Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

California L. Caldwell

Bon Secours Memorial College of Nursing

Nursing Research-4122

I pledge
AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to evaluate literature related to childhood obesity

factors, particularly in relation to family, environment, and socioeconomic factors. The rate of

childhood obesity has reached an epidemic proportion in countless worldwide countries and

cultures. Currently, research on this topic is undergoing consistent discussion and investigation,

in an effort to seek a solution. A great deal of research shows the correlation between a childs

socioeconomic standing, as well as family health in relation to the childs Body Mass Index.

Databases such as PubMed were used to seek relevant articles. 164 articles were found. Of the

164, 5 articles were selected based on greatest relevance to the chosen topic. These five articles

best display the factors involved in the childhood obesity epidemic, as well as providing solid

evidence of best practices needing to be implemented in the future. As a result of articles limited

specifically to one factor, this review has limitations and is not entirely factor specific. Further

research in this field should focus on single specific interventions applied in families at high risk

for overweight children.

AN INTEGRATIVE REVIEW 3

An Integrative Review

Overweight children are becoming a normal, accepted part of modern society. Nearly 30

percent of children in Egypt alone, are overweight or clinically obese (Hadhood, S., Ali, R.,

Mohamed, M., & Mohammed, E. (2017). Childhood is already a multifactorial equation, which

can be irreparably complicated by weight and health issues. Due to multiple influences on each

child, there are several different factors accounting for the statistical prevalence of overweight

children worldwide. The purpose of this integrative review is to analyze literature relevant to the

reviewers PICOT question, do parents significantly influence healthy weight in pediatric patients

over the duration of their childhood? A great deal of research is available regarding childhood

weight and obesity, however much of it investigates multiple separate influencing factors, as

opposed to focusing on a single possible causative variable. The reviewer felt interested in this

topic due to her appreciation for fitness and nutrition, in addition to her experience with

childcare, particularly her frustration with families ignoring the inappropriate nutritional status of

their child.

Design and Search Methods

This review specifically evaluates 5 separate research articles. PubMed was the greatest

asset used to search for relevant articles, fitting the reviewers criteria. The predominant key

terms utilized to search the databases included, maternal influence, paternal influence,

socioeconomic factors, maternal education, overweight children, childhood obesity,

lifestyle, parents perception, roles, role, demographic, children, and functioning.

PubMed yielded 164 articles. Google Scholar yielded 302 articles, none of which were utilized

for the purposes of this review.

For this review, search criteria filters were used to eliminate articles
AN INTEGRATIVE REVIEW 4

written before 2012, without full text, in a language other than English, or not published in an

academic journal. After evaluating the available articles, the reviewer further narrowed criteria to

studies completed during or after 2015, to present the most updated information. Five articles

that met these expectations, with dependable authors were selected to be reviewed. The review

assesses 4 quantitative articles, and 1 qualitative article that relate to the PICOT question or to

one another.

Findings and Results

The results show a clear relation between health and education of parents and unhealthy

weight of children (Hadhood et al., (2017); Hassan, N. E., El-Masry, S. A., Farid, T., & Khalil, A.

(2016); Lu et al., (2016); Rodrguez et al., (2016); White, D. A., Rofey, D. L., Kriska, A. M.,

Venditti, E. M., & Barone Gibbs, B. (2016). A comprehensive summary of each research article

is located in Table 1 of the Index. This review will include the following categories: parent

perception, parent education, and parent health in relation to weight.

Parent Perception

Two studies, one quantitative, one qualitative, investigated the effect that the parents

perception of their childs weight has on the childs weight itself (Rodrguez et al., 2016; White

et al., 2016). In the qualitative study performed by Rodriguez et al. (2016), four children and five

of their parents were interviewed to evaluate view on food, family patterns, and beliefs about

weight, and weight solutions. This study was an attempt to seek a correlation between the

parents perception of the childs weight and the childs perception of their own weight. This

perception on the part of each party was evaluated in relation to its significance in seeking a

solution to weight control issues. Children undergoing treatment for weight issues, or with a

history of metabolic, neurologic, metabolism, psychiatric, or mental diseases were excluded from
AN INTEGRATIVE REVIEW 5

the study. An interview guide led open ended, semi structured questions during three sessions,

one with parent, one with child, and one with parent and child. These interviews were audio

recorded, then electronically transcribed. While most of the participants pointed to hereditary

factors as the cause for childhood weight control issues, the results of the study indicate that

family communication, family eating habits, and interactions with extended family have the

greatest impact on weight during childhood. This shows that the inaccurate perception of a

family can become the reason a child does not maintain a healthy weight. Therefore, changing

the family perception of the cause of childhood obesity can become a solution.

