Confident Body, Confident Child: A novel program for ......•Overweight/obesity (Rodgers Paxton et al 2013; Clark, Goyder et al 2007) •Body dissatisfaction (Agras, Bryson et al

Confident Body, Confident Child: A novel program for preventing

body dissatisfaction and unhealthy eating patterns in preschoolers

Dr Laura Hart [email protected], October 2019

mailto:[email protected]

1. Background• Body attitudes

• Body image

• Weight bias

• Eating patterns

• The role of parents

2. The CBCC resource

3. Preparatory research

4. Evaluation: CBCC RCT

Presentation Overview

Background

Body image – what is it?

• The way a person thinks and feels about their body

• Not just about how you look

• Developing from as young as 3 years

Body Image

• Can be positive:Being accepting of and happy with one’s body shape and size “body satisfaction”

• Can be negative:Disliking one’s body, which may cause shame, low self-esteem or distress“body dissatisfaction”

• Can be a bit of both

Body dissatisfaction in children

• 34% of 5 year old girls report using dietary restraint at least sometimes (Damiano et al, 2015)

• Of 8-9 y.o. boys:

• 45% scared of overweight;

• 86% “think a lot about being skinny and having no muscles” (McCabe & Ricciardelli, 2003)

• 30% of 15-19 year olds

• ‘extremely’ or ‘very’ concerned about body image

• n = 21,846 (Annual Youth Survey, Mission Australia)

Why worry about body image?

• Having body dissatisfaction in early adolescence makes a child more likely to:• Do less exercise• Have low fruit/veg intake• Have low self-esteem• Become depressed• Have unhealthy eating habits (binge/diet)• Be overweight • Develop an eating disorder

• Body image is an important public health concern

(from Paxton et al, 2006/ Neumark-Sztainer et al, 2006/ Van den Berg & Neumark-Sztainer, 2007)

• Negative attitudes towards larger bodies, positive attitudes towards thin/muscular ones

• Body attitudes are being established in early childhood

• Weight bias occurs at a very young age

Weight bias

1 2 3 4 5 6 7 8 9

• Naughty• Not invite to birthday party• Mean

• Good• Invite to birthday party• Has the most friends

Development of Weight Bias

0

1

2

3

4

5

6

7

8

9

1 2 3

Mea

n F

igu

re S

ize

Sele

cted

Age 3 Age 4 Age 5

Mean child figure size selection score for positive and negative characteristics

Negative Characteristics

Positive Characteristics

Spiel et al., 2012 BJ Dev Psych

Why does this matter?

• Research into weight bias in children is new• Stigmatisation and bullying of

overweight (Latner & Schwartz, 2005)

• Greater body dissatisfaction for overweight (Puhl & Latner 2008)

• Greater eating pathology (binge eating) (Puhl et al 2007)

• Poorer psychological wellbeing if overweight (Davison et al, 2008)

Eating patterns in early childhood

• Healthy patterns: Balance• Responding to hunger and satiety

• Acceptance of a broad range of foods

• Enjoying food for nutrition and celebration

• Unhealthy patterns• Overeating (eating too much/too often/imbalance)

• Using food to regulate emotions

• Fussy/picky eating and neophobia (rarely lead to nutrient deficiencies)

• Clinical eating disorders• Rare in children, not often measured

• Binge eating/dieting can be present

Problem Eating Behaviour

• Emotional eating

• Restrained eating/Dietary restraint

• External eating/Food responsiveness

Influences on body attitudes and eating

• Genetics and temperament

• Psychological/cognitive frameworks

• Socio-cultural forces• Media and advertising

• Peers

• Family members• Siblings

• Adult relations

• Parents

The role of parents

• Parental risk factors

• Own body image and weight attitudes

• Appearance-based teasing of child

• Physical activity

• Own eating practices

• Parental feeding practices

Parental Feeding Practices

• Behaviours to control what, how much or when children eat (Ventura & Birch, 2008)

• Shown to be associated with the development of child• Disordered eating (Fisher, Sinton & Birch 2009; Blisset, Haycraft & Farrow 2010)

• Overweight/obesity (Rodgers Paxton et al 2013; Clark, Goyder et al 2007)

• Body dissatisfaction (Agras, Bryson et al 2007; Brown & Ogden, 2004)

