Preventing Chronic Disease

VOLUME 6: NO. 3, A106 JULY 2009

Using the Family to Combat Childhood and

Adult Obesity

REVIEW

Suggested citation for this article: Gruber KJ, Haldeman

LA. Using the family to combat childhood and adult obe-

sity. Prev Chronic Dis 2009;6(3):A106. http://www.cdc.

gov/pcd/issues/2009/jul/08_0191.htm. Accessed [date].

PEER REVIEWED

Abstract

The purpose of this article is to emphasize the value of

the family as a source of behavior change, particularly

with respect to attaining achievable goals of weight loss

and regular physical activity for youth and their families.

We present a review of the literature, providing support

for the value of the family in influencing children to form

good diet and exercise behaviors and as a source of support

and motivation for individuals seeking to lose or control

their weight and to start and maintain a physically active

lifestyle. Recognizing the importance of family behavior in

the development of weight control and weight loss activi-

ties is essential. Future work should focus on identifying

measurable parameters of family-level weight control

behaviors and ways to apply those parameters to help cre-

ate new interventions that use the strengths of the family

for achieving weight control goals.

Introduction

The extensiveness of the obesity issue and the potential

for obesity to affect the quality of life of individuals and

families underscore the urgent need for actions that can

produce safe weight loss and result in effective weight

management (1). The solution seems simple — take in

fewer calories than you expend — but for most people

this remedy is challenging. Diets and exercise routines

can fail for many reasons. In part, this failure occurs

because achieving weight loss through dieting or exer-

cise requires maintenance of behavior change, which

is difficult to sustain unless people have support (2-4).

Support occurs most readily in a social environment that

facilitates healthy eating and health-promoting exercise.

Many efforts that help people to achieve weight loss fail to

establish the supportive social and interpersonal context

that can reinforce and help maintain weight loss–related

behavior (5). Effective approaches should include these

contextual influences and focus on making changes in

the environment rather than in the individual. The social

context most likely to support making healthy behavior

changes is the family.

Why a Family-Based Approach?

For many people, the family is a major mechanism of

influence in effecting change both in other family members

and in themselves (6). The concept of family has many

connotations. For the purposes of this review we believe

“family” should be defined inclusively rather than exclu-

sively, similar to Medalie and Cole-Kelly’s (7) description

of a family as a complex of configurations representing

census, biologic, household family, and functional family

connections. We add the observation that family includes

a parent-child connection and a sharing of responsibilities

that functions for the welfare of both the individual mem-

bers and the family unit.

The reciprocal nature of the adult-child relationship

merits strong attention as a means of influencing health

behavior of both children and adults (8). Efforts to achieve

and maintain weight loss are more successful with fam-

ily involvement (9). Positive eating behavior changes last

longer if interventions are aimed at family rather than

individuals’ attitudes and habits (10).

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the

Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and

does not imply endorsement by any of the groups named above.

www.cdc.gov/pcd/issues/2009/jul/08_0191.htm • Centers for Disease Control and Prevention 1

Kenneth J. Gruber, PhD; Lauren A. Haldeman, PhD

VOLUME 6: NO. 3

JULY 2009

It has been well established that physical, norma-

tive, and social characteristics of the family influence

adoption and maintenance of health-promoting behavior.

Family dynamics including family rules, emotional sup-

port, encouragement, reinforcement from other family

members, and family member participation are important

determinants of the family’s health-behavior patterns (6).

Viewed in this context, the family system is a major deter-

minant of how and whether families engage in health-pro-

moting physical activities (5).

Because most health behaviors are initiated in child-

hood, influencing the health behavior of individuals when

they are children is reasonable and practical (10). It is

well recognized that eating habits developed in childhood

and adolescence may be difficult to change. Consequently,

effecting behavior change when individuals are children is

critical. The family shapes children’s dietary intake and

eating habits (11-13) and their physical activity patterns

(14). Family influences also are present in the develop-

ment and control of weight problems in children and

adults (15-20).

