Google Scholar]
- 7. Erkelenz N, Kobel S, Kettner S, et al. Parental activity as influence on childrens BMI percentiles and physical activity. J Sports Sci Med 2014;13:645. [PMC free article] [PubMed] [Google Scholar]
- 8. Fuemmeler BF, Anderson CB, Masse LC. Parent-child relationship of directly measured physical activity. Int J Behav Nutr Phys Act 2011;8:17. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Members EP, Jensen MD, Ryan DH, et al. Executive summary: guidelines (2013) for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society published by the Obesity Society and American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Based on a systematic review from the The Obesity Expert Panel, 2013. Obesity 2014;22(S2):S5–S39 [DOI] [PubMed] [Google Scholar]
- 10. Martin C, Herrick K, Sarafrazi N, Ogden C. Attempts to lose weight among adults in the United States, 2013–2016. NCHS Data Brief 2018):1–8 [PubMed] [Google Scholar]
- 11. Dev DA, McBride BA, Fiese BH, et al. Risk factors for overweight/obesity in preschool children: An ecological approach. Child Obes 2013;9:399–408 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Wrotniak BH, Epstein LH, Paluch RA, Roemmich JN. Parent weight change as a predictor of child weight change in family-based behavioral obesity treatment. Arch Pediatr Adolesc Med 2004;158:342–347 [DOI] [PubMed] [Google Scholar]
- 13. Andriani H, Liao CY, Kuo HW. Parental weight changes as key predictors of child weight changes. BMC Public Health 2015;15:645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Lloyd A, Lubans D, Plotnikoff R, Morgan P. Impact of the ‘H ealthy D ads, H ealthy K ids’ lifestyle programme on the activity-and diet-related parenting practices of fathers and mothers. Pediatr Obes 2014;9:e149–e155 [DOI] [PubMed] [Google Scholar]
- 15. Ewald H, Kirby J, Rees K, Robertson W. Parent-only interventions in the treatment of childhood obesity: A systematic review of randomized controlled trials. J Public Health (Oxf) 2014;36:476–489 [DOI] [PubMed] [Google Scholar]
- 16. Ball GD, Ambler KA, Keaschuk RA, et al. Parents as Agents of Change (PAC) in pediatric weight management: The protocol for the PAC randomized clinical trial. BMC Pediatr 2012;12:114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Jull A, Chen R. Parent-only vs. parent-child (family-focused) approaches for weight loss in obese and overweight children: A systematic review and meta-analysis. Obes Rev 2013;14:761–768 [DOI] [PubMed] [Google Scholar]
- 18. Neumark-Sztainer D, Wall MM, Larson N, et al. Secular trends in weight status and weight-related attitudes and behaviors in adolescents from 1999 to 2010. Prev Med 2012;54:77–81 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Adv Data 2000:1–27 [PubMed] [Google Scholar]
- 20. Hirsch AG, Wood GC, Bailey-Davis L, et al. Collateral weight loss in children living with adult bariatric surgery patients: A case control study. Obesity (Silver Spring) 2014;22:2224–2229 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21. Woodard GA, Encarnacion B, Peraza J, Hernandez-Boussard T, Morton J. Halo effect for bariatric surgery: Collateral weight loss in patients' family members. Arch Surg 2011;146:1185–1190 [DOI] [PubMed] [Google Scholar]
- 22. Watowicz RP, Taylor CA, Eneli IU. Lifestyle behaviors of obese children following parental weight loss surgery. Obes Surg 2013;23:173–178 [DOI] [PubMed] [Google Scholar]
- 23. O'connor DP, Gugenheim JJ. Comparison of measured and parents' reported height and weight in children and adolescents. Obesity 2011;19:1040–1046 [DOI] [PubMed] [Google Scholar]
- 24. 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] [PubMed] [Google Scholar]
- 25. Lundahl A, Kidwell KM, Nelson TD. Parental underestimates of child weight: A meta-analysis. Pediatrics 2014;133:e689–e703 [DOI] [PubMed] [Google Scholar]
- 26. Ventura AK, Birch LL. Does parenting affect children's eating and weight status? Int J Behav Nutr Phys Activ 2008;5:15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Neumark-Sztainer D, Wall M, Story M, Standish AR. Dieting and unhealthy weight control behaviors during adolescence: Associations with 10-year changes in body mass index. J Adolesc Health 2012;50:80–86 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Braden AL, Crow S, Boutelle K. Child self-reported motivations for weight loss: Impact of personal vs. social/familial motives on family-based behavioral weight loss treatment outcomes. Eat Weight Disord 2015;20:205–213 [DOI] [PubMed] [Google Scholar]
- 29. Song M, Lee CS, Lyon KS, et al. Assessing the feasibility of parent participation in a commercial weight loss program to improve child body mass index and weight-related health behaviors. SAGE Open Med 2018;6:1–12 [DOI] [PMC free article] [PubMed] [Google Scholar]