qualitative research papers attached and for that paper, identify and comment on the theoretical perspective and key ethical issues apparent in the paper.


lable at ScienceDirect

Social Science & Medicine 119 (2014) 114e122

Contents lists avai

Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

“Don't eat that, you'll get fat!” Exploring how parents and children conceptualise and frame messages about the causes and consequences of obesity

Samantha L. Thomas a, *, Timothy Olds b, Simone Pettigrew c, Melanie Randle d, Sophie Lewis e

a School of Health and Society, Faculty of Social Sciences and Australian Health Services Research Institute, Faculty of Business, University of Wollongong, Building 41, Northfields Avenue, NSW 2522, Australia b Health and Use of Time (HUT) Group, University of South Australia, Australia c School of Psychology and Speech Pathology, Curtin University, Australia d School of Management, Operations and Marketing and Australian Health Services Research Institute, Faculty of Business, University of Wollongong, Australia e Health Systems and Global Populations, Faculty of Health Sciences, University of Sydney, Australia

a r t i c l e i n f o

Article history: Received 6 May 2014 Received in revised form 8 August 2014 Accepted 19 August 2014 Available online 19 August 2014

Keywords: Obesity Weight Health Children Parents Family Discourses Communication

* Corresponding author. E-mail addresses: [email protected] (S.L. Tho

(T. Olds), [email protected] (S. Petti (M. Randle), [email protected] (S. Lewis).

http://dx.doi.org/10.1016/j.socscimed.2014.08.024 0277-9536/© 2014 Published by Elsevier Ltd.

a b s t r a c t

Family interactions about weight and health take place against the backdrop of the wider social discourse relating to the obesity epidemic. Parents (and children) negotiate complex and often contradictorymessages in constructing a set of beliefs and practices aroundobesity andweightmanagement. Despite this, very little research attentionhasbeengiven to thenature of family-unit discourseon the subjectof bodyweight and it's potential influence on the weight-related behaviours of family members. This includes the broad influence that dominant socio-cultural discourses have on family conceptualisations of weight and health. Using in- depth qualitative interviews with 150 family ‘groups’ comprised of at least one parent and one child in Victoria and South Australia, we explored how parents and children conceptualise and discuss issues of weight- and health-related lifestyle behaviours. Datawere analysed using Attride-Stirling's (2001) thematic network approach. Three thematic clusters emerged from the analysis. First, both parents and children perceived that weight was the primary indicator of health. However, parents focused on the negative physical implications of overweight while children focused on the negative social implications. Second, weight and lifestyle choices were highly moralised. Parents saw it as their responsibility to communicate to children the ‘dangers’ of fatness. Children reported that parents typically used negatively-framedmessages and scare tactics rather than positively-framed messages to encourage healthy behaviours. Third was the perception among parents and children that if you were thin, then eating habits and exercise were less important, and that activity could provide an antidote to food choices. Results suggest that both parents and children are internalising messages relating to obesity and weight management that focus on personal re- sponsibility and blame attribution. These views reflect the broader societal discourse, and their consolida- tion at the family level is likely to increase their potency and make them resistant to change.

© 2014 Published by Elsevier Ltd.

1. Background

The prevalence of adult overweight and obesity is increasing across the developed and developing world, with about two thirds

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of North American, British and Australian adults categorised as being overweight or obese (World Health Organisation, 2013a). Childhood obesity, while showing a plateau over the last decade in many countries, remains unacceptably high (Olds et al., 2011). Overweight and obesity are associated with increased likelihood of many diseases, including diabetes, cardiovascular disease, arthritis and some cancers (World Health Organisation, 2013a,b). Further- more, there is uneven spread across the population, with obesity being disproportionately high amongst low socio-economic and rural populations in Australia (AIHW, 2013).

S.L. Thomas et al. / Social Science & Medicine 119 (2014) 114e122 115

There is widespread recognition that obesity is an urgent issue for public health prevention initiatives (National Preventative Taskforce, 2010). Some researchers argue that the notion of an obesity epidemic arises partly from largely uncontested biomedical data and partly from a socially constructed sense of panic, risk and urgency, coupled with a set of social and cultural values about bodies and body practices (Bordo, 2003; Gard and Wright, 2005; Campos et al., 2006; Monaghan, 2005; Monaghan et al., 2013; Moffat, 2010). Information about the causes and consequences of obesity plays out on a socio-cultural stage, where a narrative is constructed by a range of players with different interests (e.g. biomedical researchers, commercial interests, government agencies, healthcare providers) (Gard andWright, 2005; Saguy and Almeling, 2008). Medically-based discourses predominantly frame obesity as an issue of personal responsibility e arising from poor individual choices e that individuals and families can ‘solve’ by losing weight and/or making appropriate food and lifestyle choices (Campos, 2004; Gard and Wright, 2005; Murray, 2008; Rich and Evans, 2005; Saguy and Riley, 2005; Thomas et al., 2008).

