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The Challenge of Preventing and Treating Obesity in Low-Income, Preschool Children
Perceptions of WIC Health Care Professionals
Leigh A. Chamberlin, MEd, RD;
Susan N. Sherman, DPA;
Anjali Jain, MD;
Scott W. Powers, PhD;
Robert C. Whitaker, MD, MPH
Arch Pediatr Adolesc Med. 2002;156:662-668.
ABSTRACT
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Background Obesity has become a common nutritional concern among low-income, preschool
children, a primary target population of the Special Supplemental Nutrition
Program for Women, Infants, and Children (WIC). Nutrition counseling efforts
in WIC target childhood obesity, but new approaches are needed that address
the different perceptions about obesity that are held by clients and health
care professionals.
Objective To develop these new approaches, we examined WIC health care professionals'
perceptions about the challenges that exist in preventing and managing childhood
obesity.
Design A qualitative study using data transcribed from audiotapes of focus
groups and individual interviews. We independently read each transcript and
coded themes; then, the common themes were selected through group meetings
of the authors.
Setting Kentucky WIC.
Participants Of the 19 health care professionals participating, all had provided
nutrition counseling in WIC and all but one were white women.
Results Twelve major themes clustered into 3 domains. The first domain centered
on how WIC health care professionals perceived the life experiences, attitudes,
and behaviors of the mothers they counseled. They perceived that mothers (1)
were focused on surviving their daily, life stresses; (2) used food to cope
with these stresses and as a tool in parenting; (3) had difficulty setting
limits with their children around food; (4) lacked knowledge about normal
child development and eating behavior; (5) were not committed to sustained
behavioral change; and (6) did not believe their overweight children were
overweight. The second domain described WIC health care professionals' perceptions
of counseling interactions. They felt that (7) they might offend mothers when
talking about weight, (8) counseling was driven by protocols, and (9) their
nutritional advice often conflicted with the advice from the mothers' relatives,
friends, or primary care physicians. The last domain described programmatic
suggestions WIC health care professionals offered to address childhood obesity:
These included (10) promoting a more client-centered approach to counseling,
(11) establishing behavioral change goals that were small and endorsed by
the mother, and (12) working with primary care physicians to create a more
uniform approach to counseling on obesity.
Conclusions To become more responsive to the problem of childhood obesity, WIC should
consider the following: (1) providing staff training in counseling skills
that educate parents on child development and child-rearing and that elicit
the client's social context and personal goals, (2) shifting time allocation
and programmatic emphasis in the WIC visits away from nutritional risk assessment
and toward counseling, and (3) developing collaborations with primary health
care providers and community agencies that impact childhood obesity.
INTRODUCTION
FOR 30 YEARS the Special Supplemental Nutrition Program for Women, Infants,
and Children (WIC) has provided supplemental foods, nutrition education, and
health care referrals to low-income mothers and children considered at nutritional
risk. Among the concerns that motivated the development of WIC was that many
low-income children were inadequately nourished to have optimal growth and
development. Although such concerns still exist, obesity is a far greater
nutritional problem facing children enrolled in WIC.1
The WIC program is evaluating whether its traditional strategies in food supplementation
and nutrition counseling are the most appropriate for preventing the problem
of obesity in young children.2-3
The WIC program has the potential to influence the problem of childhood obesity
because almost half of all infants in the United States and one fourth of
the 1- to 4-year-olds are enrolled in the program.4
The magnitude of the childhood obesity problem, the current lack of proven
interventions for prevention or treatment of obesity, and the ability of WIC
to reach so many children should make all those providing health care to children
interested in how WIC addresses the problem of obesity.
There is evidence that the dialogue that is occurring in WIC nutritional
counseling sessions between WIC health care professionals and the mothers
of preschool children is failing to increase awareness and action in mothers
about the problem of obesity in their children. For example, the vast majority
of mothers who have overweight preschool children enrolled in WIC do not identify
their children as being even "a little overweight,"5
and most mothers have views about the definition, cause, and management of
obesity that differ greatly from those of most health care professionals.6 This gap in perception between those providing nutrition
counseling and the mothers receiving that counseling must be better understood
before new strategies can be developed to prevent obesity in the WIC population.
