The importance of parental beliefs and support for physical activity and body weights of children: a population-based analysis.
Ploeg, Kerry A. Vander ; Maximova, Katerina ; Kuhle, Stefan 等
Overweight and obesity in childhood are major public health
concerns. They negatively impact self-esteem and academic performance.
(1,2) Because overweight children tend to become overweight adults, an
increasing number of children will face chronic disease in their
lifetime. (3,4) In Canada, the prevalence of childhood overweight has
more than doubled in the past decades. Recent estimates indicate that
about 30% of children are overweight or obese. (5)
Insufficient physical activity (PA) is a proximate risk factor of
childhood overweight. (6) In Canada, most children are not sufficiently
active; (7) 9% of boys and 4% of girls accumulate the recommended 60
minutes of daily moderate-to-vigorous activity. (7) Promotion of PA is
therefore a priority for the prevention of childhood overweight.
Parental beliefs and support for PA have been suggested as key
areas for health promotion. Recent reviews report that parents influence
children's PA behaviour by modeling and by supporting PA (e.g.,
being active together, encouraging PA). (8,9) However, research is
limited and inconsistent when comparing the importance of parental PA
beliefs and support for overweight relative to normal-weight
children's PA. (10,11) Furthermore, the literature lacks
generalizability because studies have not been population-based.
Additionally, parental beliefs and support for children's PA have
not been associated with children's weight status.
To support the development of health promotion strategies and
interventions for the prevention of childhood overweight, our primary
objective is to use a population-based sample of children and parents to
assess whether parental beliefs and support for PA are associated with
childhood overweight. We also aim to assess the association of parental
beliefs and support with PA, and whether this association is distinct
for normal-weight compared to overweight children.
METHODS
Study design/setting
Raising healthy Eating and Active Living (REAL) Kids Alberta is a
population-based study of grade 5 children and parents in Alberta,
Canada. The survey was conducted in 2008 and 2010 and employed a
one-stage stratified random sampling design as described elsewhere. (12)
In 2008, 148 of 184 (80.4%) schools participated. We sent 5,321 students
home with surveys containing parental consent forms for their parent(s)
to complete and return to school; 3,704 (70%) surveys were returned,
3,645 (98% of the 3,704) students received parental consent, and 3,421
children completed student surveys, resulting in a participation rate of
64%. We repeated data collection among grade 5 students and parents in
2010 from the schools that participated in 2008. In 2010, 7 schools were
closed or not available to participate; we replaced these schools with
10 additional schools. We distributed 5,597 home surveys from 151
schools; 3,687 (66%) home surveys were returned, 3,656 (99% of the
3,687) students received parental consent to participate, and 3,389
children completed student surveys, resulting in a participation rate of
61%. Among these children, 3,300 in 2008 and 3,285 in 2010 had complete
responses on parental beliefs and support, self-report PA, and BMI
scores and were considered in the analysis.
Assessment of parental beliefs and support
The parent survey included three questions related to beliefs and
support that were adapted from the activity-related parenting practices
scale by Davison et al. (13) These included: 1) how much do you
personally care about staying fit and exercising; 2) to what extent do
you encourage your grade 5 child to be physically active; and 3) how
often do you or another parent/guardian usually engage in PA together
with your child. The questions we used are available at:
www.REALKidsAlberta.ca
Assessment of outcome measures
Physical Activity
The student survey included the Physical Activity Questionnaire for
Older Children (PAQ-C). The PAQ-C is a validated 7-day recall instrument
that provides a summary score for general PA for children, aged 8 to 14
years. (14-16) We derived the summary score by taking the mean score of
7 items, each scored on a 5-point scale. A summary score of 1 indicates
low PA, whereas a score of 5 indicates high PA. The PAQ-C is a valid and
reliable self-report measure for children's PA during the school
year. (14,15)
Overweight and Obesity
Trained assistants measured children's standing height to the
nearest 0.1 cm using stadiometers (Seca-Stadiometer, Germany) and body
weight to the nearest 0.1 kg on calibrated digital scales
(Health-o-meter, IL, USA). We asked children to remove their shoes for
both measurements. BMI was calculated as kg/[m.sup.2]. We defined
overweight using the International Obesity Task Force BMI cut-off point
established for children and youth. (17) The cut-off point is based on
the health-related adult definition of overweight (BMI [greater than or
equal to]25), but is adjusted to specific age and sex categories for
children.
Confounding variables
Analyses were adjusted for the confounding potential of gender,
survey completion year, parental education attainment, and combined
household income (which is known to be high in Alberta) (Statistics
Canada, 2011).