The family is a highly suitable target for health promo-

tion intervention because it provides many options and

opportunities to communicate positive health behavior

messages and change family member attitudes and

behavior. Within the family context, meal planning, food

shopping, meal preparation, eating, snacking, family

recreation, and sedentary behaviors are all opportunities

for intervention (16). The family provides the primary

social learning environment for children and the primary

setting for exposure to food choices, eating habits, and

involvement in opportunities for play and other physical

activity (21). Parental health behavior guides the devel-

opment of health practices in children, and children can

influence these same behaviors of their parents and sib-

lings (10,22-24).

Reciprocal reinforcing relationships among family mem-

bers are important for acquiring and maintaining new

behaviors (25). The family is an ideal mutually reinforcing

environment in which healthy behaviors can be intro-

duced, accepted, and maintained (26). Epstein et al (19)

reported findings from a series of weight loss interventions

targeting adults and their children with different condi-

tions of reinforcement of parents and the children, for the

children only, or for general family participation. Results

revealed that reinforcing weight loss for both the parent

and the child produced the greatest weight loss over a

5-year period. The authors concluded that the relation-

ship between parent and child weight loss can serve as a

reciprocal reinforcer for changes in diet and other weight

loss–related behaviors.

Family-based behavioral obesity treatment programs

are among the most effective for combating pediatric obe-

sity. Wrotniak et al (26) reported that concurrent treat-

ment of children with their obese parents tends to result

in positive change for both, though the effects tend to be

greater and longer lasting for children. This may be the

result of more changes to the eating and activity environ-

ment in the home or to more healthy diet and exercise role

modeling of the parents.

Family as a unit of measurement

Analyzing the family as a unit merits consideration

(5,27-30). Blackwell and Reed (27) argue that a family-

level analysis was more appropriate to accurately test the

concepts and propositions of the power-control theory.

They reasoned that because the family environment

encompasses both shared and nonshared environmental

influences and because of the differential effects of dyadic

relationships within the family unit, analysis at the family

level is appropriate when there is interest in the combina-

tion of effects of these relationships. Blackwell and Reed

concluded that family-level data allowed them “to devise

more methodologically appropriate measures and theo-

retically informative models than can be constructed with

individual-level data” (p. 396). They further argued that

family-level data provide control for “potential sources of

‘shared environmental’ characteristics” (p. 397).

Bonomi et al (28) suggested that to avoid over- and

underestimations of health intervention cost effectiveness,

a family-level assessment (eg, family functioning, fam-

ily choices) is more appropriate. Because illness seldom

affects a single individual but often affects the overall

functioning of a family as a unit, determining the well-

being of and costs borne by multiple family members

is likely to represent a more accurate view of resource

allocation. They suggest that a family well-being model,

one that encompasses individuals within a family, rela-

tionships among those individuals, and the aggregation of

the individuals constituting the unit, forms a good basis

for addressing health at the family level. Their model is

derived from systems theory, which posits that relation-

2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2009/jul/08_0191.htm

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the

Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and

does not imply endorsement by any of the groups named above.

ships between individuals and their family change over

time in response to input and events that they experience

alone and together (31).

Family as the unit of health promotion intervention

Eating dinner together as a family has been associated

with healthy weight and consumption of healthy foods (32-

35). Gillman et al (33) found that intake patterns among

children and older adolescents when eating dinner with

their parents resulted in consumption of more fruits and

vegetables, less fried food and soda, and less saturated and

trans fat; lower glycemic loads; and more fiber and more

micronutrients from food. Aside from the social context

of the family, health similarities among family members

make the family a good candidate for being the “unit” of

health promotion intervention (36). In addition to the influ-

ence of genetic factors, fitness and health can be linked to

the familial environment. Studies of eating habits (36,37),

exercise routines (38), food and activity preferences (39),

blood pressure levels (40-42), body weight (43,44), body

composition and adiposity (45,46), and physical activity

(47) have found that family members tend to share these

characteristics.