Having previously examined the perspectives of WIC mothers,6
this study explored the perceptions of WIC health care professionals about
the challenges that exist in preventing and managing childhood obesity and
about ways these challenges might be met.
PARTICIPANTS AND METHODS
To explore the complex and multifaceted topic of obesity, qualitative
research methods were used to avoid the use of close-ended questions that
often implicitly add the perspective of the researcher.7-8
The research was carried out in conjunction with the development of a documentary
videotape entitled Beyond Nutrition Counseling: Reframing
the Battle Against Obesity.9 The videotape
was part of a larger project called Fit WIC whose
overall aim was to increase the responsiveness of WIC to the problem of childhood
obesity. We designed the videotape to be used as a stimulus when conducting
facilitated group discussions among WIC health care professionals to help
them identify ways in which the program might be more effective in addressing
the problem of childhood obesity.
Between April 11, 2000, and September 19, 2000, we conducted 3 focus
groups with a total of 19 health care professionals who had provided nutrition
counseling for the Kentucky WIC program. We explored with these health professionals
what they perceived as barriers and solutions to addressing the problem of
obesity among children enrolled in WIC. In addition, 6 of these health care
professionals participated in individual interviews. The institutional review
board at Children's Hospital Medical Center, Cincinnati, Ohio, approved the
study. Informed consent was obtained from all participants.
The focus groups were assembled through convenience sampling, but they
aimed to include the varied types of health professionals that provide nutrition
counseling in the Kentucky WIC program. One focus group involved 6 health
care professionals from the Nutrition Work Group. The Nutrition Work Group
is composed of health care professionals from local WIC agencies across Kentucky,
and its function is to meet regularly with state-level WIC administrative
staff to discuss program procedures and policy changes in the Kentucky WIC
program. Another focus group was conducted with 5 health care professionals
from a rural WIC clinic serving 900 WIC participants. The last focus group
was composed of 8 health care professionals from an urban WIC clinic serving
a caseload of 1400 participants.
Of the 19 health care professionals participating in the focus groups,
7 had backgrounds in clinical nutrition and 12 had nursing backgrounds. All
19 had provided WIC nutrition counseling in the past; 13 were providing it.
Of the 13 providing nutrition counseling, 10 had at least 6 years or more
of experience. All were female and all, but one, were white. Based on self-reported
height and weight, 2 health care professionals had a body mass index (ie,
weight, in kilograms, divided by the height, in meters, squared) of 30 kg/m2 or higher and 6 had a body mass index of 25 kg/m2 or higher.10
All 3 focus groups lasted 1 hour and were moderated by a trained facilitator
(S.N.S.) from the research team. Broad, open-ended questions were followed
by probing questions that clarified participant's responses and narrowed the
discussion. These questions (available from us) were similar to those previously
used with focus groups of mothers of children enrolled in the Kentucky WIC
program.6
One of us (R.C.W.) observed 2 of the focus groups (Nutrition Work Group
and urban WIC clinic) and conducted 20- to 30-minute individual interviews
with 3 participants from each of these groups. These 6 interviewees were selected
because they were the most articulate during the focus groups. With some of
them, we also wanted to explore, in greater depth, particular comments they
made in the focus groups that had a potentially more sensitive dimension that
might not be revealed in the group setting.
Each focus group and individual interview was transcribed from an audiotape
and placed in a computerized transcript database. A "comment" was defined
as any uninterrupted utterance in response to a question. Each of the 785
participant comments was assigned a unique comment number. Four of us (L.A.C.,
S.N.S., S.W.P., R.C.W.) read the transcripts, independently identified common
themes, and selected comments as examples of each theme. Twelve major themes
were identified by group consensus and then organized into 3 domains. A total
of 370 unique comments supported these 12 themes, and 2 comments were chosen
as examples of each theme (Table 1).