In an attempt to prevent and reduce rates of obesity, govern- ments around the world have introduced various public commu- nications initiatives which aim to increase awareness of the dangers of intra-abdominal fat and the associated increased risks of chronic disease. These communications strategies have aimed to encourage behavioural changes, particularly in relation to food consumption and physical activity. While these strategies clearly play an important role in a comprehensive public health approach to obesity (alongside education, regulation of industry tactics and environmental change) to improving the health of populations (National Preventative Taskforce, 2010), some state such campaigns are problematic because they mix the behaviours that are associ- ated with overweight and obesity with the fact of being obese (Katz et al., 2012; Lupton, 2014; Thomas et al., 2010). Others argue that messages that are framed as simple ‘eat less/exercise more’ equa- tions ignore the powerful structural and market forces that drive individual and population weight gain, and further entrench social inequalities and moral judgements about those who appear to be failing to engage in ‘healthy behaviours’ (Gard and Wright, 2005; Saguy and Almeling, 2008; Herndon, 2005; Bell and McNaughton, 2007; Thomas et al., 2008). This includes how messages about personal responsibility and healthy behaviours may act to mar- ginalise other kinds of discourses, including those that would highlight the importance of social structure in terms of gender, ethnicity, social class and place (Bell and McNaughton, 2007; Ristovski-Slijepcevic et al., 2010a, 2010b, 2008).

Public health initiatives and policies which aim to address childhood obesity locate the family as a primary site for interven- tion (Ristovski-Slijepcevic et al., 2010a). Understanding how infor- mation about weight and health are understood and communicated within the family unit is particularly important given that many lifestyle behaviours are influenced within the home (Sallis and Nader, 1988). Parents are the primary source of health-related information for children and adolescents (Shonkoff and Phillips, 2000), and therefore have significant influence over their children's exposure to positive or negative information related to health andweight (Neumark-Sztainer et al., 2010). Family interactions about weight and health take place against the back- drop of the wider social discourse relating to the obesity epidemic (Gard andWright, 2005). Parents (and children) negotiate complex and often contradictory messages in constructing a set of beliefs and practices around obesity and weight management (Rail et al., 2010; Ristovski-Slijepcevic et al., 2010a). Research shows that different groups of parents may react differently to these messages. For example, some mothers perceive that it is their role and re- sponsibility to promote healthy eating beliefs and practices among

their children by conforming to official dietary guidelines (Ristovski-Slijepcevic et al., 2010a), while others distance them- selves from personal responsibility messages because they do not ‘fit’with their perceived role of providing for the collective needs of the family (Warin et al., 2008). Some studies also suggest that parents are reluctant to discuss weight with their children because of a fear of creating tension in the home or anxiety in their children about an issue that they will eventually ‘grow out of’ (Borra et al., 2003, p.724). However, surprisingly little research has examined how parents and children are influenced by messages about obesity, either at the population level or in other places of social- isation such as the family home (Neumark-Sztainer et al., 2010). This includes how lay perceptions about the relationships between (over)weight and health are formed, the nature of weight-related communications within the home environment, and the factors that may influence and characterise such discussions.

The aim of this study was to explore how parents and their children conceptualise and discuss issues of weight- and health- related lifestyle behaviours within the family environment. We conducted in-depth qualitative interviews with 150 family ‘groups’ comprised of at least one parent and one child (aged 9e18 years) to provide insight into the following research issues:

1. How do parents and children conceptualise the issue of over- weight and obesity?

2. What broader socio-cultural factors may influence how health- related messages are framed within family unit discourses?

3. What role do healthy lifestyle behaviours (eating healthily and exercising) play in the lives of parents and children?

