Evaluating parental perception and confidence managing obesity-related behaviors among children with severe early-onset obesity

doi:10.21203/rs.3.rs-4991867/v1

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Evaluating parental perception and confidence managing obesity-related behaviors among children with severe early-onset obesity

https://doi.org/10.21203/rs.3.rs-4991867/v1

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Background

Severe early-onset obesity, defined as a BMI exceeding 120% of the 95th percentile before age 5, often involves hyperphagia, characterized by insatiable hunger and shortened satiety duration. Treatment generally requires caregivers to adjust their child's diet and exercise, but research on caregiver confidence in managing these changes is limited. This study aims to assess: 1) caregivers' confidence in addressing obesity-related behaviors in children with severe early-onset obesity and 2) differences in lifestyle behaviors between children with and without impaired satiety at a specialized clinic.

Methods

Caregivers from a specialized pediatric obesity clinic completed the Lifestyle Behavior Checklist (LBC), a 25-question tool evaluating their perceptions and confidence in managing obesity-related behaviors. Diagnoses of hyperphagia or impaired satiety were based on clinical ascertainment of at least three abnormal eating behaviors across multiple settings. Data were analyzed using averages, standard deviations, and non-parametric Mann-Whitney tests to compare responses between caregivers of children with and without impaired satiety.

Results

Caregivers felt least confident managing four of the five most problematic behaviors. They identified excessive eating, requesting extra portions, and unhealthy snacking as the top 3 problematic behaviors. Conversely, the least problematic behaviors included complaints about appearance, lack of friends, and food hiding. Parents were most confident addressing food-related yelling, excessive screen time, and food hiding. However, they exhibited the least confidence in managing excessive eating, eating quickly, and unhealthy snacking. Parents rated 16 behaviors as more problematic in children with impaired satiety compared to those without, and their caregivers reported significantly lower overall confidence.

Conclusion

Participants showed reduced confidence in managing the most challenging behaviors related to severe early-onset obesity. These challenging behaviors often involve controlling food intake. Therefore, alongside providing information on lifestyle changes, there is a need to enhance caregivers' ability to manage food-related behaviors, especially for children with impaired satiety.

Health sciences/Diseases/Endocrine system and metabolic diseases/Obesity

Health sciences/Signs and symptoms

Severe early-onset obesity is a specific medical condition defined as a body mass index (BMI) greater than 120% of the 95th percentile that occurs in children before age 5 (1, 2). This is particularly troubling because preschool children who start kindergarten with obesity tend to face health challenges throughout their elementary school years and beyond (3). Severe early-onset obesity is a warning sign for different genetic causes of obesity (2). The presence of hyperphagia is an additional warning sign for genetic forms of obesity in children with severe early-onset obesity. According to the American Academy of Pediatrics, hyperphagia is an insatiable hunger where the time it takes to reach satiety is increased and lasts shorter (4). Individuals with hyperphagia are often preoccupied with food and are upset when caregivers limit food (4). Hyperphagia is a clinical diagnosis made by an experienced healthcare provider.

Childhood obesity, particularly severe early-onset cases with hyperphagia, has significant physical and mental health implications, so it is important to address obesity-related behaviors as early as possible. Specifically, children with obesity are five times more likely to have obesity in adulthood and are at increased risk of metabolic syndrome, type 2 diabetes mellitus, metabolic dysfunction-associated steatotic liver disease, and sleep apnea (3, 5, 6) Childhood obesity also leads to adverse mental health effects such as teasing, victimization, social marginalization, and obesity stigmas, resulting in body dissatisfaction, depression, eating disorders, impaired social relationships, and reduced quality of life (7, 8). Therefore, understanding obesity-related behaviors better will offer valuable insights to help treat childhood obesity and prevent these harmful conditions throughout a child’s life (2, 9, 10).

To treat obesity, caregivers are instructed to change lifestyle behaviors through diet and exercise, and caregivers have a unique influence on their children’s eating behavior issues (2, 10). Especially in younger years, children primarily consume meals at home with their families, relying on their caregivers for food choices (12, 14). Caregivers hold substantial influence over their children's eating habits and weight, which makes the family unit a key target for childhood obesity prevention interventions (11, 15). Yet, no studies analyze parental perception and confidence in managing problematic lifestyle habits, specifically in children with severe early-onset obesity. Based on our clinical encounters, we hypothesize that children with clinically defined impaired satiety would have more problematic food-related behaviors than those without impaired satiety. Additionally, we hypothesize that caregivers will be least confident in addressing the most problematic behaviors.