The remaining 415 comments were incomplete thoughts, complete thoughts that
could not be organized into any major theme, or brief utterances (eg, yes)
that merely expressed agreement with another's statement.
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Results of the 3 Domains Studied*
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RESULTS
DOMAIN 1. PERCEPTIONS ABOUT THE MOTHERS OF CHILDREN ENROLLED IN WIC
Theme 1. Mothers Are in a "Survival Mode" Because of the Challenges
They Face in Their Lives
Mothers were described as operating in a survival mode while navigating
their complex and ever-changing social circumstances (Table 1). The stressful and unpredictable lives of these mothers
interfered with implementing the nutritional advice that they received from
WIC. It was felt that these mothers faced competing demands that often required
immediate action and that contributed to high levels of chaos and low levels
of control in their lives. In this context, modifying family dietary patterns
was competing in these mothers' lives against more pressing problems with
housing, transportation, employment, and personal relationships.
Theme 2. Mothers Use Food as a Coping Mechanism and as a Parenting
Tool
As evidenced in the preceding comment, the health care professionals
believed that the high levels of stress for these mothers caused them to use
food as a coping mechanism. Mothers imbued food with functions in parenting
beyond providing nutrition. Foods were used to calm, reward, and emotionally
nurture their children. The health care professionals felt, for example, that
mothers used food to control their children's behavior by frequently giving
their children sugared snacks with low-nutrient density as a reward for good
behavior. Food was also viewed as an affordable way of indulging and expressing
affection for their child.
Theme 3. Mothers Have Difficulty Setting Limits With Their Children
Around Food
In the opinion of these health care professionals, many mothers lacked
the knowledge or ability to effectively discipline their children and, as
a result, often ended up giving their children whatever they demanded. The
health care professionals felt this problem in parenting greatly affected
the children's nutrition because mothers were often unable to set limits in
their children's diets. The health care professionals spoke often of situations
in which the child was exercising too much control over decision making.
Theme 4. Mothers Lack Knowledge About Normal Child Development and
Eating Behavior
Another experience familiar to the health care professionals was that
the mothers often lacked knowledge about normal child development. This lack
of knowledge about child development, as in the case of child discipline,
was felt by the health care professionals to affect the maternal-child feeding
interaction. For example, the health care professionals reported that it was
common for mothers to give children foods and portion sizes that were inappropriate.
The health care professionals felt that mothers were often unable to tell
when their children's cry, poor mood, or negative behavior was coming from
hunger and when it might signal another distress such as fatigue, loneliness,
or anxiety.
Theme 5. Mothers Are Perceived as Not Motivated or Committed to Changing
Behavior
The health care professionals characterized many of the mothers they
counseled as unwilling to make long-term changes in their own or their children's
diets. This perception was based on counseling experiences when parents did
not seem to adopt the suggestions that were provided by the health care professionals.
The health care professionals perceived that most mothers were primarily interested
in solutions that offered immediate results and that many mothers were not
interested in nutrition counseling.
Theme 6. Mothers Do Not Believe Their Overweight Children Are Overweight
The health care professionals pointed out that many mothers who had
overweight children did not feel their children were overweight. The health
care professionals identified this maternal perception as a major obstacle
to successful counseling around the prevention or treatment of obesity. When
the subject of overweight was raised, even delicately, many mothers appeared
offended at the suggestion of such a label for their child. The health care
professionals offered some possible explanations for this maternal perception.
Mothers might simply feel that a "large" or "plump" child, especially in infancy,
was healthier or more attractive. A number of mothers, it was thought, were
certain that their overweight child would "outgrow" their weight problem by
school age.