The resulting data was analyzed so that 6 thematic categories could be determined. These

categories include: beliefs about food, communication, beliefs about weight and body image,

family patterns, controlling eating, and attempted solutions (Rodriguez et al., 2016).

In the quantitative study by White et al. (2016), 48 parent-child groups filled out a

questionnaire about their own perception of the childs weight status and the expressed opinion

others have of the childs weight status. The aim of the researchers was to evaluate the relation

between concerns of the childs weight from the parent, when expressed by others, and if this

effected any change the parent made in the childs lifestyle to encourage a healthier weight in the

child. The 48 parent-child groups were selected to take the questionnaire after responding to a

nonspecific flyer. The children were then measured accurately using a stadiometer, a body

composition analyzer, and the CDC BMI chart (White et al., 2016). The questionnaire responses

were compared to the calculated BMI of the child to assess the accuracy of the perceptions of the

childs weight status. The surveys had the parent evaluate the childs weight status, based on their

current perceptions.
AN INTEGRATIVE REVIEW 6

Data was analyzed using the IBM SPSS 21.0 Premium. A chart was developed based on

parent response, separated into two groups. These groups consist of: parents expressing concern

for childs weight after concern was expressed to them, and parents expressing concern for

childs weight who are also concerned for their childs future weight. The statistically significant

results of the study determine that when concern for a childs weight is expressed to the childs

parent, the parent becomes more aware of the issue, and will plan better for the future weight of

the child. This study shows us that changing the parents perception of the childs weight can

influence the interventions applied to correct it.

Parent Education

Three quantitative studies specifically investigated parent education in relation to

overweight or obese children (Hadhood et al., 2016; Hassan et al., 2016; Lu et al., 2016). The

quantitative study performed by Hadhood et al. (2016) investigated the effect of maternal

education on childs weight, using questionnaires of the mothers. The sample size was 700, from

random backgrounds in Egypt. Questionnaires and consent forms were sent home from school to

the mother to fill out (Hadhood et al., 2017). Each child was accurately assessed using a scale,

stadiometer, and the CDC BMI chart. Excluded from the study were children with illnesses,

using steroids, or using hormone replacements. Outcomes were calculated using the Windows

SPSS software. The results of the study conclusively showed the direct relation of maternal

education level to childhood obesity. The less educated the mother, the more likely the child was

to become overweight or obese.

A similar quantitative study by Hassan et al. (2016) investigated the effect of the fathers

education level on the childs weight. The sample size included 154 children and their mothers.

One parent filled out a detailed questionnaire about each parents education level. Each
AN INTEGRATIVE REVIEW 7

participating parent was interviewed by a trained physician (Hassan et al., 2016). The child was

then measured accurately using a scale, a stadiometer, and an age and gender specific BMI

growth chart. The results were calculated utilizing the Windows SPSS 16 software. The resulting

data was assessed and charted. The clear result is that children with fathers from a background of

higher education are at increased risk for becoming overweight or obese. This specifically

applied to the children of fathers who are college educated or above, with a stay at home mother.

The study by Lu et al. (2016) also investigated the effect that parent education played on

the weight of the offspring. The sample size included 2,457 children and their parents.

Questionnaires were filled out by one or both parents about education levels, occupation,

income, lifestyle, environment, and health perception. Height and weight were measured

accurately, by trained professionals, with qualified equipment. BMI was measured using the

international BMI calculation. The results were organized and interpreted using the SPSS version

18.0 software. The results were charted, and trends evaluated. The data clearly shows that

children of uneducated fathers are significantly thinner, and at less risk for obesity or poor

weight control. This same study showed that mothers with lower education levels were more

likely to have offspring with a lower BMI. This is a different result than most other studies,

which discuss that higher educated mothers have lower risk for obese children. The difference is

that in this study, the availability of cheap, low quality, calorie dense food is limited. So, when a

lower income parent purchases food, it is not lower quality, cheap food, it is simply less quantity

of food overall, resulting in a lower offspring BMI.

