The Role of Self-Regulation and Parents
in Children at Risk of Developing
Obesity.
Eveline Sintnicolaas
University of Amsterdam
Bachelor Thesis Social Psychology Eveline Sintnicolaas
10203427 27-06-2014
Amount of words: 5645 Abstract: 126
Abstract
The role of self-regulation in children at risk of developing obesity is reviewed. Self-regulation failure in children is associated with higher BMI z scores and may result in weight gain into early
adolescence. As children have not yet fully developed their self-regulatory strategies, parents play an important role in promoting feeding practices to enable a child’s ability to self-regulate food intake. Authoritative feeding style is positively associated with accessibility and consumption of healthy food in contrast with authoritarian feeding style. Moreover, the role of parents is highlighted by the
effectiveness of treatment of overweight or obese children that focused solely on the parents. In conclusion, self-regulation and parents are important factors in the etiology of childhood obesity and can provide insight in effective and cost-reducing interventions.
The Role of Self-Regulation and Parents in Children at Risk of Developing Obesity.
The prevalence of overweight or obese people is disturbing. In 2012, 30% of the people living in the Netherlands of four years and older were classified as moderately overweight. In addition, 10% were classified as overweight or obese (Central Bureau for the Statistics, 2014). Childhood obesity is associated with health risks that contribute to high annual public health costs. Eating disorders and depression, as well as psychosocial factors such as body image dissatisfaction are also considered etiological risk factors for obesity. The need to identify the early predictors of childhood obesity is emphasized by the health and psychosocial costs associated with it (Graziano, Kelleher, Calkins, Keane & Brien 2013). Obesity in childhood generally continues into adulthood and increases the risk of developing, for instance, cardiovascular disease, diabetes mellitus, and certain cancers in adulthood (Francis & Susman, 2009). There are many factors, such as the social-economic status, ethnicity, BMI of the parents, external environment (e.g. School, household) and intelligence, that are involved in the etiology of childhood overweight and obesity (Patrick, Nicklas, Hughes & Morales, 2005). Better knowledge of these factors is needed. However, it is very hard to study these different factors in research. If research combines all different factors, it would be very difficult to make clear comparisons and draw conclusions. There are many confounders that could influence the results. Therefore, this review focuses on one of those factors that have been implicated in the development of obesity, namely, self-regulation. Self-regulation, or self-control, refers to the capacity to override and alter initial responses (Fransis & Susman, 2009). Eating is a particular self-control problem, because unlike other forms of self-regulation, it is not possible to avoid the temptation as a regulatory method (Vohs & heatherton, 2000). This makes self-regulation in eating behaviour an important topic to study. Research into this topic may provide more knowledge on the development of obesity in children.
In this review the role of self-regulation in children at risk of developing obesity was examined. In order to understand the development of self-regulation, research was done with children between the ages of 2 12 years. Children are not fully capable of understanding and using their self-regulatory resources (Fransis & Susman, 2009), so it can be reasoned that they depend on their parents regarding healthy eating patterns. Parents have great influence on the daily eating pattern of their child, as they are the ones who provide the food and decide when, how and how much food is offered (Golan & Crow, 2004). It has been claimed that people with obesity are hypersensitive to external cues, particularly cues that incite hunger and eating (Francis & Susman, 2009). Parents are the ones who create and maintain most of the external cues. So, it is very hard for children to change or influence cues that incite hunger and eating. In addition, the parent has a function as a role model (Vohs & Heaterthon, 2000). The child learns through social learning and imitates the social norms, attitudes and behaviours shown by the parent. Furthermore, the parents determine the social norms, or more clearly stated they are the social norm. These factors coalesce to change behaviour. A
well-supported theory that describes this is the theory of planned behaviour: “intentions to perform behaviours of different kinds can be predicted with high accuracy from attitudes toward the behaviour, subjective norms, and perceived behavioural control; and these intentions, together with perceptions of behavioural control, account for considerable variance in actual behaviour.”(Ajzen, p.179). In order to gain insight into effective preventive interventions for children at risk of developing obesity, it is also examined how parents play a role in the development of self-regulation and the treatment of obesity. Taken together, this review examined how self-regulation plays a role in children at risk of developing obesity and what role do parents play in the development of self-regulation in children and the treatment of obesity.