2. Methodology

2.1. Recruitment and sampling strategy

Two market research companies recruited the family groups from metropolitan Melbourne (Victoria) and Adelaide (South Australia) in Australia. Purposive sampling was used to recruit 75 families from each state using Socio-Economic Indicators for Areas Index of Relative Social Disadvantage (IRSD) quotas to broadly represent the population distribution of metropolitan families. If a parent agreed to be contacted by the research team, the recruit- ment company provided their contact details and the researchers then contacted the parent to provide additional information about the study via parent and child Participant Information Sheets. If they agreed to participate, an appointment was made for the interview. Written informed consent was obtained from the parent on behalf of the family group before the interview commenced.

Individuals not fluent in English were excluded from the study. For ethical reasons, children who had a history of eating disorders were also excluded. Ethics approvals were received from two Uni- versity Human Research Ethics Committees, and each family group was provided with a $100 grocery voucher as compensation for the time spent participating in the study. Confidentiality was assured and all identifying data were removed from the transcripts.

2.2. Data collection

We conducted face-to-face, semi-structured interviews with parents and children. Digitally recorded interviewswere conducted in family homes (July 2011eJuly 2012) by trained researchers. The interviews lasted approximately 45e120 min. Pairs of researchers attended the interviews, with one conducting the interviewand the other taking notes about the family dynamics during the interviews.

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Children and parents were separated out of hearing range from each other and were interviewed about their socio-demographic and weight characteristics, lifestyle behaviours and weight- related discussions within the family unit. For children, data were collected in relation to age, gender and self-reported weight and height. For parents, data were collected about age, gender, self- reported weight and height, ethnicity, household income and oc- cupations and education levels of each family member. Information was also obtained from parents and children about their lifestyle behaviours, including amount and type of physical activity and ‘screen time’ (such as computer, videogame and television time). Open-ended questions were used to explore parents' and children's attitudes, beliefs and behaviours relating to weight. Interviewers used three broad themes to encourage discussion relating to:

� How participants conceptualised the relationship between weight and health and the role of food and physical activity in determining weight/health outcomes;

� Howweight-related behaviours were discussed both within and outside of the family, and the outcomes of these discussions; and

� How participants conceptualised their own relationship with their weight, lifestyle behaviours and weight management strategies.

2.3. Data analysis

Quantitative data were entered into SPSS and analysed using basic descriptive analytical techniques. Transcripts were uploaded to NVivo 9 (QSR International) and subsequently coded. Emerging themeswere explored using a thematic network approach (Attride- Stirling, 2001). Developing on thematic analysis (Miles and Huberman, 1994), thematic network maps provide web-like illus- trations that summarise the main themes emerging from the data. This approach was used to conceptualise the connections between the explicit statements and implicit meanings in parent and child responses (Attride-Stirling, 2001). We took a systematic approach to thematic analysis, with analysis commencing after data collec- tion from a small number of families. First, parent data and child data were separated with a linking identifier used to match re- sponses from the same family. We then used open coding tech- niques to analyse the qualitative data collected in the interviews. This involved reading and re-reading the transcripts and grouping the data into text segments, initially by question. The analysts discussed and reached consensus on a preliminary set of codes that represented each of the key areas of interest relating to how chil- dren and adults viewed the connections between weight, lifestyle behaviours and health, and how issues relating to weight were communicated within and outside of the family. We grouped and then compared the grouped data using constant comparative analysis (Glaser and Strauss, 1967) to explore, organise and refine the thematic patterns that emerged within the data.

To structure the text into meaningful themes, first Basic Themes were identified. These were then grouped into Organising Themes, and then finally these were clustered into Global Themes (Attride- Stirling, 2001). Basic Themes are the most simple (or lowest or- der) characteristics of the data. The main ideas within the Basic Themes were then clustered together to represent a number of middle-order Organising Themes. Organising Themes are those themes that summarise the ‘principal assumptions of a group of basic themes’ (Attride-Stirling, 2001). The Organising Theme aims to dissect the main assumptions underlying a broader theme within the data. These themes were clustered together to form a Global Theme. Global Themes exist at the macro level to present a position

or assertion about a given issue. The aim of the Global Theme is to make sense of the clusters of lower order themes, and to delineate/ explicate/elucidate the key positions or assertions that are emerging from the text. It is important to note that more than one thematic network may emerge from the data. Finally, each theme and the associated subthemes were illustrated. These are presented in Figures throughout the text.