DOMAIN 2. PERCEPTIONS ABOUT WIC's NUTRITION COUNSELING
Theme 7. Health Care Professionals Fear They Will Offend the Mother
The health care professionals were so aware that many mothers were uncomfortable
with the suggestion that their child may be overweight or become overweight
that the topic of weight was often avoided altogether (Table 1). Fearful of offending mothers, health care professionals
would talk only indirectly about weight, search for the least offensive terminology
to describe the child's weight, or use the growth chart as an objective support
of their concern about the child's weight being abnormal.
Theme 8. The WIC Program's Counseling Is Protocol Driven
Although they were aware that obesity was a sensitive subject for many
parents, the health care professionals often felt obligated to share nutritional
information and growth chart parameters with each client according to the
guidelines prescribed in WIC protocols. The health care professionals did
not appear comfortable working outside the WIC counseling protocols, especially
in addressing the clients' social problems, because "social work" was not
part of their formal training as nutrition counselors or their training within
the WIC program. This fear of working beyond the protocol was exacerbated
by having such a small amount of time for counseling after completing the
heavy administrative requirements in certifying an individual for WIC program
eligibility.
Theme 9. Mothers Receive Conflicting Advice From WIC Staff, Physicians,
and Other Family Members
The health care professionals remarked that mothers often received advice
that appeared to contradict what they had been told in WIC nutritional counseling
sessions. For example, many WIC clients claim that their pediatricians have
not advised them that their child was either overweight or at risk of becoming
overweight. The health care professionals felt their credibility and effectiveness
was eroded when they provide information that was not corroborated by other
health care professionals, especially primary care physicians. Furthermore,
members of the extended family, especially grandparents, provided nutrition
information based on their own life experiences. Because many WIC clients
live with relatives, the clients found it difficult to negotiate the differing
opinions between the WIC health care professionals and family members about
how best to feed children.
DOMAIN 3. POTENTIAL SOLUTIONS IN THE WIC PROGRAM FOR THE PROBLEM OF
CHILDHOOD OBESITY
Theme 10. Redesign the WIC Program to Promote a More Client-Centered
Approach to Counseling
The health care professionals felt they needed more time for nutrition
counseling and more flexibility to work outside established WIC program protocols
so that they could focus their efforts during the counseling session on those
needs, even if not purely nutritional, that the client identified as having
highest priority (Table 1). There
was also the suggestion that the administrative burdens of the WIC certification
process kept health care professionals from having the time to establish the
kind of rapport with a client that is required to understand a client's life
context and to give advice that is sensitive to that context.
Theme 11. Set Behavioral Change Goals That Are Small and That Are Endorsed
by the Mother
The health care professionals recognized that changes in a client's
dietary behavior could only occur in small steps. According to these health
care professionals, counseling sessions needed to involve changing behavior
in small increments with short-term goals that were established in conjunction
with the client. The health care professionals also felt that the process
of setting nutritional goals should be respectful of the client's social circumstances.
Failing to focus on short-term, achievable, client-centered goals was likely
to make the client feel overwhelmed and uninterested.
Theme 12. Develop Between WIC Program Staff and Physicians a More United
and Coherent Approach to Obesity
These health care professionals felt that the responsibility for preventing
obesity in the population of children served by WIC should not be carried
by the WIC alone. In particular, they felt that WIC needed the help of community
physicians to create a more unified message for parents about childhood obesity.
For example, there was concern that physicians may be interpreting the growth
charts differently than the WIC health care professionals and communicating
messages to the mothers about the children's weight that were different from
those being given by WIC staff. The health care professionals found it difficult
to express concern to a mother about her child's weight if the child's physician
had not also raised the concern. Thus, the health care professionals felt
their efforts to discuss obesity with mothers were often undermined by physicians
whom the mothers regarded as the more authoritative source of information.
COMMENT
Recent changes in the social and economic environment, ranging from
increased television advertising of foods11
to increased portion sizes12 to increased demands
on parents in the workplace13 to increased
concerns about neighborhood safety,14 can all
present major challenges to parents who are trying to shape the developing
dietary and activity patterns of their young children. Thus, the nutritional
counseling in WIC can be thought of as an attempt to help parents buffer their
children from the many environmental factors that promote obesity.