The first paragraph describes more clearly what self-regulation is. The second paragraph considers the role of self-regulation in children at risk for developing obesity. Finally, in the third paragraph, the role of parents in the development of self-regulation in children and the treatment of obesity is examined. Self-regulation plays a role in a child’s ability to remain self-control. This review addresses three hypotheses. Firstly, children who fail to make proper use of their self-regulatory resources are at risk of developing obesity. Children who score low on self-regulation tasks will have higher BMI z scores than children who score higher on self-regulation. A BMI z score can be determined given a child’s age, sex, BMI, and an appropriate reference standard. It is optimal for assessing obesity on a single occasion. Z-scores are particularly useful to designate the specific BMI cut point to be the same across samples, because BMI z score are based on an external reference (Tan & Holub, 2011). Secondly, parenting style influences the development of self-regulation in children. Parents have significant influence on children, generating the environmental context in which children develop. Thirdly, taking into account that self-regulation strategies in children are not yet fully developed and that parents play an important role in attitudes, perceived self-control and social norm, treatment of obese children is more effective if focused on the parents rather than on the child.
What is self-regulation?
Self-regulation, or self-control, refers to the capacity to override and alter initial responses. This means that most of the time a natural response is overridden by a less natural, but desired response. People attempt to constrain unwanted urges in order to gain control of the incipient response. They want to change the behaviour to match a personal standard such as an ideal or goal. Self-restraint is a common form of self-regulation, but so is the amplification or prolonging of a response (Francis & Susman, 2009; Vohs & Heatherton, 2000). The ability to self-regulate is a crucial facet of selfhood, in its ability to control the self, to pay attention and to interact with the environment (Vohs & Heatherton, 2000). It’s assumed that the set of resources that people are born with enable them to modify their responses (Tan & Holub, 2011). It is likely that self-regulatory resources develop over time. The development of self-regulation is a result of increasing control over conscious processes, as well as enhanced inhibitory control over motor behaviour (Graziano et al., 2013).
There is much evidence that self-regulatory failure fits a model of strength depletion (Baumeister, Heatherton & Tice, 1994, mentioned in Baumeister, Bratlavsky, Muraven & Tice, 1998). The strength model of self-control (Baumeister et al., 1998) gives a plausible explanation as to why people so often fail to self-control. This model suggests that if people self-regulate, they make use of limited cognitive resources. When people run out of those self-regulatory resources, they end up in a state of ego-depletion. This makes them less capable of exerting self-control on a subsequent task. Ego-depletion refers to the temporary reduction of self-regulation due to prior, unrelated efforts at self-regulation. Baumeister et al. (1998) provide broad support for this model by what the effect of initial acts of self-regulation is on subsequent acts of self-regulation. A study by Job, Dweck and Walton (2010) showed that only people who thought of, or who were led to think of willpower – the capacity to exert self-control- as a limited resource showed ego-depletion.
The following research will provide more insight into this mechanism. It is interesting to find out how and if the self-resources can be restored. Tice, Baumeister, Shmueli and Muraven (2007) conducted a study to explore the possibility that a positive emotion or mood restores the self-resources. They state that “after an initial act of self-regulation, participants who watched a comedy video or received a surprise gift, self-regulated on various tasks just as well as non-depleted participants, and significantly better than those participants who experienced a sad mood induction, a neutral mood stimulus, or a brief rest period” (p. 379). Although the results indicate that a positive mood counteracts ego-depletion, it has to be taken into account that this could also depend on the motivation of the participants, which is strengthened by a positive mood that makes them more willing or motivated to continue self-regulating despite their depleted state.