3. Results

3.1. Sample description

The 150 family groups that participated in this study included 159 parents and 184 children. Most parents identified as Australian or European (95%), had completed high school (77%), were female (82%) and were in married or in de facto relationships (82%). The mean age for parents was 44.7 (range 27e63) years and the mean BMI was 28.4 (range 18.6e57.2) kg/m2. Two-thirds of parents were overweight (35%) or obese (30%). There were roughly equal numbers of boys and girls in the study, with a mean age of 13.5 (range 7e18) years and a mean BMI of 20.0 (range 14.2e37.1) kg/ m2. Nineteen per cent of all children were overweight and 4% were obese. Over half (57%) of the children exceeded two hours of leisure-based screen time per day (over the Australian Government guidelines) and most (83%) reported that they engaged in greater than or equal to one hour of physical activity per day.

3.2. Thematic networks

Three thematic networks emerged from the data and are pre- sented in Figs. 1e3. Fig. 1 illustrates Thematic Network One (TN1): weight as the primary indicator for health; Fig. 2 illustrates The- matic Network Two (TN2): the moralisation of weight and lifestyle choices, and Fig. 3 illustrates Thematic Network Three (TN3): weight and the food/activity trade-off.

3.2.1. Global Theme 1: weight as the primary indicator for health (TN1)

The majority of parents and children described body weight and shape as the primary indicators of an individual's level of health. Obesity was seen as inherently ‘bad’ for your health, while thinness was predominantly valued for social reasons.

Most parents equated thinness with good health, and fatness with poor health. Many children also identified that good health was a likely outcome of being thin, although for children the health-related benefits were clearly secondary to issues related to social acceptance from peers. Comments made by parents and children included that if an individual wanted to be healthy, they needed to be “a healthy weight”, “slim”, “skinny”, and not “too fat”, “overweight”, or “obese” or carrying “excess weight”. Most also believed that the only ‘healthy weight’ was thinness. However, parents and children conceptualised the negative consequences of obesity in different ways.

From parents' perspective, the main negative consequences associated with adult overweight or obesity related to physical health. Most situated weight and health discourses in relation to the development of chronic illnesses and life expectancy, with some recognising that weight-related health problems become more pronounced as people age. For example, some overweight and obese parents worried that their weight status would lead to premature death and that they may not live to see their children or grandchildren grow up. While these participants also believed that weight loss would enable them to avoid developing obesity-related health conditions such as Type II diabetes, heart disease, and arthritis, very few described actively trying to lose weight. Barriers

Fig. 1. Thematic Network One e weight as the primary indicator of health.

Fig. 2. Thematic Network Two e the moralisation of weight and lifestyle choices.

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to weight loss that were mentioned included a lack of awareness of practical strategies to enable them to lose weight, a lack of time to devote to exercise and previous failed weight loss attempts. In contrast to these views, a few overweight parents stated that they believed individuals could be both overweight and healthy. These individuals stated that weight was not the only, nor the most important, indicator of an individual's health and fitness.

By comparison, most children focused on the psychological and social consequences of overweight and obesity. While children acknowledged that there were physical health risks associated with obesity, most described weight as being related to social desirability. For example, some described how thinness was

strongly linked to popularity and social acceptance among their peers and family members. Both boys and girls commented that thinness was a socially and personally desirable individual attri- bute that contributed to positive body image and feelings of happiness and self-worth. Most children believed that fatness was extremely socially undesirable. They believed that if they were overweight they would “feel bad” about themselves and be socially excluded, bullied and teased. One child stated that she felt lucky to be thin because she didn't want to be “fat and teased at school”. Another stated that being “healthy” was “better than being fat” because being obese would give him a “bad life” by restricting his ability to play sport.

Fig. 3. Thematic Network Three e weight and the food/activity trade-off.

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Children's conceptualisations of the relationship between body weight and social outcomes were often based on their personal experiences of others' reactions to their own bodies. For example, some children e with a diverse range of body sizes ranging from those classified by their BMI as being in the normal range to those who were classified as obese e had personally experienced “teasing” for their body weight or shape. These childrenwere more likely to view fatness as leading to negative social outcomes. Some of these children also described that teasing or commentary from peers or family members about their weight or body shape had impacted on their self-esteem. Some of these children reported regularly thinking about how to change their body shape. For example, one child stated that teasing at school had led him to seek strategies for weight loss. After describing that he had been inter- ested in losingweight so that he could bemore involved in sport, he explained that the children at his school had been teasing him about his weight:

[I talk about] wanting to lose weight and about what I have in my lunch andwhat I should eat everyday. Mymum talks to me a lot about exercising. Normally I bring it up because lately I've been really interested in losing weight.