Based on the results of this and related studies,6, 15-16
we propose below some possible explanations for why WIC is having difficulty
preventing and managing childhood obesity, how WIC might better address the
problem, and why these issues in WIC are relevant to those providing health
care services to children. While we cannot generalize findings from this qualitative
study, the explanations we propose can be evaluated in other settings and
with different research designs.
As in much of primary care pediatrics, the counseling in WIC is a dialogue
between health care professionals and parents, usually mothers, that occurs
about children. In this dialogue, the perceptions of each party about the
other strongly shape the content and the outcome. Whatever the parent takes
away from the dialogue constitutes the causal pathway by which these counseling
sessions can affect the child's health. Likewise, what the health care professional
takes away is likely to affect future dialogues with that parent and even
with other parents. In the dialogue about childhood obesity, we believe there
is often an impasse between mothers and WIC health care professionals.
What leads to the impasse? Many WIC health care professionals may understand
that their clients have socioeconomic circumstances that affect the perception
of obesity and, in turn, the desire or ability to prevent or treat obesity.
However, this understanding may not be successfully conveyed to WIC clients.
Most health care professionals see that to address obesity, their program
needs to move beyond its traditional framework for nutritional counseling.
However, neither the time allowed for nutrition counseling in the program
nor the content of that counseling appear adequate to address the problem
of childhood obesity.
The only way that the WIC health care professional can spend more time
on nutrition counseling without increasing costs is to spend less time on
the process of certifying families for WIC benefits. This certification customarily
requires that clinical encounters in the WIC program begin with a screening
evaluation for nutritional risks. Obesity poses a particular problem in relation
to this screening process. A growth chart, whose basis may not be accepted
or understood by many parents,6 is used to
define a problem for the child that most parents do not believe exists. In
identifying obesity as a health problem or a potential health problem, a condition,
already stigmatized, may be added to a long list of nonnutritional problems
that already exist for most low-income children. The process may also implicitly
blame parents for the problem. The problem-directed counseling that follows
risk screening does not allow adequate time to understand the parent's perspectives
on obesity. Time is needed, for example, to inquire about whether obesity
is even a concern for the parents, about the parents' own history with obesity,
and about the specific social context influencing obesity in the family.
Thus, the problem of obesity provides an opportunity for the WIC health
care professional to reevaluate the current role of nutritional-risk screening,
as it has done recently with dietary risk assessment.17
In this reevaluation, the WIC program administrators may choose to consider
the following: (1) the time that screening now occupies in the already short
clinic visit; (2) the way in which the results of the screening, rather than
the client, defines the subsequent agenda and atmosphere for counseling; and
(3) whether risk identification is the appropriate emphasis for conditions
such as obesity in which evidence is lacking that the intervention of the
program alone will change the outcome.
Even if more time were reallocated from certification to nutrition counseling,
the program may need to consider altering the method and content of the counseling.
Such changes might allow a dialogue between health care professionals and
clients that generates client-centered goals for behavior change. To achieve
such a paradigm shift, the WIC program administators should consider providing
staff training that emphasizes listening skills to elicit information about
the client's social context, barriers to change, and perceptions about obesity.
The process of listening is likely to build trust between the health care
professional and the client. This, in turn, may also lead to more behavioral
change if the client feels that the health care professional has taken time
to understand one's life circumstances before giving advice. The technique
of motivational interviewing incorporates many of these concepts, and it may
provide a useful model for the WIC progam administrators to consider in approaching
childhood obesity.18-19
The health care professionals reported that, in many cases, the parents
were unable to implement nutritional advice without first acquiring a better
understanding of their child's development and more capabilities in child-rearing.
Thus, to be more responsive to the problem of childhood obesity, WIC health
care professionals may need the training to provide anticipatory guidance
about normal child development and aspects of parenting such as establishing
routines, setting limits, and child discipline.
The WIC program may be able to play a more important role in preventing
obesity if it partners with those providing primary health care to children.