The above findings can be applied to self-regulation and eating behaviour. Eating is a particular self-control problem, because unlike other forms of self-regulation it is not possible to avoid the temptation as a regulatory method. People need to eat to stay alive and healthy. According to Vohs and Heatherton (2000) this results in chronic self-regulation. Despite having firm, clear goals to manage food consumption, people often fail to achieve these goals. In a study (Vohs & Heatherton, 2000) that demanded dieters regulate their emotions while watching a sad movie, the resource was depleted that would have later helped dieters to control eating behaviour. Dieters who had to suppress their emotions ate more ice cream afterwards than those who were allowed to show their emotions. The exertion of self-control in an initial task appeared to increase subsequent rates of undesirable behaviours that would otherwise have been controlled. This indicates that inhibition in one domain exerts a generalized effect on behaviours in other domains. In addition, it has been suggested that inhibitory control is related to energy regulation. Children high in inhibitory control may be more able to direct their attention away from foods that are desirable or may use different strategies to redirect their attention (Tan & Holub, 2011). It can be concluded that self-regulation is an important key to successful human functioning. However, it depends on limited resources, and so when those resources has been depleted by recent use, people are less effective at self-regulating (Tice et al., 2007). When
people are in a state of ego-depletion it is more likely that undesirable behaviours take over. Regarding eating behaviour, this leads to more food consumption.
What is the role of self-regulation in children at risk of developing obesity?
As said earlier, self-regulatory resources develop over time. During childhood children develop their self-regulatory skills and by doing so they develop inhibitory control at the expense of motor behaviour (Graziano et al., 2013). As eating is a particular self-control problem (Vohs & Heatherton, 2000), it is important to understand the role of self-regulation in children and obtain better knowledge regarding the development of obesity.
Francis and Taylor (2009) examined the extent to which self-regulatory capacities in children from age 3 to 12 years were based on the extent to which they exhibited regulation in a self-control procedure at age 3 years and a delay of gratification procedure at age 5 years. Francis and Taylor showed that at ages 3 and 5 years, children who exhibited signs of self-regulation failure had higher BMI z scores and experienced rapid weight gain in early adolescence. It is likely that failure to self-regulate energy balance in the early years continues over time (Graziano et al., 2013). Therefore, self-regulation failure in early childhood may predispose children to excessive weight gain through early adolescence (Francis & Taylor, 2009). A study by Graziano et al. (2013) supported these statements by showing that very early self-regulation failures remain significant risk factors for the development of weight problems 8 years later. Graziano concluded that under-developed self-regulation skills in toddlers represent significant risk factors for the development of weight problems at age 10 years.
It has been argued that self-regulation also contains impulse action tendencies that can be linked to, and often are, the consequence of automatically activated evaluations. More precisely, automatically activated evaluations of a stimulus result in impulsive action tendencies to approach or avoid a particular stimulus (Hofman, Rauch & Gawronski, 2007). Therefore, they suggested that ego-depletion has 2 impacts; behaviour is determined either by automatic attitudes or by personal standards. According to the theory of planned behaviour (Ajzen, 1991), behavioural intentions are determined by attitudes. Hofman et al. (2007) argued that behaviour should be predominantly influenced by automatic attitudes when self-regulation resources are low, but by personal standards when self-regulation resources are high. Obese children show self-regulation failure and it can be reasoned that their impulsive action tendencies are influenced by automatic attitudes. Their automatic attitudes towards food and food consumption, which are likely to be non-desirable, predict eating behavioural intentions and these predict actual behaviour.
These studies provide insight into self-regulation failure in children and the development of obesity. Self-regulation skills in children predict risk of developing obesity. It has been shown that self-regulation failure in early childhood results in weight gain into early adolescence. This highlights the risk factor of self-regulation failure in children and the risk of developing obesity.
What role do parents play in the development of self-regulation in children and treatment of obesity?
Research (Francis & Susman, 2009) demonstrates that self-regulation strategies are not yet fully developed in children. Children do not have the existing strategies that could help them better use their self-regulatory resources. Parents have a big influence on the development of their children, providing both genes and development environment. During childhood parents guide their children through the process of self-regulation development and help them obtain better understanding and use of self-regulation strategies. Parents play an important role, as they are the ones who provide food and decide when, how and how much food is offered (Golan & Crow, 2004). They determine the food patterns that are necessary for children to grow and be healthy. Both child and parents need to be in the possession of knowledge about healthy food consumption. Many factors contribute to the success or failure of promoting a child’s ability to self-regulate food intake. One such factor associated with food intake is a parent’s feeding style (Patrick et al., 2005).