Families as a Support Context

Familial social support has been well demonstrated to be

a key factor for promoting and sustaining health behavior

change (2,48-50). Spousal support has been identified as

an important factor influencing weight reduction among

obese women with type 2 diabetes (18). Familial support

has been reported effective in producing health-promoting

behaviors among patients with cardiovascular disease (51)

and for chronically ill family members achieving physical

activity guidelines and practicing better dietary behaviors

(52). Finally, family support consistently correlates posi-

tively with physical activity levels (49,53,54).

Ethnic and sociocultural considerations in using families

as a source for health promotion

Because of traditional values, social networks, patterns

of inter- and intrafamilial support, food preferences, and

recreational choices, ethnic and sociocultural factors must

be considered. Food habits are deeply rooted in a family’s

culture, which represents both their ethnic and commu-

nity identity (55). Families must contend with outside

influences that affect the availability of preferred foods

and with the introduction of new foods and different ways

of food preparation. As a result, the change in dietary prac-

tices, at least among families with children, often occurs

at the family level; most family members adopt new food

choices and eating habits. This process is evident among

immigrant groups as they assimilate into a new culture.

As families become more acculturated, traditional foods

are consumed less often.

It is widely recognized that ethnic and sociocultural influ-

ences create differences in health behaviors. For example,

research has shown that Hispanics tend to be less knowl-

edgeable about cardiovascular risk factors, prepare more

of their foods by frying, and engage in less physical activity

than whites (56). Members of ethnic groups respond dif-

ferently to health promotion messages and interventions.

Nader et al (57) found that white families reported more

change in their dietary and physical activity habits than

did Mexican American families after an intervention to

reduce cardiovascular risk among school children. The use

of an ecological perspective as a means for understanding

maintenance and change in dietary practices among immi-

grant ethnic groups is also applicable to the family unit.

Hispanic families are strongly family-centric, which

makes the influence of the family both a facilitator and

a barrier for participation in physical activity. For many

Hispanic wives and mothers, both the family and care of

the home comes before self (58). To overcome this barrier,

Hispanic immigrants feel that activities that involve the

family, particularly their children, can provide them the

necessary incentives and opportunities to be physically

active (58). Thus, family-based interventions developed

within the cultural context of the target audience (taking

cultural considerations into account) may result in more

effective dietary and physical activity behavior change.

Family-Based Interventions

Dietary and exercise behaviors are well suited for fam-

ily interventions because meals and recreational activities

often involve the entire family. Lasting change is more like-

ly when it involves the family unit because of the increased

likelihood that family members will take action and sus-

tain behaviors. Interventions that target the family unit

also are likely to have a collective impact on the family.

Cousins et al (54) compared a family-oriented intervention

with a traditional (individualized) weight-loss program

VOLUME 6: NO. 3

JULY 2009

www.cdc.gov/pcd/issues/2009/jul/08_0191.htm • Centers for Disease Control and Prevention 3

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the

Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and

does not imply endorsement by any of the groups named above.

VOLUME 6: NO. 3

JULY 2009

and an information-only control group involving obese

Mexican American women. They found that, although the

family-based individualized program was associated with

significantly greater weight loss than the control group,

the family-oriented (total family) intervention produced

the greatest weight loss. The authors noted this occurred

despite the fact that in the total family group other fam-

ily members’ (primarily the husbands’) attendance was

inconsistent, and changes in meal planning often were not

followed because of the lack of full family participation.

With more consistent family member participation, fam-

ily-oriented interventions could potentially produce more

behavior change.

Family environment and childhood obesity

Although it has been argued that, for successful child

obesity treatment, the primary agent of change should

be the parent (16,21,59), it is clear that the family envi-

ronment plays a critical role in both the development

and reduction of obesity. Parental influence is a critical

determinant of children’s food preferences (60,61). Though

the data are limited, research does suggest that some

food preferences developed in early childhood persist into

adulthood (62). Evidence indicates that direct involvement

of at least 1 parent improves a child’s weight management

(15). Parental support has been reported as a determinant

of children’s involvement in physical activity (63-66). In

addition, parental involvement has been identified as

an important determinant influencing young girls to be

physically active (14,67,68).