Aside from the co-location of primary health care and WIC progam services,
there needs to be more dialogue between WIC program administrators and WIC
health care professionals about the services provided, the approaches to nutritional
counseling, and the specific messages conveyed. Eliminating duplicate services
may allow more time in both health care and WIC program settings for more
counseling. In addition, health care professionals and the WIC program need
to establish a coherent and unified approach to growth assessment and the
use of the growth charts. Primary care providers must use their well-earned
influence with families to support the efforts of those in the WIC program
and to avoid the appearance, though likely unintended, of contradicting or
undermining the efforts of WIC health care professionals. As has been recently
emphasized by the American Academy of Pediatrics, children will be the primary
beneficiaries of a closer collaboration between WIC and primary health care
professionals.20
Addressing the problem of childhood obesity raises many questions for
the WIC program. Among them are whether (1) there should be a different approach
to nutritional risk screening, (2) the content of counseling should expand
beyond nutrition to include factors influencing obesity such as child development
and parenting, and (3) stronger partnerships should be built with the health
care provision system or with other community organizations that also have
the ability to influence the problem of childhood obesity. Answering these
questions will require a broader public and political dialogue about the best
way to reshape a program that still has enormous potential to influence the
health and well-being of low-income families, but which, like the health care
system, is currently struggling to deal with obesity.
| What This Study Adds
Obesity is an increasing nutritional problem among the large number
of low-income children served by the WIC program. Mothers of low-income preschool
children do not have the same perceptions about obesity as WIC health care
professionals, and exploring these differences in perception may improve obesity
prevention strategies in the administration of the WIC program. Although those
providing nutrition counseling in the program understand many client perceptions
about obesity and the social context that shapes those perceptions, they are
often unable to respond to those perceptions because of limitations in their
training and programmatic constraints in the WIC program. To be more responsive
to the problem of childhood obesity the WIC program should consider (1) expanding
the scope of counseling beyond nutrition, (2) shifting programmatic emphasis
away from nutritional risk assessment and toward counseling, and (3) developing
collaborations with primary health care providers and community agencies that
affect childhood obesity.
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AUTHOR INFORMATION
Accepted for publication March 29, 2002.
This work was supported by federal funds from Cooperative Agreement
No. 59-3198-8-500, the US Department of Agriculture, Food, and Nutrition Service,
Washington, DC.
This study was part of the Fit WIC Project, a multistate project to
examine how the WIC can be more responsive to the problem of childhood obesity.
The participating State WIC agencies include California, Virginia, Kentucky,
Vermont, and the Inter-Tribal Council of Arizona. The 5 grantees are working
collaboratively with the US Department of Agriculture's Food and Nutrition
Service and with the Centers for Disease Control and Prevention, Atlanta,
Ga.
We give special thanks to the health care professionals from Kentucky
WIC who participated in this study. We would also like to extend our gratitude
to Fran Hawkins, MS, RD, manager of the Nutrition Services Branch at the Kentucky
Department for Public Health, for her support of Kentucky's Fit WIC Project.
The contents of this publication do not necessarily reflect the views
or policies of the US Department of Agriculture, nor does mention of trade
names, commercial products, or organizations imply endorsement by the US government.
Corresponding author and reprints: Robert C. Whitaker, MD, MPH, Children's
Hospital Medical Center, Division of General and Community Pediatrics, TCHRF-6527,
ML 7035, 3333 Burnet Ave, Cincinnati, OH 45229-3039 (e-mail: lachman{at}chmcc.org).
From the Divisions of General and Community Pediatrics (Ms Chamberlin
and Dr Whitaker) and Psychology (Dr Powers), Children's Hospital Medical Center,
Cincinnati, Ohio; SNS Research, Cincinnati (Dr Sherman); Department of Pediatrics,
University of Chicago, Chicago, Ill (Dr Jain); and the University of Cincinnati
College of Medicine (Drs Powers and Whitaker).
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