Parental support in childhood overweight and obesity: the More and Less study

Why is parental support needed for overweight and obesity?

As many as 20% of children in Sweden have developed overweight or obesity in adolescence. Unhealthy weight is not only a serious risk factor for health problems later in life such as cardiovascular disease or several types of cancer. Already at the age of two, it puts a strain on the body, including increased inflammation. While in older children surgery is the only effective method to cure obesity, in younger children there is a unique opportunity to achieve favourable results through lifestyle changes alone. However, the effects of treatment interventions early in life need to be further explored, particularly in terms of how to best support parents.

Our research on parental support

The More and Less study was initiated in 2011 by Paulina Nowicka, a registered dietician and family therapist, who chose to conduct her postdoctoral research at the renowned Oregon Social Learning Centre (OSLC), in Eugene, Oregon, USA. Researchers at OSLC have long studied how and what parenting promotes child development, and these studies are behind many established parenting support programmes such as KOMET, Triple P and The Incredible Years. Paulina Nowicka was inspired by KEEP, a programme developed by OSLC, as it systematically introduces parents to different behaviours that strengthen a positive interaction with the child and thereby facilitate changes in habits and routines. Together with her team, first at Karolinska Institutet and later at Uppsala University, Paulina Nowicka (now Professor of Nutritional Sciences at Uppsala University), has developed the parental support programme, More and Less, which is specifically designed for families with overweight or obese preschool children, aged 2-6 years.

What is More and Less?

The More and Less programme introduces parents to different tools to promote healthy habits in the family. An appreciated part of the programme is meeting parents who are in the same situation. More and Less was first evaluated in a randomised controlled trial in collaboration with child health services and paediatric and adolescent medical clinics in Stockholm in 2012-2016. The study showed that More and Less had good effects on children's weight status, healthy habits, and well-being in both children (4-6 years old with obesity) and parents, both one year and four years after the programme (Ek et al. 2019, Ek et al. 2022). As a next step, the programme has been added to the EU project STOP (2018-2022) and has been evaluated in Spain, Romania and Sweden, where families with children from the age of two with obesity was included.

Close dialogue with parents has been crucial to the development of the programme, including interviews with parents about their experience of the programme. This has led to several qualitative publications (Ek et al, Appetite 2020, Nowicka et al 2022a, Nowicka et al 2022b). Overall, the programme has been described and evaluated in some 20 scientific publications and two doctoral theses (Anna Ek, Karolinska Institutet 2016 and Maria Somaraki, Uppsala University 2019). Both the group leader and parent manuals have been translated into five languages.

How the programme works

The More and Less programme consists of 10 group meetings of 1.5 hours each once a week. Each session is based on a specific theme.

• how much food is appropriate and how to limit your child's screen time.
• how to change habits and how parents can best encourage children to learn new, more difficult things.
• how parents can deal with nagging, why it is important to be able to say no, how to avoid conflict situations and many other important aspects of parenting.

The aim of the programme is to give parents new tools for parenting and to make them feel more confident about their child's weight development, food and exercise. It is about finding solutions that suit the family in question.

The group meetings are led by two group leaders with healthcare training and further training in the More and Less programme. The group leaders supervise a group and then lead groups independently. The group consists of 6-10 families where both parents are invited, groups can be held both digitally and physically. In physical groups, childcare can be offered to those who need it.

In connection with each meeting, all parents receive material with the most important information. The information includes many tips on healthy habits, portion sizes, drinks, cooking and exercise tips, and tips on how to stay motivated on weekdays and weekends.

Ongoing research

We are currently evaluating the long-term effects of obesity treatment started in preschool age. We do this with quantitative studies (focusing on weight status, children's metabolic health and eating behaviour and parents' psychosocial health) and qualitative studies with both children and parents. PhD student My Sjunnestrand is specifically studying parents' experiences of weight talk and body image in children who have participated in treatment at preschool age.

We also evaluate the effects of the More and Less programme implemented in Spain and Romania as part of the EU project STOP.

Finally, we have started a new study (principal investigators Anna Ek and Markus Brissman at KI) that aims to adapt More and Less to families with children who have both obesity and ADHD. This is an unexplored group of children who have both diagnoses, which can have a major impact on everyday life for many families.

A selection of 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.