Parent Health in Relation to Weight

AN INTEGRATIVE REVIEW 8

Hassan et al. (2016) conducted a quantitative study that evaluated the relation between

overweight parents and overweight children. The sample size of 154 children were assessed in

relation to one parent. Each child and parent was measured with a scale, stadiometer, and a BMI

chart. Each participating parent was interviewed and filled out a questionnaire. The results were

calculated using the SPSS software by Windows. The outcome of the study is that child BMI has

a significant positive correlation to the parent BMI. This provides conclusive data to support that

children of overweight parents are far more likely to become overweight or obese themselves.

Hadhood et al. (2017) also wrote about a quantitative study interested in the impact obese

parents have on the weight of their children. 711 children were studied and related to either or

both parents, based on availability. Each child and parent or parents was measured using accurate

technology, and assessed using a credible BMI calculator. The parents filled out a questionnaire,

and the results were generated using Windows SPSS software. The conclusion of this study is

that parent BMI significantly impacts the childs BMI. If a parent has a higher BMI, or is

overweight, the childs chances of being overweight are greatly increased.

Discussion/Implications

The articles reviewed show obvious relationships between parent education, parent

health, and parent perception, in relation to healthy or unhealthy childhood weight. These articles

support and respond to the reviewers PICOT question. Influencing the parents of children can

impact childhood obesity directly. The results were statistically significant, clear, and revealed

obvious patterns and trends. The trend shows that healthier parents, with realistic perceptions,

and higher educated mothers, have lower risk of overweight or obese offspring.

More resources need to be in place to educate parents about these patterns, so that they

can participate in prevention. Healthcare workers can use these studies to educate and promote
AN INTEGRATIVE REVIEW 9

better practices to decrease these statistics. Healthy, well-educated parents can promote healthier

children. In the future, more research needs to be done on interventions and the outcomes of

interventions. The interventions need to be applied toward parents, rather than focusing on

children. If efforts are not applied to stop this epidemic, it will only become worse.

Limitations/Conclusion

This review has multiple limitations. The chosen topic is not as specific as possible, due

to a limitation of number of studies. The reviewer is inexperienced, thus somewhat unreliable.

Additionally, the reviewer had a difficult time narrowing down a specific topic, thus the

reviewed articles touch on different portions of the PICOT question. The reviewers PICOT

question was, do parents significantly influence healthy weight in pediatric patients over the

duration of their childhood?

The findings in these studies reveal the significant role parents play on their childs

weight. The first step in solving the problem is easier than originally thought. Instead of needing

to educate children, it is the parents who need to be educated. Adults are, in theory, easier to

educate and require less resources. Education about health, weight, and education should be

provided globally to expecting mothers or couples to provide prevention, rather than action. In

the future, scientists can further investigate the effect parents have on their offspring. This needs

to be done more specifically, rather than looking at several factors at the same time. For example,

exploring the relation between maternal education and child obesity, as opposed to multiple

factors being evaluated in one study. Additionally, the study samples need to be larger, above 800

participants, to provide more conclusive data on a larger scale.

AN INTEGRATIVE REVIEW 10

References

Hadhood, S., Ali, R., Mohamed, M., & Mohammed, E. (2017). Prevalence and correlates of

overweight and obesity among school children in Sohag, Egypt. Open Journal of

Gastroenterology, 7, 75-88.

Hassan, N. E., El-Masry, S. A., Farid, T., & Khalil, A. (2016). Influence of parental and some

demographic characteristics on overweight/obesity status among a sample of Egyptian

children. Open Access Macedonian Journal of Medical Sciences, 4(3), 342.

Lu, J. K., Gong, J. H., Yin, X. J., Ji, L., Watanabe, T., & Tanaka, T. (2016). Association of

socioeconomic and lifestyle behavioral factors with obesity and thinness among migrant

peasant workers children, by comparison with rural and urban children in China.

International Journal of Clinical Experience Med, 9(10), 19611-19622.