Findings from research (Birch & Fisher, 1995, mentioned in Patrick et al., 2005) suggest that a parent’s feeding style is associated with a child’s food consumption pattern. Based on Baumrind’s (1971) taxonomy of parenting styles, they identified three child-feeding patterns: permissive, authoritarian and authoritative. Permissive feeding is characterized by high responsiveness of the child’s request, allowing the child to eat whatever and however much he or she wants. Authoritarian feeding is characterized by controlling and restricting what the child eats, generally disregarding the child’s preferences. These parenting styles might negatively affect the child’s self-regulation, because the child isn’t challenged to control him or her self. Authoritative feeding is characterized by providing a lot of support for the child to eat healthy foods, while the child is given some choice about eating options. Research about parenting styles found authoritative feeding rather than authoritarian feeding was a more effective child-feeding style (Kremers, Brug, Vries & Engels, 2003, mentioned in Goldin & Crow, 2004). The permissive feeding style was not studied. Permissive feeding, as the name suggests, is likely to have a negative impact on a child’s ability to learn to self-regulate with regard to eating behaviour. The study of Patrick et al. (2005) supports the finding of authoritative feeding to be effective rather than authoritarian feeding. Authoritative feeding was positively associated with availability, attempts to consume, and with the amount of dairy and vegetables a child consumes. In contrast, authoritarian feeding was found to have a negative relation with these three outcomes. More importantly, after controlling for potential confounding variables including gender and BMI of the child, BMI and education of the caregiver, and ethnicity, all of these associations remained significant. It can be reasoned that parents influence the development of self-regulation through differing parenting styles.
Additionally, self-regulation in children is not yet fully developed therefore, it might be effective for treatment of obesity to focus on the environment and the parents to help guide the child
through this process. There is some evidence (Jansen, Mulkens & Jansen, 2011) that treatment focusing on the parents is successful in achieving weight loss in the child. In the parent’s treatment group, the BMI percentile of overweight children decreased significantly compared with children in the waiting-list control group. In addition, no significant relapse occurred after a 3-month follow-up. Remarkably, the parent’s treatment not only affected the weight of the child, the BMI of the participating parents also decreased significantly from pre-treatment to post-treatment. Another study conducted by Goldin and Crow (2004) showed that targeting the parents in a family-based treatment approach led to greater weight loss in obese children at the end of treatment and at follow-up visits at intervals of 1, 2, and 7 years. It seems that parenting feeding styles and family environment may constitute an environmental influence of possible risk factors for development of obesity on children (Goldin & Crow, 2004). For a long-term change improved food choice and calorie reduction in obese children is required for positive effects. So, treatment that targets parents shows both short-term and long-term positive results.
Taking into account the above findings, it can be suggested that intervention programs for children at risk of developing obesity should focus on the parenting feeding style to contribute to changes in children’s food consumption patterns. Parents play an important role in promoting feeding practices to enable a child’s ability to self-regulate food intake. Parent’s feeding styles have implications for the development of children’s eating patterns, especially those styles that facilitate intake of healthy foods (Patrick et al., 2005). Furthermore, above research has suggested that treatment of obese children is successful when focusing on the parents. Parenting skills regarding healthy food consumption are the foundation for successful intervention that includes weight loss in obese children (Goldin & Crow, 2004).
General Conclusion
In summary, this review reviewed the role of self-regulation and parents in children at risk for developing obesity. Self-regulation is an important factor in the etiology of childhood obesity. Consistent with the first hypothesis, children who fail to self-regulate have higher BMI z scores and may predispose children to excessive weight gain through early adolescence. Furthermore, parent’s feeding style influences the child’s ability to self-regulate. Authoritative feeding style rather than authoritarian feeding style was a more effective child-feeding style and is positively associated with accessibility and consumption of healthy food. This is in line with the second hypothesis. Finally, treatment of obese children is more effective if focused solely on the parents rather than parents and child. These finding contribute to the TPB as explanation for eating behaviour; parents play an important role in attitudes, perceived self-control and social norm.