Participants & Recruitment

The Genetic Disorders of Obesity Program (GDOP) at Texas Children’s Hospital (TCH) was developed in April 2019. The GDOP clinic is designed for pediatric patients who developed a BMI > 120% of the 95th percentile (according to the U.S. Centers for Disease Control and Prevention (CDC) growth charts) before age 5. A full description of the program and its outcomes to date is under review for publication. Through this clinic, we recruited parents to participate in an online patient database. This study is approved by the Baylor College of Medicine Institutional Review Board and is registered at clinicaltrials.gov (NCT05747976).

Measures

Demographics

Caregivers provided sociodemographic information about themselves, their child, and their family dynamics through an online questionnaire. This demographic data included the caregiver's relationship to the child, age, gender, race, ethnicity, and self-reported height and weight. Caregiver BMI scores were calculated (wt[kg]/ht[m]²). Child characteristics, such as age, gender, race, and ethnicity, were collected through a questionnaire, with health records providing height and weight data; BMI scores were also calculated as above, and percentiles were extracted from the medical record based on CDC growth charts.

Lifestyle Behavior Checklist (LBC)

Caregivers also completed the LBC. The LBC is a reliable and valid tool to assess parental perceptions of obesity-related behaviors and caregivers’ confidence in managing these behaviors (14, 16). The LBC contains twenty-five questions divided into four subscales to assess misbehaviors about food, overeating, emotional concerns about obesity, and physical activity concerns (16). Behaviors are rated on a scale from 0 to 7, with 0 indicating the behavior was “not a problem” and 7 indicating it was “very much a problem”. Additionally, caregivers also rated their confidence in managing each behavior using a 10-point scale, ranging from 1 (“certain I can’t do it”) to 10 (“certain I can do it”).

Hyperphagia/Impaired Satiety Clinical Diagnosis

Hyperphagia was defined clinically based on the ascertainment of the timing of hunger after meals, preoccupation with food, portion sizes, food seeking, and reactions to food denial. Questions used by the clinical team to define satiety regulation are listed in Supplemental Table 1. Some patients did not seem to have true hyperphagia but did have abnormal satiety (for instance, someone who accepted limits on food well but did need more than one portion to feel full and asked for food frequently). Thus, for this publication, we included all individuals with clinically diagnosed satiety impairments. Upon review of our patients, individuals with a diagnosis of hyperphagia or significant satiety impairment displayed at least three of the abnormal eating behaviors across multiple settings and in relationship to a variety of foods (unless the individual had cognitive impairment leading to sensory abnormalities which limited food preferences).

Statistical Analysis

Averages and standard deviations were reported for each behavior and confidence item on the LBC. Two rankings were created to list behaviors from least problematic to most problematic and from least confident to most confident. The rankings were plotted against each other on a heat map. Lighter colors indicated lower confidence and problem levels, and darker colors indicated higher confidence and problem levels. Next, multiple non-parametric Mann-Whitney tests identified statistically significant differences (Q/p-value < 0.05) between caregivers of children with and without impaired satiety for each behavior and confidence, LBC subscale, overall total, and demographics. Behavior perceptions and confidences of each group were compared using two radar maps.

The study included 89 children, with a nearly equal distribution of genders (52% female, 48% male). Most caregivers identified their children as Hispanic/Latino (61%), followed by White (29%) and Black/African American (20%). On average, the children were 7.32 (± 3.95) years old. Their average BMI was 32.54 (± 9.42), with an average extended BMI of 152.17% (± 41.33) of the 95th percentile. Caregivers, predominantly mothers (96%), had a mean age of 36.80 (± 7.85) years and an average BMI of 34.55 (± 10.04). Full demographic information on children, caregivers, and family dynamics can be found in Table 1.

Table 2 illustrates the mean and standard deviation values for the parental perception of obesity-related behaviors and caregivers' confidence in managing these behaviors. The top five most problematic behaviors observed by caregivers were: eating too much, requesting extra portions, consuming unhealthy snacks, requesting food continuously between meals, and eating too quickly. The least problematic behaviors were: complaining about being unattractive, complaining about not having enough friends, hiding food, complaining about being teased, and yelling about food. From a confidence standpoint, parents felt most confident with: yelling about food, spending too much time playing video or computer games, hiding food, complaining about being unattractive, and eating for comfort. They were least confident with: eating too much, eating too quickly, consuming unhealthy snacks, requesting extra portions, and complaining about being overweight. Interestingly, the top four behaviors caregivers were least confident in addressing were in the top five most problematic behaviors. The comparison of behavior problems and caregiver confidence is visually represented in Fig. 1.

