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
25 www.confidentbody.net
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
26 www.confidentbody.net
Teaching healthful attitudes
27 www.confidentbody.net
• 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
MeasureSig group diff
at 6-weeksSig group diffat 6-months
Knowledge test (+)Positive intentions (+)Negative intentions (-)Family Meal atmos (+)Family Meal sched (-)Family Meal tv (-)Family Meal freq (+)
✓
XXXX✓
✓
✓
XXXXXX
Results
MeasureSig group diff
at 6-weeksSig group diffat 6-months
Sig group diffat 12-months
Knowledge test (+)Positive intentions (+)Negative intentions (-)Family Meal atmos (+)Family Meal sched (-)Family Meal tv (-)Family Meal freq (+)
✓
XXXX✓
✓
✓
XXXXXX
✓
XXXXXX
Results
MeasureSig group diff
at 6-weeks
Instrumental feeding (-)Emotional feeding (-)Pushing to eat (-)Fat restriction (-)Weight restriction (-)Monitoring (+)
✓
XXX✓
X
Results – Parental Feeding Practices
MeasureSig group diff
at 6-weeksSig group diffat 6-months
Instrumental feeding (-)Emotional feeding (-)Pushing to eat (-)Fat restriction (-)Weight restriction (-)Monitoring (+)
✓
XXX✓
X
XXXX✓
X
Results – Parental Feeding Practices
MeasureSig group diff
at 6-weeksSig group diffat 6-months
Sig group diffat 12-months
Instrumental feeding (-)Emotional feeding (-)Pushing to eat (-)Fat restriction (-)Weight restriction (-)Monitoring (+)
✓
XXX✓
X
XXXX✓
X
XXXXXX
Results – Parental Feeding Practices
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