Data analysis
T-test and chi-square tests were used to test for differences
between the 2008 and 2010 samples. Because observations were clustered
within schools, we applied random effects models with students nested in
schools. For each of the parental beliefs and support variables, we
first applied univariable linear regression models to determine their
associations with children's self-reported PA. Second, we applied
multivariable linear regression models to adjust for the confounding
effects of gender, parental educational attainment, household income,
and year (Model 1). Third, we considered all predictors simultaneously
to quantify their independent importance for children's
self-reported PA (Model 2). We repeated these analyses stratified by
normal-weight and overweight or obese children. Estimates of the effect
size were derived from each model and are presented as estimates of the
Partial Eta Squared. Last, to assess the effects of parental beliefs and
support for PA on childhood overweight, we applied logistic random
effects models. Missing values for parental education attainment and
household income were treated as separate covariate categories, however,
we do not present their estimated values.
All analyses were weighted to account for the effect of the study
design. Therefore, the estimates are population-based and apply to the
grade 5 student population of Alberta, Canada. We used Stata Version 11
(Stata Corp, TX, USA) to perform the statistical analyses. The Health
Research Ethics Board of the University of Alberta approved this study,
including data collection and parental informed consent forms in 2008
and 2010.
RESULTS
There were no differences between the 2008 and 2010 samples (Table
1). Boys reported higher levels of PA relative to girls (p<0.001).
Increased parental care about staying fit and exercising, parental
encouragement of PA, and parental engagement in PA with their child were
associated with increased self-reported PA among children (Table 2).
Parental encouragement of PA, and engagement in PA together were
independent determinants of children's self-reported PA (Table 2:
Model 2 beta coefficients).
Overweight children whose parents cared "quite a lot"
about staying fit and exercising were reportedly significantly less
active compared to normal-weight children whose parents cared
"quite a lot" (Table 3: [beta]=-0.07, 95% CI: -0.12, -0.03).
Table 3 depicts similar findings for encouragement of PA ([beta]=-0.04,
95% CI: -0.08, 0.01) and engagement in PA together ([beta]=-0.07, 95%
CI: -0.10, -0.03).
Parents and children engaging in PA together and parental care
about staying fit and exercising were not associated with childhood
overweight. The single statistically significant independent parent
factor that was negatively associated with childhood overweight was
increased parental encouragement. Relative to children whose parents
encouraged PA "quite a lot", children whose parents encouraged
PA "very much" had 22% lower odds of being overweight (Table
4: Model 2 OR=0.78, 95% CI: 0.68-0.89).
DISCUSSION
This study demonstrated that increases in parental care about
staying fit and exercising, encouragement of PA, and parental engagement
in PA with their child were associated with increased rates of
self-reported PA among children. These gradients persisted after
stratification based on weight status. A novel finding of this study was
that the impact of parental encouragement of children's PA was also
reflected in a lower prevalence of overweight.
Our findings are consistent with previous reviews indicating that
parental beliefs and support for PA are positively related to
children's PA, self-reported or otherwise. (8,9) We found that
parental engagement in PA and parental encouragement of PA were stronger
predictors of children's reported PA than parental care about
personal fitness. Other studies report similar findings. (18,19) For
example, McGuire et al. (19) showed that parental encouragement was
significantly related to boys' and girls' PA, but parental
concern about personal fitness was not related. These results are
further supported by the fact that parental care about personal fitness
reflects modeling behaviour, (20) which often less directly affects
children's PA than more proximate forms of support. (21)
Colley et al. (22) reported that Canadian adults are not
sufficiently active. Yet many parents report to engage in physical
activities with their children. This study found that parental
engagement in PA with their child was the strongest predictor of
children's self-reported PA. This finding is consistent with some
(23) but not all studies. (24) This discrepancy, however, may be an
effect of children's age. The mean age of the children sampled by
Adkins et al. (23) was 8.8 years, while the children sampled by Robbins
et al. (24) were 11-14 years. There is some evidence (25) to suggest
that as children move into adolescence, parental involvement in
children's PA becomes less important and other types of support
(e.g., encouragement and peer involvement) become more important. To our
knowledge, this is the first study to report population-based results;
therefore our results indicate that at a population level, targeting
parents to encourage and spend time being active with their children may
be an effective strategy to increase grade 5 children's PA.
We also found that increased parental care about staying fit and
exercising, increased parental encouragement of PA, and increased
engagement in activities were associated with increased rates of
self-reported PA among both normal-weight and overweight children. These
findings are consistent with those of others. (10,26) However, the
associations were distinct for normal-weight and overweight children.
