INTRODUCTION

Type 2 diabetes is rising among adolescents, paralleling obesity. It is imperative to develop effective, culturally grounded approaches to adolescent overweight.1 Some studies have found greater tolerance for overweight among African-American girls.2,3 We aimed to understand practices and beliefs regarding nutrition and weight among overweight African-American youth ages 9–13 years and their parents preparatory to developing a family-based diabetes prevention intervention.

METHODS

Design

A multidisciplinary group developed scripts (Table 1) addressing key issues identified through literature and prior studies from this community.4 The University of Chicago Institutional Review Board (IRB) approved this study.

Table 1 Key Prompts for Focus Groups and Interviews
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Participants

Urban, African-American focus group participants were recruited through flyers in community sites (YMCA, grocery market, neighborhood organizations, clinics) asking “Are you concerned about your child’s weight?” Median household income in this community is approximately $28,000.5 Families were screened by telephone for inclusion criteria: African-American family with a 9- to 13-year old child (chosen to inform development of a program for youth this age). Families whose child’s reported weight exceeded the 85th percentile for age and gender were included. At least 1 parent had to accompany the child to the focus group session in a community room at a local grocery store. Parents provided written informed consent; children assented. Each family received $50.

From 12/01 through 6/02 we conducted 13 focus groups with children and parents. Of 43 families agreeing to participate, 32 families comprising 32 children and 35 adults came to focus group sessions. Nearly all children were above the 95th percentile of weight for age. Six focus groups comprised 2–6 same-sex children (four girls’ and two boys’ groups); 6 comprised these children’s parents. Thirty-two mothers and 3 fathers participated in parents’ groups, run separately but concurrently with children’s groups. One group comprising both parents and children together was less successful at eliciting frank discussion and was not repeated.

Semistructured interviews with 9 community leaders complemented family perspectives. We identified potential interviewees by contacting community leaders with whom we had prior relationships and through referrals from other leaders. All leaders contacted agreed to participate (YMCA director, fitness coach, parish nurse, social service worker, elementary school vice-principal, school outreach worker, dietitian, health educator, and alderman). A semistructured interview format (Table 1) facilitated in-depth probing of each leader’s perspective.

Analysis

Transcripts from audiotaped focus groups and interviews were analyzed using grounded theory.6 Readers independently identified recurring themes that were discussed at meetings, modified by consensus, and arranged into major domains. Further description of methods is available in an online Appendix.

RESULTS

We observed theme saturation after 6 child and 6 parent focus groups. Sixteen themes emerged, clustering into 4 domains (Domains 1–4, Table 2). We report in this paper the most prominent themes; additional quotations are available in an online Appendix.

  1. D1:

    Barriers to Healthy Nutrition and Exercise ranged from environmental and socioeconomic barriers to preferences for sedentary activities and high-fat foods. Time pressures presented significant barriers to physical activity and healthy nutritional habits; fast food was convenient. Parents often could not prepare meals, especially breakfast; children grabbed snacks on their own. Neighborhood safety issues presented barriers to physical activity. Financial pressures made healthy nutrition and weight lower priorities. Healthy foods were perceived as expensive and affordable recreation opportunities limited. Children preferred sedentary activities (movies, telephone calls, computers) and high-fat foods (pizza, cheeseburgers, French fries, chips, ice cream). Children liked fruit; some reported limited availability. Vegetables were not favored, unless served with cheese sauce, dip, or butter. Time pressures and preferences for sedentary activities and high-fat foods dominated discussion of barriers to healthy nutrition and exercise, and appeared most salient to families.

  2. D2:

    Parental Challenges and Concerns described limits in parents’ knowledge and skills, parent/child interactions, and ability to create a healthy family environment. Parents wanted information about healthy nutrition and weight. Parents felt confused; many felt doctors did not advise enough about children’s weight and nutrition. Children often got sweets/junk foods outside the home. Children accessed snack foods at vending machines, stores, and from friends. Parents said children often received unhealthy foods from grandparents and others. Parents reported difficulty setting limits on television time and food intake. Limiting children’s food intake felt challenging because of parents’ desires not to “deprive” children. Parents worried about psychosocial effects of overweight on children and hesitated to address weight issues for fear of damaging children’s self-esteem. Limiting television and self-esteem concerns appeared to present the most serious challenges for parents.