Family environment factors, such as parental feed-

ing practices (45,69,70) and family mealtime behaviors

(32,71), have been linked to overweight in children. Birch

and Fisher (45) found in an assessment of parent-to-child

weight status that heavy mothers tend to have heavy

daughters and that daughters’ weight status was affected

by mothers’ feeding practices. Mothers often exert influ-

ence over their daughters’ dietary intake, which has been

shown to negatively impact self-control over energy intake.

Birch and Fisher also reported that among preschool chil-

dren, efforts by mothers to use control and restrictive

feeding practices produced the unintended consequence of

poor self-control over food intake. Parent food purchasing

and mealtime behaviors have also been correlated with

poor dietary intake. Ayala et al (72) found that among

Mexican families, children of parents who purchase foods

seen on television or who purchase fast foods were more

likely to consume more soda and dietary fat. They identi-

fied family support for healthful eating and eating regular

meals together as “two modifiable targets for family-based

interventions.”

Golan and colleagues argue that to effectively combat

child obesity, it is essential to create a family or home envi-

ronment that promotes healthy family habits (16,59,73).

Part of that environment involves the establishment of

effective parenting behavior, which includes parents being

informed about both appropriate nutrition and eating hab-

its and adopting a physically active lifestyle that includes

regular exercise. Epstein (15) reported that, in treating

obese children, involving at least 1 parent as an active

participant in the weight loss process improves short- and

long-term weight regulation of children. He concluded that

improved outcomes occur because factors in the shared

family environment are targeted for change. In a 7-year

follow-up, Golan and Crow (21) reported a significant

mean reduction in percentage of overweight among mem-

bers of the parent-focused group compared with members

of the child-focused group. Robinson (17) notes that one

of the keys to successful treatment of childhood obesity

is improved parenting behavior relating to goal setting,

reward immediacy, use of praise, appropriate modeling,

and limit setting.

The family as a solution to the obesity problem

Although the purpose of this article has been to empha-

size the value of the family as a source of health behavior

change, by no means are we arguing that individual-based

interventions are neither effective nor often the best

practice. We share the perspective of Baranowski and

Nader (74) who suggest that rather than pit an individual

approach and a family-oriented approach against each

other, involving the entire family may be helpful in deter-

mining how to best promote behavior change among all its

members. As Lindsay et al (75) write,

[p]arents play a critical role at home preventing

childhood obesity, with their role changing at dif-

ferent stages of their child’s development. By better

understanding their own role in influencing their

child’s dietary practices, physical activity, seden-

tary behaviors, and ultimately weight status, par-

ents can learn how to create a healthful nutrition

environment in their home, provide opportunities

for physical activity, discourage sedentary behav-

4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2009/jul/08_0191.htm

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the

Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and

does not imply endorsement by any of the groups named above.

iors such as TV viewing, and serve as role models

themselves. Obesity-related intervention programs

can use parental involvement as one key to success

in developing an environment that fosters healthy

eating and physical activity among children and

adolescents. (p. 179)

Because parents are often key to the development of a

home environment that fosters healthful eating and par-

ticipation in physical activity, their role is likely critical to

most solutions to combating obesity. They reinforce and

support healthy eating and exercise behaviors and may

be best able to provide the necessary rewards to effect and

maintain positive behavior change (15,75).

Many of the recommendations for addressing child and

individual obesity and obesity-related factors, such as

eating habits and exercise and physical activity patterns,

are family-based. Suggestions include creating safe spaces

to allow families to exercise or be physically active (76),

increasing parental education and awareness (77,78),

instructing parents to try to change children’s eating and

physical activity patterns (79), facilitating supportive fam-

ily environments (80), and promoting positive parental

support and modeling (81).

Most nonclinical interventions involving child and ado-

lescent eating and physical activity patterns are school-

based (82-86) rather than parent-based or family-based

(87-90). Many school-based interventions, however, such

as CATCH (Coordinated Approach to Child Health) (91),

Hip-Hop to Health Jr. (92), and Students and Parents

Actively Involved in Being Fit (93) include a family or par-

ent component.

The family as a barrier to obesity prevention

Because obesity tends to run in families, effective inter-

ventions should involve parents and other family members.