For example, the association between parental encouragement and
self-reported PA, while positive among both overweight and normal-weight
children, was stronger among normal-weight children. This seems
consistent with a study that found that family social support was
positively associated with PA in normal-weight boys, but not in
overweight boys. (11) The importance of parental encouragement on
overweight children's PA may be influenced by the tendency of these
children to report more barriers to PA. (27) Conversely, the
associations between parental engagement in PA together and reported PA
behaviour among normal-weight and overweight children were similar,
suggesting that parental engagement in PA may help overweight children
to overcome barriers to PA.
We also showed that encouraging PA was negatively associated with
childhood overweight. Studies indicate that parent encouragement is
mediated through psychosocial attributes such as improved self-efficacy
and liking of and attraction to activity. (18,20) Health promotion
strategies and interventions to increase children's PA and/or
reduce childhood overweight should include programs to teach parents how
to effectively support their children to be physically active. Rhea
recommended introducing overweight children gradually to enjoyable
activities that will build their sense of self-efficacy. (28)
Strengths of our study include our large representative sample,
generalizability of our results, measured heights and weights, and a
high response rate for school-based research. (29) A limitation relates
to the cross-sectional design, and necessitates caution with respect to
interpretations of directionality and causality. Also, self-report
measures are prone to bias and may produce socially desirable responses
to questions surrounding parental beliefs and support, and an
overestimation of children's PA. (30) Objective measures of PA
(e.g., pedometers) would provide a more accurate estimate of
children's PA, however, pedometers may be logistically and
financially challenging in large population-based studies, as was the
case in this study.
CONCLUSION
We showed the importance of parental beliefs and support for
children's PA and body weight status. Health promotion strategies
and programs that educate parents on how to effectively support their
child in developing an active lifestyle may contribute to increasing PA
and preventing overweight among children.
Received: January 16, 2012
Accepted: May 26, 2012
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Kerry A. Vander Ploeg, [1] Katerina Maximova, PhD, [1] Stefan
Kuhle, MD, PhD, [2] Aline Simen-Kapeu, MD, PhD, [1] Paul J. Veugelers,
PhD [1]
Author Affiliations
[1.] School of Public Health, University of Alberta, Edmonton, AB
[2.] Departments of Pediatrics and Obstetrics & Gynecology,
Dalhousie University, Halifax, NS
Correspondence: Paul J. Veugelers, Population Health Intervention
Research Unit, School of Public Health, University of Alberta, 3-50
University Terrace, 8303 112 Street, Edmonton, AB T6G 2T4, Tel:
780-492-9095, Fax: 780-492-5521, E-mail:
[email protected]
Acknowledgements: We thank all grade 5 students, parents and
schools for their participation, the evaluation assistants for the
execution of the data collection, and Connie Lu for data management and
validation. The research was funded through a Canada Research Chair in
Population Health and Alberta Innovates Health Solutions Health
Scholarship to Dr. Paul Veugelers.
Conflict of Interest: None to declare.
Table 1. Descriptive Characteristics of Grade 5 Children and Their
Parent(s) in Alberta, Canada Including Means (95% Confidence Interval)
and Prevalences
2008 Prevalence
n=3300
Mean age (95% CI) 10.67 (10.66-10.68)
Proportion boys, % 48.3
Overweight (including obese), % 28.5
Obese, % 6.7
Mean PAQ-C (95% CI) 3.30 (3.28-3.32)
Parental educational attainment, %
Secondary or less 26.9
College diploma 39.7
University or graduate degree 33.4
Household income, %
[less than or equal to]$50,000 24.0
$50,001-$75,000 17.7
$75,001-$100,000 22.0
[greater than or equal to]$100,001 36.3