Rodrguez, C. C., Chvez, L. E. O., Serrano, M. D. L. P., Cabrera, T. D. J. V., Solis, M. G. O.,

Gonzlez, M. ., & de Len, J. C. B. (2016). Children and parents perceptions of family

functioning relating to childhood obesity. Advances in Applied Sociology, 6(10), 330.

White, D. A., Rofey, D. L., Kriska, A. M., Venditti, E. M., & Barone Gibbs, B. (2016). The

impact of expressing concern for a childs weight on the parents perception of child

weight and the parents concern for future weight problems. Journal of Childhood

Obesity, 1, 23.
AN INTEGRATIVE REVIEW 11

Table 1- Article Evaluation

First Author Hadhood (2017)- Faculty of Pediatrics, Sohag University,

(Year)/Qualifications Sohad, Egypt

Background/Problem Obesity in children is growing. Culture is changing to

Statement become increasingly unhealthy. Many factors are
involved in childhood obesity.

Conceptual/theoretical Researchers were interested in the factors contributing to

Framework childhood obesity, and how many were correlated to the
parents and lifestyle. No theoretical framework identified.

Design/Method/Philosophical Quantitative. Cross sectional study. Stratified and cluster

sampling. Identify factors of childhood obesity, by
Underpinnings questionnaires filled by parents.

Sample/ Setting/Ethical 711 children. Villages and schools in and around Sohag City,
Considerations Egypt. Informed consent, Approved by Ethics Committee.

Major Variables Studied (and Control group- children with normal BMI.
their definition), if
appropriate Variables- children labeled obese or overweight based on
BMI.

Measurement Tool/Data Demographic info. BMI calculations. Questionnaire for

Collection Method parents.

Data Analysis Chi tests, Windows SPSS software, descriptive data

analyzed.

Findings/Discussion Lifestyle of children greatly influences BMI, as does intake.

The lower a mothers education level, the higher the obesity
risk was for her child. Two obese parents, urban areas, and
bottle feeding also increased risk.
AN INTEGRATIVE REVIEW 12

Appraisal/Worth to practice Shows correlation in mothers education, parents BMI and

child. Revealed other relevant factors to child weight control or
lack of.
AN INTEGRATIVE REVIEW 13

First Author Rodriguez (2016)- employee at the Pediatric Hospital of

(Year)/Qualifications the National West Medical Center, and the University
Center for Health Sciences at the University of
Guadalajara in Guadalajara, Mexico.

Background/Problem The perception of a childs weight is related between the

Statement parents and the child. If the parents think the child is
overweight and needs to make healthier choices, the
child will also. Family function plays an important part in
childhood obesity, which is a growing epidemic.

Conceptual/theoretical Family systemic theory. What role the perception of the

Framework parents plays on childhood obesity.

Design/ Qualitative. Semi structured interview, small selected group

based on BMI, convenience sampling, snowball sampling.
Method/Philosophical The perception of parents was compared to childs BMI.
Underpinnings

Sample/ Setting/Ethical 4 children and their parents. Urban public elementary school
Considerations in Guadalajara, Jalisco, Mexico. Ethics committee approved,
Ethics explained to each participant and parents, consent
forms obtained.

Major Variables Studied (and Control group- overweight children

their definition), if
appropriate Experimental group- parents of overweight children who had
been told their child is overweight

Measurement Tool/Data BMI classification. Charting of groups based on terminology

Collection Method and assessment.

Data Analysis

Transcribed electronically using thematic content analysis,

categorized.

Findings/Discussion Communication, eating habits, foods, and family patterns play

AN INTEGRATIVE REVIEW 14

a large role on obesity. Beliefs about weight and health play a

larger role. If a parent or child does not believe there is a
weight issue, it is unlikely that a solution will be sought or
utilized.

Appraisal/Worth to practice Showed a correlation between the childs health and the
parents perception of the childs health. Not a large enough
sample size to develop a reliable plan.