Although some conclusion on self-regulation in children can be drawn from earlier research, more research is needed in order to understand more precise how self-regulation is involved and how this knowledge can be adapted in interventions. This research gap needs to be filled in order to make
successful interventions for obese children. Moreover, it is extremely difficult to distinguish the role of the parent. There are many different factors that affect parental influences on development of a child. An intervention that focus on parents exclusively is, compared with the common ‘child- and parent-focused interventions’, cost-reducing, as fewer treatment sessions are required (Jansen et al., 2011). If parent sessions alone yield the same effects as a combination of both child and parent sessions, this means that fewer sessions are needed to reach the same goal, resulting in a less-expensive treatment. This finding should be taken into further research, because it contributes to more effective interventions for obese or overweight children.
There are a few limitations in the review. To make a clear conclusion on the role of self-regulation in children at risk of developing obesity, it should be taken into account that this review only examined two different aspects implicated in the development of obesity. Child’s characteristics relevant to self-regulation were not examined. The following characteristics, for instance, are also involved; gender of the child, BMI of the parents, intelligence, social-economic status (SES) and ethnicity. Gender differences might have a predictive value, because of differences in attention and emotional regulation (Jansen et. al., 2011). Furthermore, relevant risk factors of self-regulation failure and early onset of obesity in children were not monitored in all studies. For example, BMI of the parents, intelligence, SES and ethnicity are likely to predict self-regulation (Jansen et al., 2011). Differences in ethnicity may play a role in certain cultural believes regarding food and eating behaviour. In addition, parents with lower IQ are stronger associated with lower SES than parents with high IQ. Parents with low SES could be more accessible to self-regulation failure for a simple reason that the less healthy food choice is often cheaper than the healthy one. Environmental factors may also play a role, for example the place where they live. Often in disadvantaged neighbourhoods many snack bars and fast food restaurant are located, making it very inviting to eat take away food. Furthermore, BMI of the parents is also a predictor of overweight in children. If parents are overweight, then their child is more vulnerable to become overweight as well (Jansen et al., 2011). It may be also explained by their knowledge of food and motivation of acquiring knowledge regarding nutrition.
These risk factors should be all taken along in further research in order to draw clear conclusions on the role of self-regulation in children at risk for developing obesity. Future studies should also examine the extent to which parenting practices influence child weight status via child deficits in self-regulation (Tan & Holub, 2011). As a child becomes older, parents are no longer their most important role models. This makes it more difficult to control the environmental cues. Childhood’s obesity is associated with health risks and high annual costs. Therefore more and better information on the role of self-regulation is needed, which may result in effective and cost reducing interventions.
Research Proposal
Implementation Intentions for the Effectiveness of Treatment of Obesity in Children with the Parents as Target Agents.
The aim of this research is to test the effectiveness of implementation intentions in treatment of obese children that focus solely on the parents. It is suggested that implementation intentions can work as a self-regulatory strategy to help ‘bridge’ the gap between people’s intention and people’s behaviour (Adriaanse, Gollwitzer, De Ridder, De Wit & Kroese, 2011). The study of Jansen et al. (2011) serves as the basis for this research. They found that treatment focusing on the parents is successful in achieving weight loss in the child. Unexpectedly, they did not find an effect of treatment with regard to changes in actual eating behaviour. In order to find a significant effect, the addition of implementation intentions could possible provoke an effect on eating behaviour. It could be that implementation intentions result in more awareness of eating behaviour and counteract on habitual intentions (Adriaanse et al., 2011). This research examined the use of implementation intentions (“If I encounter situation X, then I will perform behaviour Y”) for promoting the effectiveness of treatment of obesity in children that focuses solely on the parents. It has been shown that treatment focusing on the parents is effective. In addition, research (Brandstätter, Lengfelder & Gollwitzer, 2001) into the treatment of obese adults showed that implementation intentions are effective action initiations. These action initiations may lead to more positive behaviour regarding food consumption (Nooijer, de Vet, Brug & de Vries, 2006). Research into the use of implementation intention in interventions for obese children has not been conducted yet. It can be reasoned that if simple goal-plans are activated it may result in more realization of actual desired behaviour. More realization of desired behaviour may contribute to greater weight loss and that will make existing interventions more effective.