The study also examined the differences in parental perception of obesity-related behaviors among children with and without impaired satiety. Overall, the two groups were similar in demographics (Table 1). Between both groups, there were statistically significant differences in the overall behavior perception and all four LBC subscales: misbehaviors related to food, overeating, emotional concerns about obesity, and physical activity concerns (Table 2). Specifically, children with impaired satiety had higher scores (indicating more problematic) in the mean parental perception of sixteen behaviors, as noted in Table 2 and Fig. 2. Interestingly, while children with impaired satiety were perceived to have more problematic expressions of behavior, the top problematic behaviors were very similar between both the group with impaired satiety and the one without. Eating too much emerged as the most problematic behavior in both groups.

Similarly, the study analyzed differences in confidence levels regarding addressing obesity-related behaviors in caregivers of children with and without satiety impairments as noted in Table 2 and Fig. 3. The overall confidence scores showed statistically significant differences between those with and without hyperphagia (Table 2). Additionally, we found nominal significance in eleven confidences using a less stringent threshold using a false discovery rate of 10% (Table 2). Overall, there were parallels between the caregivers’ confidences. Both groups ranked eating too much as the behavior they were least confident in handling and eating too quickly ranked among the three least confident behaviors for both groups. Additionally, yelling about food and spending too much time playing video or computer games were among the most confident behaviors in both groups.

The current study evaluated parental perceptions of obesity-related behaviors and caregivers' confidence in managing these behaviors, specifically in caregivers of children with severe early-onset obesity. The study also evaluated differences in these behaviors and confidence levels between two groups of children: those with and without clinically diagnosed satiety impairments. Overall, in this sample, we found that overeating was both the most problematic behavior and the behavior that caregivers were least confident in addressing. The rankings of behaviors and confidence levels were generally similar between children with and without satiety impairments, but those with impaired satiety displayed more problematic behaviors in sixteen behaviors compared to those without impaired satiety. There was a lack of significant differences in parental confidence between the two groups. This suggests that the study might not have had enough statistical power to detect any discrepancies in confidence scores among caregivers of children with or without impaired satiety.

Caregivers’ lack of confidence can worsen their child’s problematic behavior, as supported by our data (17). When a child's problematic behavior intensifies, the caregiver's self-efficacy decreases, and they perceive the issue as more significant (18). This, in turn, may lead to a higher frequency of problematic behaviors from the child, causing further feelings of incompetence and reduced confidence in the caregiver (18). In our study caregivers felt the least confident when their child ate too quickly, ate unhealthy snacks, demanded extra portions, and ate too much food, and these were the five most problematic behaviors. This is clinically relevant because current obesity prevention often involves limiting portion sizes and food intake, but parents need guidance on managing problematic behaviors that may arise from these recommendations. The relationship between parental confidence, perceived problematic behaviors, and their regulation illustrates the complexities of parent-child dynamics. Understanding these dynamics will further enhance parental responses and self-efficacy in addressing and modifying childhood obesity behavioral challenges.

Although the overall rankings of problematic behaviors were highly consistent between individuals with and without impaired satiety, there were significant differences in their actual averages. As previously mentioned, there were sixteen statistically significant differences in the mean parental perception of behaviors LBC. Twelve of these statistically significant differences were found to be associated with the food misbehaviors and overeating subscales. Eating for comfort was the only food-related behavior that caregivers of children without hyperphagia found more problematic. Hyperphagia is characterized by increased impulsivity and lack of eating control (19, 20). Compared to their peers without hyperphagia, children with hyperphagia are never satiated. The Dykens Hyperphagia Questionnaire, which is validated in children with Prader-Willi syndrome, has recently been shown to evaluate childhood eating behaviors to diagnose severe hyperphagia in children with early-onset obesity (19, 20). Children with hyperphagia have higher scores on the Dykens Questionnaire because they exhibit heightened food-seeking behaviors, a fixation on food, struggles with controlling their eating, low tolerance for dietary restrictions, and psychological distress compared to their peers who do not have hyperphagia (19). The trends on the Dykens Hyperphagia Questionnaire align with our impaired-satiety sample. Our findings and the recent study indicate that incorporating the LBC and Dykens Questionnaire could enhance the clinical diagnosis of satiety impairments (19). Future studies could attempt to validate both the LBC and Dykens Questionnaire as tools for measuring hyperphagia and satiety impairments in children with severe, early-onset obesity. However, we also found that some children were perceived as having very problematic behaviors but were not diagnosed with clinical hyperphagia. These individuals often either only displayed these behaviors at home (and had no issues at school) or only displayed these behaviors for highly palatable foods (and would go without food if offered a meal they didn’t like). Thus, while questionnaires may be useful, there is likely still an important role in clinical judgment and further ascertainment of behaviors.