First Author Lu (2016) staff at Laboratory of Adolescent Health

AN INTEGRATIVE REVIEW
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
15
Assessment and Exercise Intervention of Ministry of
Education and the School of Physical Education and
Health, East China Normal University, Shanghai, China.
Migrant peasant children have lower growth status than
all other citizens in China. Thin children also have lower
education history in the family, as well as lower family
income.
What is the relation of socioeconomic factors and lifestyle
among different children, in relation to obesity or thinness. In
comparison to other members of society in Shanghai, are
migrant workers at higher risk of malnutrition?
Quantitative. Cross sectional survey. School questionnaires
and BMI measurements combined. Children whose parents
answered the questionnaire had their BMI measures
accurately to evaluate an alignment between demographic
information and BMI.
Sample 2457 children. Elementary schools in Shanghai City in
Anhui Province, China. Research plan reviewed by Ethics
Committee.
Control- children of urban areas.
Experimental group- children of rural, migrant workers.
Physique measurements. Questionnaire. Demographic
information.
Chi squares, logistical regression, statistical analysis using
SPSS 18.0 software.
Thinness is more prevalent in rural migrant workers children.
Obesity is more prevalent in those with highly educated
parents, and higher family income.
AN INTEGRATIVE REVIEW 16

Appraisal/Worth to practice Showed conclusive results that education and income are
linked to obesity, in relation to parents. Results were
significant, and sample size was large enough to provide
reliability.

First Author Hassan (2016) staff at Biological Anthropology

(Year)/Qualifications Department in Cairo, Egypt.

Background/Problem Obesity is a growing problem in pediatrics. Factors of

Statement obesity include multiple factors, such as social,
AN INTEGRATIVE REVIEW
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
17
economic, and environmental factors. Some combination
of these is creating a huge statistic of overweight
children.
Researchers wanted to study the social, environmental, and
economic facets of the lives of children, and how it affected
their BMI.
Quantitative, cross sectional survey. Trained interviewers
filling out a questionnaire using the childs mother. BMI of child
and parent calculated using accurate measurements. Results
of interview were then compared with BMI of both parties to
assess correlation.
Sample 154 children. National Research Center and
surrounding area, Egypt. Consent forms filled, approval by the
Medical Ethical Committee.
Experimental group- children with high BMI.
Control group- children with average to low BMI.
Anthropometric measurements, BMI calculator, questionnaire,
interview, demographic information.
SPSS by Windows version 16, used to assess and compile
data. Means, frequency distribution, chi square tests,
Spearmans correlation test.
Obesity is more prominent in urban children, the offspring of
well-educated fathers, and the offspring of less educated
mothers. Parent education and occupation, or income play a
large role in child BMI, by impacting parent BMI.
Significant data showing parent BMI related to child BMI, by
AN INTEGRATIVE REVIEW 18

evaluating additional factors, such as occupation and

education. Also, directly correlated BMI of each parent with
BMI of child, to reveal positive correlation.

First Author White (2016) staff at Childrens Mercy Hospital and

(Year)/Qualifications Clinics, Kansas City, MO, US.

Background/Problem Parents with overweight children often underestimate the

Statement childs weight, and the health concern involved. This
results in the child staying overweight, longer. Often,
when someone the parent trusts express concern for the
AN INTEGRATIVE REVIEW
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
19
childs weight, it raises the parents own concern.
To explore, what is the effect of expressing concern for an
overweight child, to the parent of that child?
Quantitative, cross sectional study. Parent perception of their
childs weight was evaluated after concern being expressed
by someone close to them, was compared to parents of
overweight children who had never received concern from
other for childs weight. Parent perception for childs weight
and future weight was then assessed to seek correlation.
48 parent-child dyads. Community centers and schools in or
around Pittsburg, PA. Approved by the University of Pittsburg
Institutional Review Board. Informed consent obtained.
Control group- parents of children who have never heard or
received concern for their childs weight
Experimental group- parents of overweight children who had
received or heard concern for their childs weight
Interview of parents. Demographic data. BMI calculator. Child
anthropometric measurements.
Fishers exact test, frequency and percent of sample, assess
using the IBM SPSS 21.0.
Parents were more concerned over childs weight if concern
was previously expressed by someone to them. The more
trusted and educated the other person, the more effective the
statement was at causing the parent to modify lifestyle to be
healthier for the child.
This study is valuable as it shows a different perspective on
parenting role in childhood weight. The sample size was not
large enough to provide conclusive data, but the results were
AN INTEGRATIVE REVIEW 20

statistically significant enough to need further research.