  3. D3:

    Definitions of Overweight: Parents expressed that bigger people are just built differently; charts do not always apply. Parents did not define overweight as problematic, per se. Many said larger-framed individuals would not look healthy if their weight conformed to standardized body mass index (BMI) charts. Children were more apt than parents to use size and appearance to determine overweight, defining healthy weight as “medium-sized,” or “not too skinny, not too thick.” Children reported that peers considered overweight were teased, depressed, socially isolated, and perceived as greedy and lazy. Parents perceived overweight as problematic when functional limitations resulted. Physical limitations, aches and pains, breathing troubles, and clothes not fitting provided defining points for overweight. Participants perceived health risks of overweight, mentioning high blood pressure, diabetes, and heart attacks. Children cited Big Pun, a severely obese rap artist who died prematurely, but also associated excessive thinness with poor health.

  4. D4:

    Program Recommendations comprised ideas regarding a proposed family-based intervention for overweight children. Parents expressed strong interest in learning general skills like time-management and goal setting, as well as nutrition-related skills such as healthy food preparation, and children suggested activities they would like to try.

Table 2 Selected Themes and Sample Quotes**
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DISCUSSION

This study of attitudes and beliefs among overweight African-American children, their parents, and community leaders corroborates previous findings and offers new insights. Parents defined overweight in functional terms rather than by measurement or charts. Similar results were noted in qualitative studies of African-American women7,8 and among low-income families.9 In the presence of limited resources and confusing messages about nutrition, parents often feel overwhelmed. One study of low-income mothers suggested the best approach to childhood obesity may be to focus on improving parenting skills.9 Time pressures, competing priorities, and financial constraints are commonly cited barriers to physical activity and healthy nutrition.8,9

Children, parents, and community leaders agreed about many topics, but some significant tensions also appeared. Community leaders portrayed families as living chaotic, “crisis management” lifestyles that precluded action on health and nutrition concerns expressed in our focus groups. Nonetheless, parents’ concerns about their children’s diet and the social and health consequences of overweight suggests readiness to change,10 which can be leveraged in a family-based intervention.

Another divergence occurred between children and parents defining overweight. Parents chose a functional definition and appeared more lenient than children, who relied more on physical appearance. Children’s experience is grounded in schoolyard reality; they see and openly suffer the social consequences of overweight, whereas overweight adults may become resigned or face more subtle discrimination. In an intervention, parents may respond to motivation around functional outcomes, whereas children’s preferences for medium build can be engaged, as long as self-esteem is bolstered and healthy nutrition practices are emphasized.

Children expressed preferences for peer-related activities, whereas parents enjoyed working with their kids. The bonding that developed among peers even during brief focus groups could provide significant reinforcement for participants in a group intervention. Parents expressed catharsis after sharing experiences and airing frustrations; many exchanged contact information after focus groups. Some children who had never met before hugged after the focus groups.

Limitations

Focus group participants were self-selected, and the sample size was relatively small. Children’s weight was self-reported by parents in phone screening. We did not collect income information. Results may not generalize beyond our urban African-American population.

IMPLICATIONS

We have identified family and community strengths and challenges as targets for intervention. Most research aimed at reducing childhood overweight and related risk factors has not focused on specific ethnic groups. Few culturally sensitive interventions have been developed for African-American women,4,11–13 children,14–17 or families.18 Weight control interventions for youth work best when they involve both children and parents.19 Our first 3 domains enrich program development on a deeper cultural level by suggesting which beliefs, knowledge, and skills should be targeted, and what strengths augmented, in this community to increase healthy nutrition and exercise behaviors in families.20 For example, program leaders will incorporate motivational interviewing techniques to engage parents’ concerns about functional status associated with overweight. Families will practice shopping for and preparing lower-fat and lower-calorie alternatives to preferred foods, identified from focus groups.

Community leaders expressed significant interest about focus group findings and wanted to continue involvement in the developing project. We have built a Community Advisory Board for our family-based intervention project. A local grocery store and YMCA were identified for nutrition and exercise sessions. As researchers gain access to community sites, local institutions benefit from educational and financial resources associated with the project and increased community recognition. Such community-based participatory research techniques have significant promise for dispelling mistrust while developing a sense of community ownership for practical, culturally grounded programs.12,15,16