• Important targets for reducing child risk

Parental Feeding Practices

Instrumental Feeding – Using food as reward or punishment

Emotional Feeding – Giving food to soothe/calm

Pushing to Eat – Encouraging to eat more/certain foods

Fat Restriction – Restriction of foods the child is eating

Weight-based Restriction – Attempt weight control

Monitoring – Keeping track of what is eaten

(Rodgers et al., IJBNPA 2013)

The role of parents

• Parental risk factors

• Own body image and weight attitudes

• Appearance-based teasing of child

• Physical activity

• Own eating practices

• Parental feeding practices

• Parents are not the only source of influence… but

• Critical agents biological/social environment

• In early childhood they are gatekeepers

• Peers

• Media

• Other family members

Confident Body, Confident Child

Resource

• An evidence-based resource for parents of pre-school children (roughly 2- to 6- years)

• Designed to promote positive body image and healthy eating patterns

Confident Body, Confident Child

CBCC Parent Book

• Healthy Body Weight• What is healthy?• Dieting• Physical activity• Screen time

• Common Parental Concerns• Overweight• Body image• Fussy eating

• Activities

• Referral Pathways

• Body Image• Social influences: Family, Peers,

Media

• Parent Body Image

• Child Self-esteem

• Teasing

• Healthy Eating Patterns• Healthy attitudes

• Sustainable patterns

• Family meals

• Reward feeding

CBCC Parent Session

• 2 x2h session

• Group 4-15 px

• PPT/manual

• Group discussion

• Activities

1. Body Image

2. Healthy Eating Patterns

3. Healthy Body Weight

• A balanced variety of foods

• Balance of energy in and energy out through fun physical activity

Healthy eating – what it is

24 www.confidentbody.net

Parent book p.47

• But it is also

• A healthful attitude to food

• Food for health and pleasure

• Enjoying a wide variety

• Eating without feeling bad about it and without it affecting your sense

of self

• Sustainable patterns of eating

• Eating when hungry, stopping when full

• Allowing times for celebration

• No strict rules

Healthy eating – what it is


Parent book p.47-49

• Enjoy eating without guilt or moralising

• “Sometimes” and “everyday” foods instead of

• Healthy vs unhealthy

• Good vs bad

• Junk / Treat/ Naughty

• When talking about sometimes foods, talk about the effect on the body

Teaching healthful attitudes


Teaching healthful attitudes


• Too much salt can:

• Stop your kidneys from making wee

• Make you really, really thirsty

• Too much sugar can:

• Give you holes in your teeth

• Make it hard to concentrate

• Too much oily food can:

• Make you feel sick

• Stop the blood from pumping around your body

properly

Preparatory research

CBCC Program of Research

Phase 1Child and family health study

Systematic literature reviews

Stakeholder focus groups

Delphi expert consensus study

Phase 2Resource development

Piloting – in person/survey

Finalisation

Phase 3 RCTBaseline (T1)

6-weeks post-intervention (T2)

6-months post-intervention (T3)

12-months post-intervention (T4)

Phase 4Effectiveness Pilots

Child data

Train-the-trainer networks

Evaluation Dissemination!

Systematic Literature Review

• Parents

• Prevent/Risk/Protect

• Body dissatisfaction

• Disordered eating

Risk factorsProtective factors

CBCC Content

Image area

• Develop expert consensus

• Enhance decision making where RCT not possible

• Questionnaires sent to experts for rating

• Iterations with feedback to build consensus

• Outcome: series of statements/actionswith high level of expert agreement

The Delphi Method

Participants

Round 1• N=28

• 54% Research, 40% Clinical work, 40% Education/Training

• 26 (93%) Female

• Age range 27-69 (M=44.34, SD=12.09)

• Australia, Canada, Ireland, United Kingdom, United States

Round 3• 89% retention rate (R1)

28.6 %

32.1 %

25.0 %

14.3 % Aus

Cana

USA

UK

Endorsed strategies

• 335 potential parenting strategies presented

• 153 (46%) endorsed

Consensus reached on a wide range of issues:• How to promote positive body image in

young children• How to talk about dieting and healthy

weight management• Encouraging regular physical activity• What to do about appearance-based

teasing

Examples

35

QnrSection

Proposed strategyParents should…

Participant endorsement

Healthy eating

...avoid labelling some foods as ‘bad’, as this may lead their child to desire these foods more and feel guilty when they are eaten.

100%

Body image

...encourage their child to take pride in their appearance, but balance this with emphasising other positive qualities not related to appearance.

86% Round 185% Round 2

Body image

...avoid frequently praising their child’s physical appearance.

68%

Body image

...reassure their child about their physical appearance and other physical attributes such as strength or balance.