In January 2023, the American Academy of Pediatrics (AAP) updated its guidelines on treating childhood obesity (4). They recommend increasing healthful food consumption, eliminating sugary beverages, encouraging daily physical activity, and reducing sedentary hobbies. The AAP also identified Intensive Health Behavior and Lifestyle Treatment as one of the most effective evidence-based treatments for pediatric obesity (4). IHBLT promotes healthy behavior changes through 26 hours of frequent visits with pediatricians and multidisciplinary treatment teams over 3–12 months. However, this study identifies a critical gap. Caregivers need to be taught effective parenting strategies to improve their confidence in meeting the AAP guidelines and addressing problematic food-related behaviors. Specifically, caregivers feel least confident addressing unhealthy snacking, yet the AAP guidelines advocate for promoting healthy food choices and eliminating sugary drinks. On the other hand, caregivers were confident in addressing physical inactivity and excessive video game use. Overall, IHBLT and other physician-led interventions should prioritize addressing caregivers' less confident behaviors. There is a need to provide evidence-based parenting strategies and empower parents to effectively manage retaliatory behaviors that may arise from their child while regulating food intake and promoting healthy habits.

While this study highlights the contrasting parental perspectives on obesity-related behaviors and their confidence levels in managing these behaviors among caregivers of children with and without satiety impairments, limitations exist. First, participants were all recruited from the Genetic Disorders of Obesity Program, which is a specialty clinic. Tertiary clinics usually require a referral from a primary or secondary care provider and are typically only available at specialized medical centers. Our patient population at this clinic may not be representative of all children with severe early-onset obesity who may not have access to this highly specialized healthcare. Next, most of our participants were Hispanic, which might decrease the generalizability to other non-Hispanic populations since parenting food practices vary because of different cultural, ethnic, and racial backgrounds. However, we had a good representation of participants who self-identified as non-Hispanic white and Black individuals, each comprising 20% or more of the total participants. Regardless, since Hispanic and Black children are more likely to develop obesity, our study encompasses the most relevant populations (21, 22). Finally, most caregivers in the current sample are identified as female, mothers. Similarly, most of the existing literature primarily collects data from mothers (3, 11, 14, 23–28). This overrepresentation of mothers in research studies can be attributed to societal norms and traditional gender roles regarding caregiving, meal preparation, and child feeding (23–25). However, in today's evolving family dynamics, more fathers are taking on caregiving responsibilities and becoming involved in their mealtime routines (25). It is unknown if fathers would perceive the behaviors of their children similarly to their mothers.

Given these findings, there are several areas for future research. To understand the utility of the LBC in severe, early-onset childhood obesity, research is needed to compare differences between larger, ethnically, and racially diverse samples to better understand how various demographic differences affect caregivers’ perceptions and confidence. Additionally, to enhance the completeness of childhood obesity perception studies, future studies should compare mother and father dyads, as well as different living situations (eg: two-household families, same-gender families) to better understand differing parental perceptions and confidences regarding childhood obesity behaviors.

In conclusion, caregivers from this specialized clinic have less confidence in managing the most problematic behaviors in children with severe early-onset obesity. The most problematic obesity-related behaviors require caregivers to act as gatekeepers limiting food. Thus, in addition to providing information on what lifestyle modifications to implement, there is a significant need to empower caregivers to manage food-related behaviors effectively. This need is amplified in those children with clinically defined impaired satiety.

Acknowledgements: We would like to thank the Genetic Disorders of Obesity Program clinic and USDA/ARS Children's Nutrition Research Center for providing the necessary resources and facilities to conduct. We are also grateful for our study participants and their children who contributed their time to this project.

Author Contributions: JMM conducted the literature review, wrote the manuscript, extracted and analyzed data, and interpreted the results. SS designed the study and the research questions, recruited participants, administered LBC, performed clinical diagnoses of impaired satiety, conducted statistical analyses, and assisted in interpreting the results. MG and CE recruited participants and administered the LBC. SS, MG, CE, and CSA provided feedback on the manuscript.

Competing Interests: The authors declare no competing financial interests

Data Availability: The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Funding/Support:

Research reported in this publication was supported by USDA Cooperative agreement 58-3092-0-001 to SS.

Disclosures:

Ms. Morales, Drs. Gonzalez, Elatrash, Soler Alfonso, and Sisley report no direct competing interests to declare. SS has received speaking and consulting fees from Rhythm Pharmaceuticals in the past. SS has received clinical trial support paid to her institution from Rhythm Pharmaceuticals and Eli Lilly and Company.

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Tables 1 and 2 are available in the Supplementary Files section.

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Evaluating parental perception and confidence managing obesity-related behaviors among children with severe early-onset obesity

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Participants & Recruitment

Measures

Demographics

Lifestyle Behavior Checklist (LBC)

Hyperphagia/Impaired Satiety Clinical Diagnosis

Statistical Analysis

Results

Discussion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1