Interventions for obese children are designed to change existing unhealthy eating behaviour into healthy eating behaviour and support physical exercises (Jansen et al., 2011). The theory of planned behaviour (Ajzen, 1991) identifies three factors that influence behavioural intentions; behavioural attitude, subjective norm, and perceived behavioural control. Behavioural attitude is directly influenced by behavioural believes. The subjective norm is influenced by normative beliefs. Finally the perceived behavioural control is affected by control believes. Interventions can focus on these three factors in order to make changes in ones eating behaviour. However, behavioural intentions are not sufficient predictors for actual behaviour. A so-called Intention-Behaviour Gap (IBG) exists (Sniehotta, Schwarzer, Scholz & Schüz, 2005). The IBG explains the missing link between having behavioural intentions and the actual performance of that behaviour. Often intentions are formed but not realized. A mechanism for bridging the IBG is the use of implementation intentions (Gollwitzer, 1999, mentioned in Adriaanse et al., 2011). Implementation intentions can function as a self-regulatory strategy to manage habitual response and the ability to act and counteract
on it (Adriaanse et al., 2011). By linking intentions to a particular context and specifying where and when it will be performed, implementation intentions facilitate cueing actions in context and therefore initiate action automatically (Gollwitzer, 1999, mentioned in Adriaanse et al., 2011). Research (Brandstätter et al., 2001) regarding effective treatment for obese adults indicates that implementation intentions (‘If I encounter situation X, then I’ll perform behaviour Y’) are effective action initiations. To be more precise, implementation intentions are effective in promoting goal-directed behaviour. A study by de Nooijer et al. (2006) provides some indications that implementation intentions could be a useful strategy to induce a short-term increase in fruit intake.
In order to provide better and more extensive knowledge of effective interventions for obese children, this research will examine the effectiveness of implementation intentions in interventions that focus on the parents alone. Parent-focused treatment is less expensive than child-parent-focused treatment, because fewer sessions are needed to reach the same goal. Implementation intentions can function as a self-regulatory strategy that parents can use and children can imitate. In order to make interventions for obese children more effective and less expensive, implementation intentions may play an important role in goal achievement. Based on the findings by Jansen et al. (2011) and research on implementation intention, I formulated five following hypothesizes. First, the BMI z score of children will decrease in both treatment conditions, unlike the BMI z score of children in the control conditions that will remain constant or even increase. Second, BMI z score of children will decrease more in the treatment condition with implementation intentions, compared to the treatment condition without implementation intentions. As third, treatment with implementation intentions will increase healthy eating behaviour, compared to treatment without implementation intentions and control condition. Fourth, parents in treatment conditions will have healthier BMI z scores after treatment, in contrast with parents in the control condition who have no differences in their BMI z score. Finally, a younger age of a child, lower BMI z score of child before treatment, absence of parental overweight and higher SES would positively influence treatment outcome.
Design
The participants are parents of obese children at age 7 to 13 years. Parents were recruited by advertisements in local newspapers and information leaflets at primary school. They voluntarily signed up for the treatment. Similar to the study of Jansen et al. (2011), parents of 98 overweight or obese children are selected. Selection of the parents is made by their children’s BMI z score, which is determined given a child’s age, sex, BMI, and an appropriate reference standard. The participating parents are randomly assigned to either the ‘control-treatment group, the ‘implementation intentions-treatment’ group or the ‘waiting-list control’ group.
The treatment is derived from Jansen et al. (2011). The participating parents receive a cognitive-behavioural treatment, wherein they are requested to visit 8 2hr-sessions in 10 weeks. Cognitive-behavioural therapist carried out the treatment and the sessions are provided in groups of
4-7 parents. The purpose is not only to provide information about nutrition and physical activity, but also enhancing the parenting tactics. These parenting tactics contain knowledge on how parents can influence the child’s behaviour. The sessions consisted of two hours, of which the first hour was interactive and the second hour was set up more informative and practically. The ‘implementation intentions-treatment’ group differed from the ‘treatment control group’ in that five implementation intentions were formed during the sessions. The ‘implementation intentions-treatment’ involved the task of forming an implementation intention for how, where and when eating behaviour of the child would be managed. So, they are asked to link specific feeding practices to specific context. Participants are required to formulate their implementation intention in the following form: ‘If …(situation X), then… (Behaviour Y)’ In addition they are required to specify when they would make use of their implementation intention. The participants are asked to write their formulation down and to show this to their therapist. Together with the therapist, participants evaluate the implementation intentions, thereby controlling for mistakes in formulation. Participants have to sign an agreement for actual use of their implementation intentions. They do not have to share their implementation with the other group members.