61%

Physical activity

...promote to their child that physical activity is a means of losing weight.

7%

Endorsement = rating of "Essential” or "Important"

EvaluationRandomized controlled trial

(RCT)

Four Arm Randomised Controlled Trial

A.CBCC Resource

Pack plus session

B. Resource pack only

C. Nutrition resource

D. Wait list control – Surveys only

Happy Healthy Kids for Life

• Dietary guidelines

• Parental Feeding Practices• Instrumental

• Emotional

• Pushing to eat

• Monitoring

• Family meals, tv off

• Sample menus

• Pictorial portion sizes

Measures

Parenting Variables• Knowledge Test for Body Image and Eating

Patterns in Childhood (+)

• Parenting Intentions for Body Image and Eating Patterns in Childhood• Positive intentions subscale (+)

• Negative intentions (-)

• Family Meal Times• Atmosphere (+)

• Schedules (-)

• Television (-)

• Frequency (+)

• Parental Feeding Practices• Instrumental feeding (-)

• Emotional feeding (-)

• Pushing to eat (-)

• Fat restriction (-)

• Weight Restriction (-)

• Monitoring (+)

RCT: Participants

• Eligibility• ≥ one child between the ages of 2-6 years• 18+ years• Sufficient English skills for questionnaire completion• Reside in Victoria

• N = 345• 334 mothers (97%)

• 24 and 51 years (M = 37.5)• BMI: 15 and 45 (M = 25)• 82% completion of a university degree

• 11 fathers (3%)• 31 and 43 years (M = 37.5)• BMI: 21 and 30 (M =26)• 73% completion of a university degree

Participant retention

Baseline6-week

follow-up6 month follow-

up12 month follow-up

Group ACBCC resource + parent workshop

77 68 58 50

Group BCBCC resource only

106 92 81 71

Group CNutrition resource

86 76 65 55

Group DWait-list control

76 69 59 51

TOTAL 345305

(88%)263

(76%)227

(66%)

Data analyses

• Conservative approach• Linear mixed effects model (GLMM) was fitted for each parenting outcome

to compare group allocation (ABCD) over time (Baseline, 6w, 6m, 12)• DV: parenting outcome

• IVs: group allocation, time and group x time interaction

• Intention to treat (participants with missing data included, N=345)

• p-values adjusted for multiple comparisons

• No sig differences across groups at baseline

MeasureSig group diff

at 6-weeks

Knowledge test (+)Positive intentions (+)Negative intentions (-)Family Meal atmos (+)Family Meal sched (-)Family Meal tv (-)Family Meal freq (+)

✓

XXXX✓

✓

Results


at 6-weeksSig group diffat 6-months


✓

XXXX✓

✓

✓

XXXXXX

Results



Sig group diffat 12-months


✓

XXXX✓

✓

✓

XXXXXX

✓

XXXXXX

Results


at 6-weeks

Instrumental feeding (-)Emotional feeding (-)Pushing to eat (-)Fat restriction (-)Weight restriction (-)Monitoring (+)

✓

XXX✓

X

Results – Parental Feeding Practices




✓

XXX✓

X

XXXX✓

X




Sig group diffat 12-months


✓

XXX✓

X

XXXX✓

X

XXXXXX


Summary• Early childhood is an important time for promoting healthy body attitudes and

eating patterns

• Parents play an especially important role in shaping pre-schooler development

• The CBCC resource was carefully designed to meet parent needs and teach evidence-based strategies

• RCT revealed • A significant, positive impact on knowledge (12m) and weight-restriction (6m)• Group A appeared to perform slightly better• Follow-up data were important in revealing how long lasting impacts were• Not sure whether the significant improvements in parenting variables resulted in

meaningful changes for children

• But our more recent studies have confirmed significant improvements in Body Esteem among children of parents receiving CBCC

Thank you• CBCC Research Team

• Susan Paxton

• Laura Hart

• Stephanie Damiano

• Agus Salim

• Connie Li Wai Suen

• Fiona Sutherland

• Chelsea Cornell

• Deirdre Ryan

• Robin Massey

• Rianna Chapman

• Funding support from • Australian Rotary Health

• Cages Foundation

• La Trobe University Building Healthy Communities

Contact:[email protected]/ confidentbodystudy

Documents

Confident Body, Confident Child: A novel program for ......•Overweight/obesity (Rodgers Paxton et al 2013; Clark, Goyder et al 2007) •Body dissatisfaction (Agras, Bryson et al