2010 Prevalence
n=3285
Mean age (95% CI) 10.88 (10.87-10.89)
Proportion boys, % 49.2
Overweight (including obese), % 27.4
Obese, % 8.8
Mean PAQ-C (95% CI) 3.32 (3.30-3.34)
Parental educational attainment, %
Secondary or less 25.1
College diploma 39.2
University or graduate degree 35.7
Household income, %
[less than or equal to]$50,000 24.0
$50,001-$75,000 17.6
$75,001-$100,000 20.4
[greater than or equal to]$100,001 38.0
Combined Prevalence
n=6585
Mean age (95% CI) 10.78 (10.77-10.79)
Proportion boys, % 48.7
Overweight (including obese), % 27.9
Obese, % 7.7
Mean PAQ-C (95% CI) 3.31 (3.30-3.32)
Parental educational attainment, %
Secondary or less 26.0
College diploma 39.5
University or graduate degree 34.5
Household income, %
[less than or equal to]$50,000 24.0
$50,001-$75,000 17.6
$75,001-$100,000 21.3
[greater than or equal to]$100,001 37.1
Table 2. Prevalences and Associations (Beta Coefficient and 95%
Confidence Interval) of Parental Beliefs and Support for Grade 5
Children's PA in Alberta, Canada
Prevalence
Care about staying fit
and exercising
Not at all /A little bit 23.1
Quite a lot 46.1
Very much 30.8
Encourage PA
Not at all /A little bit 13.1
Quite a lot 45.0
Very much 41.9
Engage in PA together
Never or <1 time/week 39.3
1-3 times/week 51.7
[greater than or equal 9.0
to]4 times/week
Univariable
[beta] 95% CI Effect
Size
([double dagger])
Care about staying fit
and exercising
Not at all /A little bit -0.16 -0.19, -0.12 0.016
Quite a lot 0.00 -- --
Very much 0.15 0.11, 0.19 0.015
Encourage PA
Not at all /A little bit -0.28 -0.33, -0.24 0.033
Quite a lot 0.00 -- --
Very much 0.22 0.19, 0.25 0.040
Engage in PA together
Never or <1 time/week -0.44 -0.47, -0.41 0.163
1-3 times/week 0.00 -- --
[greater than or equal 0.34 0.30, 0.38 0.035
to]4 times/week
Multivariable
Model 1 *
[beta] 95% CI Effect
Size
([double dagger])
Care about staying fit
and exercising
Not at all /A little bit -0.15 -0.18, -0.11 0.014
Quite a lot 0.00 -- --
Very much 0.14 0.11, 0.18 0.013
Encourage PA
Not at all /A little bit -0.27 -0.31, -0.22 0.030
Quite a lot 0.00 -- --
Very much 0.21 0.17, 0.24 0.036
Engage in PA together
Never or <1 time/week -0.44 -0.47, -0.41 0.171
1-3 times/week 0.00 -- --
[greater than or equal 0.36 0.32, 0.41 0.045
to]4 times/week
Multivariable
Model 2 ([dagger])
[beta] 95% CI Effect
Size
([double dagger])
Care about staying fit
and exercising
Not at all /A little bit -0.02 -0.05, 0.01 <0.001
Quite a lot 0.00 -- --
Very much 0.02 -0.01, 0.05 <0.001
Encourage PA
Not at all /A little bit -0.19 -0.23, -0.15 0.020
Quite a lot 0.00 -- --
Very much 0.13 0.10, 0.16 0.019
Engage in PA together
Never or <1 time/week -0.40 -0.43, -0.37 0.147
1-3 times/week 0.00 -- --
[greater than or equal 0.33 0.28, 0.37 0.040
to]4 times/week
Note: We combined responses to the first two categories for each
question due to small cell sizes.
* Model 1 is adjusted for gender, household income, parental
educational attainment and year of data collection.
([dagger]) Model 2 is adjusted for parental care about staying fit and
exercising, encouraging PA, engaging in PA together, gender, household
income, parental educational attainment, and year of data collection.
([double dagger]) Partial Eta squared.
Table 3. Prevalences and Associations (Beta Coefficient and 95%
Confidence Interval) of Parental Beliefs and Support for Normal-
weight and Overweight (Including Obese) Grade 5 Children's PA in
Alberta, Canada
Prevalence
Care about staying fit and
exercising
Normal weight
Not at all /A little bit 16.1
Quite a lot 33.0
Very much 23.1
Overweight/Obese
Not at all /A little bit 7.0
Quite a lot 13.1
Very much 7.7
Encourage PA
Normal weight
Not at all /A little bit 8.9
Quite a lot 31.5
Very much 31.7
Overweight/Obese
Not at all /A little bit 4.3
Quite a lot 13.5
Very much 10.1
Engage in PA together
Normal weight
Never or <1 time/week 28.0
1-3 times/week 37.7
[greater than or equal to]4 6.4
times/week
Overweight/Obese
Never or <1 time/week 11.3
1-3 times/week 14.0
[greater than or equal to]4 2.6
times/week
Univariable
[beta] 95% CI Effect Size.