However, this raises the question of how to best intervene

with families. Epstein (15) and others (94-98) suggest that

effective interventions for childhood obesity involve active

participation by 1 or more parents. Parents need to learn

how to talk with their children about exercising and eat-

ing well and how to encourage them to be more active (94).

Many parents refuse to acknowledge that their children

are obese (95,96). Some parents believe that actions that

could help their children lose weight are ill-advised, so

they refuse to support their engaging in strenuous activity

or reducing their food consumption. In other cases cul-

tural or familial factors affect parents’ assessment of their

children’s weight and body image (97,98). As noted earlier,

eating behaviors and physical activity habits must change,

and if parents or children do not support such changes

then weight of those at risk or already obese will likely not

be well controlled (96).

In some cases it is not the intention of the family not to

adopt or maintain healthy behaviors; other factors may

prevent them from doing so. For example, in the case of

a family member who needs to change dietary practices,

family members may object or resist the introduction

of new food choices (99,100). In other instances, fam-

ily responsibilities such as child care responsibilities or

managing the home are barriers to engaging in physical

activity among parents (53). Roos et al (101) reported that

the conflict between work and family life interfered with

a Finnish sample of women and men in achieving recom-

mended food habits or physical activity levels. Perceptions

of environmental factors such as neighborhood safety also

have been noted as barriers to physical activity (32).

Need for a Theory of Family Behavior

Change for Reducing Obesity

A further limitation to families providing the solution is

that no theory involving family has been created to explain

family involvement in promoting health behavior change

(74). Because of the different ways (eg, modeling, support/

encouragement, access to food, physical activity variety) a

family may affect its members’ dietary and exercise habits,

it is difficult to conceive of 1 theory that accounts for fam-

ily influence. As Baranowski and Nader (74) note, simply

accounting for adolescent behavior and matching parental

support influencing the adoption and maintenance of

positive health behaviors is a major challenge. Behavior

considered as positive and supportive in one parental-ado-

lescent relationship may be perceived as controlling and

confrontational in another. Soubhi et al (5) suggest that

determining a family typology might be useful for focus-

ing interventions to achieve behavior change so that the

essential health-related message that is communicated is

compatible with the family’s structure, behavior, values,

and beliefs.

To more effectively advance the notion that family (as

defined by its members) be considered as a central unit

VOLUME 6: NO. 3

JULY 2009

www.cdc.gov/pcd/issues/2009/jul/08_0191.htm • Centers for Disease Control and Prevention 5

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the

Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and

does not imply endorsement by any of the groups named above.

VOLUME 6: NO. 3

JULY 2009

for making behavior changes that support healthy eating

and physical activity habits, recognizing the importance

of family behavior in the development of weight control

and weight loss activities is essential. A major challenge

to determining family activity impact on individual mem-

bers’ weight management behaviors is the lack of this kind

of framework with which specific activities are related to

individual and family-level change. A framework by which

the collection of individual-level data can be combined to

form family-level aggregation of critical characteristics can

combat this problem. This framework might capture who,

how often, how much, to what extent, for how long, and

how invested family members are as individuals and as

a family unit to specific weight control actions and behav-

iors. A next step is to test the utility of such a framework.

Future work should build on the intricate relation-

ships between diet and exercise and physical activity and

food consumption built around the family environment.

Achievable diet and physical activity goals are likely better

enacted if determined by using the strengths and abilities

of the family to develop and institute a plan agreed on by

all family members. We hope we have described a perspec-

tive worthy of consideration by others who will build on

our thesis and develop better means to convince individu-

als and families that a path to good health is through a

lifestyle of dietary moderation and physical activity to the

point of exhilaration and the desire to keep moving.

Author Information

Corresponding Author: Kenneth J. Gruber, PhD, School

of Human Environmental Sciences, University of North

Carolina at Greensboro, Greensboro, NC 27402-6170.

Telephone: 336-256-0365. E-mail: kjgruber@uncg.edu.

Author Affiliation: Lauren A. Haldeman, University

of North Carolina at Greensboro, Greensboro, North

Carolina.

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