Parental support for overweight and obesity in children: The More and Less Study
Why is parental support needed for overweight and obesity?
As many as 20% of children in Sweden develop overweight or obesity during childhood and adolescence. While obesity is difficult to treat in adolescence, early childhood presents a unique opportunity to provide effective treatment through lifestyle changes alone.. However, the effects of treatment interventions early in life need to be further examined, paying particular attention to how parents can be best supported when implementing lifestyle changes for their families.
Our research on parental support
The More and Less Study was started in 2011 by Paulina Nowicka, Ph.D. dietitian and family therapist, who chose to carry out her postdoctoral research at the renowned research institute Oregon Social Learning Center (OSLC), in Eugene, Oregon, USA. The researchers at OSLC have long studied how and what kind of parenting promotes healthy development in children; their studies have informed many established parental support programs such as KOMET, Triple P and The incredible years. Paulina Nowicka was inspired by KEEP, a program developed by OSLC, which introduces parents in a systematic way to behaviors that strengthen a positive interaction with the child and facilitate changes in habits and routines. Together with her team, first at Karolinska Institutet and later at Uppsala University, Paulina Nowicka (now Professor at Uppsala University), has developed the parental support program, The More and Less, which is specifically designed for families of preschoolers, 2–6 years old, with overweight or obesity.
What is More and Less
In the More and Less program, parents attend group sessions to learn about and try different tools that promote healthy habits in the family. Participants have said that meeting parents who are in the same situation is a highlight of the program. More and Less was first evaluated in a randomized controlled trial in collaboration with child health care and pediatric and adolescent medicine clinics in Stockholm 2012–2016. The study showed that More and Less was effective in improving several health outcomes in children 4–6 years old with obesity one year and four years after the program (Ek et al 2019, Ek et al 2022). As a next step, the program has been included in the EU project STOP (2018–2022) and has been evaluated in Spain, Romania and Sweden. In this study, families of children from the age of two and children with overweight were included.
Close dialogue with parents has been crucial for the development of the program, and we have conducted interviews with parents exploring their experiences of the program. This has led to several qualitative publications (Ek et al., Appetite 2020, Nowicka et al. 2022a, Nowicka et al. 2022b). Overall, the program has been described and evaluated in more than twenty scientific publications and two doctoral theses (Anna Ek, Karolinska Institutet 2016 and Maria Somaraki, Uppsala University 2019). Both the group leaders’ and parents’ manuals have been translated into five languages.
How the program works
• The More and Less program consists of 10 group meetings of 1.5 hours once a week. Each meeting is based on a specific theme.
• Parents and group leaders (two per group) discuss strategies and concrete tips, for example:
o how much food is adequate and how to limit the child's screen time.
o how habits can be changed and how parents can best encourage children to learn new, slightly more difficult things.
o how parents can deal with tantrums, why it is important to be able to say no, how conflict situations can be avoided, and other important aspects of parenting, for example, how to be a “fair” parent.
The aim of the program is to empower parents in adopting new parenting tools and supporting their child's health, healthy eating habits and physical activity. It's about finding solutions that suit each family.
The group meetings are led by two group leaders who have health care background and additional education in the More and Less program. The group leaders first train by leading a group under supervision and then lead groups independently. Each group consists of 6–10 families where both parents are invited, and groups can be held both digitally and face-to-face. In the case of face-to-face groups, childcare can be offered to those who need it.
All parents receive written materials related to each group meeting. These materials include many tips on healthy habits, portion sizes, drinks, cooking and exercise, as well as guidance on how to keep motivated, on both weekdays and weekends.
We are currently evaluating long-term effects of obesity treatment started at the preschool age, using the data from the randomized controlled trial, the More and Less study. We do this with quantitative studies (with a focus on weight status, children's metabolic health and eating behavior and parents' psychosocial health) and qualitative studies, exploring the experiences of both children and parents. The doctoral student My Sjunnestrand specifically studies parents' experiences of weight talk and body image in children who have participated in treatment at the preschool age.
We are also evaluating the effects of the More and Less program implemented in Spain and Romania as part of the EU project STOP.
Finally, we have started a new study (led by Anna Ek and Markus Brissman at KI) which aims to adapt More and Less to families with children who have both obesity and ADHD. It is an unexplored group of children who have both diagnoses, which can have a major impact on the everyday lives of many families.
Selected scientific publications
Ek A, Chamberlain Lewis K, Sorjonen K, Hammar U, Malek Etminan M, Sandvik P, Somaraki M, Nyman J, Lindberg L, Nordin K, Ejderhamn J, Fisher PA, Chamberlain P, Marcus C, Nowicka P. A parent treatment program for preschoolers with obesity: A randomized controlled trial. Pediatrics 2019, 144(2):e20183457
Ek A, Nordin K, Delisle Nyström C, Sandvik P, Eli K, Nowicka P. Responding positively to ”children who like to eat”: Parents’ experiences of skills-based treatment for childhood obesity. Appetite 2020, 145:104488.
Nowicka P, Keres J, Ek A, Nordin K, Sandvik P. Changing the home food environment: Parents’ perspectives four years after starting obesity treatment for their preschool aged child. International Journal of Environmental Research and Public Health 2021, 18, 11293
Nowicka P, Ek A, Grafström E, Johansson T, Nordin K, Neuman N, Reijs Richards H, Eli K. How do interpersonal relationships affect children’s weight management? A qualitative analysis of parents’ long-term perceptions after obesity treatment. Childhood Obesity 2022, 18(4):274–280.
Paulina Nowicka, Professor, projektansvarig. Paulina.email@example.com
Professor at Department of food studies, nutrition and dietetics