Measures
Weight (kilograms) and height (meters) are measured and BMI z scores (Children's BMI-for-Age Calculator) are calculated for each child and also for the participating parents. The BMI z scores of the children are collected before and after treatment, and at 6-month follow-up. The study of Jansen et al. (2011) measured at 3-month follow-up, however in order to measure long-term effect the current study measure at 6-month follow-up. A One-way ANOVA is conducted to compare the BMI z scores at the three times of measurement and between conditions.
Similar to the study of 3Jansen et al. (2011) parents filled out a questionnaire with demographic items, before treatment. The SES is derived from family income. Family income is measured on a 5-point rating scale (1 representing <12 000 euros and 5 representing >38 000 euros). Scores ranged from 1 to 5, with a mean score of 3.90.
The Child Eating Disorder Examination Questionnaire (ChEDE-Q) is conducted to measure the existence and frequency of eating-disorder psychopathology (Decaluwe, 1999, aangehaald in Jansen et al., 2011). In the study of Jansen (2011), Cronbach's α of the ChEDE-Q subscales ranged from 0.48 to 0.82. The overweight child in the presence of a parent and a trained interviewer fills out the ChEDE-Q.
Via an interview before and after treatment, and after 6-month follow-up, information regarding eating behaviour of the child is collected and scored by a cognitive-behavioural therapist. The interviews are hold at the houses of the participants. The Netherlands Nutrition Centre (mentioned in, Jansen et al., 2011) constructed a list of frequently consumed food items, which are labelled into three categories: red (unhealthy food items), orange (less healthy food items), and green
(healthy food items). This list is used to register how many unhealthy food items (red) the children consume per day. The children of the participating parents are asked to recall every food and drink item they consume on a day that is representative for an average day. If necessary, the parent could add or correct information. Additionally, the regularity of the children’s eating pattern is studied (Jansen et al., 2011). An example question is: ‘How many eating moments are there on a typical week day?’ This question is scored on a 0 to 7 point-scale, whereby a higher score indicate a more regular eating pattern.
A manipulation check (Jansen et al., 2011) is conducted to examine whether parents learned from the treatment sessions. Before treatment they complete a test consisting of 29 multiple-choice items. An example question: ‘in what category (green, orange or red) does this food item belong: a boiled egg?’ Every correct answer is rewarded with 1 point, resulting in a maximum score of 29 points. Two comparable versions of this knowledge test are constructed. The parents receive either test A or B before treatment, and after treatment they receive the other version. Thereby controlling for a possible learning effect.
A 3 (time: pretreatment vs. post treatment vs. follow-up) x 3 (implementation intentions vs. no implementation intentions vs. control) repeated measures analyses of variance is carried out for all outcome measures (BMI z score of child, BMI z score parent, eating behaviour and ChEDE-Q subscales) to analyze the effects of the parent treatment. For significant interactions, post-hoc analyses are conducted. Finally, to identify predictors of treatment success, a linear regression analysis is carried out. Age, SES, child and parental BMI z score before treatment are entered as predictors in the regression. The dependent variable is treatment success. Treatment success is represented by decrease of child BMI z score from pretreatment to 6 month follow-up.
Implications of Results
It is expected, treatment with implementation intentions can achieve greater weight reduction than treatment without implementation intentions. Children in the ‘implementation intention-treatment’ group will show greater weight loss than children in the ‘control-intention-treatment’ group. In addition, both treatment conditions will show greater weight loss than the ‘waiting-list control’ group. Moreover, parents in the ‘implementation intention-treatment’ group will report changes in actual eating behaviour of their child and will have healthier BMI z scores, in contrast with parents in the ‘control-treatment’ group. Finally, age, SES, BMI of the parent and BMI of the chid, are predictors for treatment outcome.