([double
dagger])
Care about staying fit and
exercising
Normal weight
Not at all /A little bit -0.15 -0.20, -0.11 0.011
Quite a lot 0.00 -- --
Very much 0.14 0.11, 0.18 0.011
Overweight/Obese
Not at all /A little bit -0.24 -0.29, -0.19 0.014
Quite a lot -0.08 -0.12, -0.04 0.003
Very much 0.09 0.02, 0.16 <0.001
Encourage PA
Normal weight
Not at all /A little bit -0.29 -0.34, -0.23 0.024
Quite a lot 0.00 -- --
Very much 0.23 0.19, 0.27 0.033
Overweight/Obese
Not at all /A little bit -0.32 -0.40, -0.24 0.016
Quite a lot -0.04 -0.08, 0.00 0.001
Very much 0.13 0.07, 0.19 0.004
Engage in PA together
Normal weight
Never or <1 time/week -0.43 -0.47, -0.40 0.117
1-3 times/week 0.00 -- --
[greater than or equal to]4 0.32 0.27, 0.37 0.025
times/week
Overweight/Obese
Never or <1 time/week -0.53 -0.58, -0.48 0.108
1-3 times/week -0.07 -0.11, -0.04 0.004
[greater than or equal to]4 0.32 0.23, 0.41 0.007
times/week
Multivariable *
[beta] 95% CI Effect Size.
([double
dagger])
Care about staying fit and
exercising
Normal weight
Not at all /A little bit -0.14 -0.19, -0.10 0.010
Quite a lot 0.00 -- --
Very much 0.13 0.10, 0.17 0.009
Overweight/Obese
Not at all /A little bit -0.23 -0.28, -0.18 0.013
Quite a lot -0.07 -0.12, -0.03 0.003
Very much 0.09 0.02, 0.16 <0.001
Encourage PA
Normal weight
Not at all /A little bit -0.27 -0.32, -0.21 0.022
Quite a lot 0.00 -- --
Very much 0.22 0.18, 0.26 0.030
Overweight/Obese
Not at all /A little bit -0.30 -0.38, -0.22 0.014
Quite a lot -0.04 -0.08, 0.01 0.001
Very much 0.13 0.07, 0.19 0.003
Engage in PA together
Normal weight
Never or <1 time/week -0.43 -0.46, -0.40 0.123
1-3 times/week 0.00 -- --
[greater than or equal to]4 0.34 0.30, 0.39 0.032
times/week
Overweight/Obese
Never or <1 time/week -0.53 -0.58, -0.48 0.111
1-3 times/week -0.07 -0.10, -0.03 0.003
[greater than or equal to]4 0.35 0.26, 0.43 0.011
times/week
* Adjusted for gender, household income, parental educational
attainment, and year of data collection.
([double dagger]) Partial Eta squared.
Table 4. Prevalences and Associations (Odds Ratio and 95% Confidence
Interval) of Parental Beliefs and Support for Childhood Overweight
Among Grade 5 Children in Alberta, Canada
Univariable
Prevalence OR 95% CI
Care about staying fit and
exercising
Not at all /A little bit 23.1 1.08 0.93, 1.25
Quite a lot 46.1 1.00 --
Very much 30.8 0.87 0.75, 1.02
Encourage PA
Not at all /A little bit 13.1 1.13 0.95, 1.34
Quite a lot 45.0 1.00 --
Very much 41.9 0.76 0.67, 0.87
Engage in PA together
Never or <1 time/week 39.3 1.07 0.93, 1.23
1-3 times/week 51.7 1.00 --
[greater than or equal to]4 9.0 1.03 0.82, 1.30
Multivariable
Model 1 * Model 2([dagger])
OR 95% CI OR 95% CI
Care about staying fit and
exercising
Not at all /A little bit 1.06 0.91, 1.23 1.02 0.87, 1.20
Quite a lot 1.00 -- 1.00 --
Very much 0.90 0.77, 1.05 0.98 0.84, 1.15
Encourage PA
Not at all /A little bit 1.11 0.93, 1.32 1.10 0.92, 1.33
Quite a lot 1.00 -- 1.00 --
Very much 0.78 0.69, 0.89 0.78 0.68, 0.89
Engage in PA together
Never or <1 time/week 1.05 0.91, 1.21 1.00 0.87, 1.15
1-3 times/week 1.00 -- 1.00 --
[greater than or equal to]41.01 0.80, 1.27 1.07 0.85, 1.34
* Model 1 is adjusted for gender, household income, parental
educational attainment and year of data collection.
([dagger]) Model 2 is adjusted for parental care about staying fit and
exercising, encouraging PA, engaging in PA together, gender, household
income, parental educational attainment, and year of data collection.