Interviewer: Why are you interested in losing weight?

Well, I don't know. I just want to be able to domore things, more running and physical activity … Other kids at school give me a hard time sometimes e just teasing.

- 12 year old boy, overweight.

Poor body image and body dissatisfaction were not solely the domain of children who were overweight or obese. One boy described how his close friends and family members told him he was “too skinny” and that he felt that he needed to put onweight to make him feel better about himself:

I know myself I need to put on some more weight. When someone close to me says that, I'm fine with it. It's also the way they say it too. It makes me feel more comfortable [and] makes me want to do it as well. Sometimes I look at myself [and] feel like I'm too skinny. I don't let it affect me, but I don't know, it's one of those little things I need to work on.

- 14 year old male, normal weight.

3.2.2. Global Theme 2: the moralisation of weight and lifestyle choices (TN2)

This thematic network focuses on the moralisation of weight and lifestyle choices and, in particular, the negative framing of messages about overweight and lifestyle choices. Almost all of the parents in this study described how they regularly communicated the risks associated with unhealthy food choices and lack of physical activity to their children. Most felt that it was their parental responsibility to warn their children of the dangers of becoming overweight. Much of the family conversation about weight within the household was focused on the negative conse- quences of overeating or eating unhealthy foods. For example, most parents described that they often reminded children to limit their intake of junk food. A much smaller proportion of parents focused on physical activity or the amount of screen time that childrenwere engaging in. These parents reported telling their children that they weren't doing enough physical activity and/or that they were watching too much television.

Most parents appeared to use weight, and in particular ‘fatness’, rather than overall health or wellbeing, as the ‘stick’ to warn their children about the social and health risks associated with un- healthy lifestyle choices. One father stated that he regularly prompted his daughter to value thinness as he believed that becoming obese would reduce her life opportunities. A few parents also allowed siblings to reinforce the risks about overweight to other siblings and described how the children within the family monitored each other's food consumption patterns based on their body size. For example, the following mother described how her eldest daughter “took the pressure off” her parenting re- sponsibilities because she constantly policed what her younger sibling ate:

[My older daughter's] very conscious of what she eats so she'll often tell [the younger daughter] off and say ‘that's really bad for your weight’ and ‘you eat so much rubbish’. So she'll actually pull them all into line so we don't have to do it as much.

- 44 year old mother, normal weight.

Rather than discouraging teasing, a few parents explained that they thought teasing for overweight children (particularly between siblings) could be helpful in managing a child's weight because it made them realise that fatness was a “bad thing”. For example, one mother stated that childhood teasing played an important role in motivating her son to lose weight:

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My son was an overweight kid before. Well, not hugely over- weight, but compared to the other skinny minis in the family he felt self-conscious about it. But then he started martial arts and he was really focussing on proper diet. I guess he was sick of being stirred by his sister who continues to call him ‘obese’.

- 44 year old mother, overweight.

Some children, and in particular girls, reported that their par- ents taught them to fear becoming fat to encourage them to eat a more healthy diet. Many of thesemessages were negatively framed. These children described how their parents regularly warned them that if they continued with unhealthy behaviours they would become fat. For example, one 13 year old girl said that her parents warned her that she could become overweight whenever she was being “lazy” as a way to motivate her to exercise. A few children described how their parents said that if they were not more active theywould end up on the reality weight loss show The Biggest Loser.

Children also described that the messages about weight from their parents were negatively framed. Children reported that their parents communicated to them that overweight and obesity were the result of making bad choices or doing the wrong thing. One 10 year old girl stated that her parents often pointed out fat people on television or in public as examples of what would happen if you did “the wrong thing”. Television was a ‘theatre of morality’, where morality tales about fatness played out:

If we're having too much chocolate or chips, we'll talk about “you see those people on TV who are fat, you don't want to end up like that”.

- 10 year old girl, normal weight.

Children's perceptions of their own bodies and the desire to change their body shape or weight were strongly influenced by their peers. Girls described how they prioritised their body weight and image emainly thinness e over their health. For example, one 10 year old overweight girl described how she didn't “care about being healthy” but that she did not want to “get fat”. Older girls also described how “fat talk” was common with peers, and mostly occurred at school. Girls described how their discussions with school friends were focused on body dissatisfaction and hatred, weight loss and dieting. They also described how “we all talk …