This research provides insight into a psychological mechanism in health behaviour and shows how this knowledge can contribute to effective interventions for obese children. Implementation intentions can be used to guide parents in their feeding practices and may help to overcome unhealthy eating habits by changing unhealthy food habits into healthy ones. Moreover, implementation intentions can be easily and inexpensively implemented in existing intervention programs. In
conclusion, this study provides an additional support for implementation intentions as a helpful self-regulating strategy to bridge the IBG by promoting the automatic performance of desired behaviour. Further research on how implementation intentions can be best used to promote healthy eating is needed to provide more knowledge on effective intervention programs for obese children. Research also needs to be carried out into whether implementation intentions are effective in bridging the IBG for eating behaviour. These could also be used to enhance physical exercise in obese children. Implementation intentions could be a very instrumental mechanism, which would be easy to implement in practise.
Literature
Ajzen, I. (1991). The theory of planned behaviour. Organizational behaviour and human decision
processes, 50(2), 179-211.
Adriaanse, M. A., Gollwitzer, P. M., De Ridder, D. T., De Wit, J. B., & Kroese, F. M. (2011). Breaking habits with implementation intentions: A test of underlying processes. Personality and Social Psychology Bulletin, 37(4), 502-513.
Baumeister, R. F., Bratslavsky, E., Muraven, M., & Tice, D. M. (1998). Ego depletion: is the active self a limited resource?. Journal of personality and social psychology, 74(5), 1252.
Brandstätter, V., Lengfelder, A., & Gollwitzer, P. M. (2001). Implementation intentions and efficient action initiation. Journal of personality and social psychology, 81(5), 946.
Francis, L. A., & Susman, E. J. (2009). Self-regulation and rapid weight gain in children from age 3 to 12 years. Archives of pediatrics & adolescent medicine, 163(4), 297-302.
Graziano, P. A., Kelleher, R., Calkins, S. D., Keane, S. P., & Brien, M. O. (2013). Predicting weight outcomes in preadolescence: the role of toddlers’ self-regulation skills and the temperament dimension of pleasure. International Journal of Obesity, 37(7), 937-942.
Golan, M., & Crow, S. (2004). Targeting Parents Exclusively in the Treatment of Childhood Obesity: Long‐Term Results. Obesity research, 12(2), 357-361.
Hofmann, W., Rauch, W., & Gawronski, B. (2007). And deplete us not into temptation: Automatic attitudes, dietary restraint, and self-regulatory resources as determinants of eating behaviour.
Journal of Experimental Social Psychology, 43(3), 497-504.
Jansen, E., Mulkens, S., & Jansen, A. (2011). Tackling childhood overweight: treating parents exclusively is effective. International Journal of Obesity, 35(4), 501-509.
Job, V., Dweck, C. S., & Walton, G. M. (2010). Ego depletion—Is it all in your head? Implicit theories about willpower affect self-regulation. Psychological science, 21(11), 1686-1693. de Nooijer, J., de Vet, E., Brug, J., & de Vries, N. K. (2006). Do implementation intentions help to
turn good intentions into higher fruit intakes?. Journal of nutrition education and behavior,
Patrick, H., Nicklas, T. A., Hughes, S. O., & Morales, M. (2005). The benefits of authoritative feeding style: caregiver feeding styles and children's food consumption patterns. Appetite, 44(2), 243-
249.
Sniehotta, F. F., Schwarzer, R., Scholz, U., & Schüz, B. (2005). Action planning and coping planning for long‐term lifestyle change: theory and assessment. European Journal of Social
Psychology, 35(4), 565-576.
Tan, C. C., & Holub, S. C. (2011). Children’s self-regulation in eating: Associations with inhibitory control and parents’ feeding behavior. Journal of pediatric psychology, 36(3), 340-345.
Tice, D. M., Baumeister, R. F., Shmueli, D., & Muraven, M. (2007). Restoring the self: Positive affect helps improve self-regulation following ego depletion. Journal of Experimental Social Psychology, 43(3), 379-384.
Vohs, K. D., & Heatherton, T. F. (2000). Self-regulatory failure: A resource-depletion approach.
