Introduction
Overweight and obesity are leading global public health challenges. Globally, 1.9 billion adults have a Body Mass Index (BMI) in the overweight range and 650 million are living with obesity (World Health Organization,
2021). Currently, Australia ranks within the top 10 of all developed countries in terms of obesity rates as a percentage of total adult population (OECD,
2020), with 67% of Australian adults living with overweight or obesity (Australian Institute of Health and Welfare,
2020). The high prevalence rates pose a considerable health and economic burden on individuals, families and nations (Tremmel et al.,
2017). Specifically, obesity is associated with a range of non-communicable diseases including type 2 diabetes, cardiovascular disease, and certain cancers (Blüher,
2019). Further, the global economic impact of obesity was estimated to be US $2.0 trillion or 2.8% of the global gross domestic product (GDP) (Dobbs et al.,
2014). In 2017, 18% of deaths worldwide were attributable to obesity-related diseases (Lin et al.,
2020).
Obesity among males is especially concerning. In Australia, 75% of males live with overweight or obesity, compared to 60% of females. Further, adult men are more likely to have greater abdominal fat tissue than women (Wirth & Steinmetz,
1998), which independently increases metabolic syndrome and related cardio-metabolic risk (Després,
2006). Despite this, males remain less likely to perceive themselves as overweight, attempt weight loss or take part in weight loss programs (French et al.,
1994; Lovejoy et al.,
2009; Morgan et al.,
2011c; Young et al.,
2012).
The transition to fatherhood is recognized as a major social determinant of men’s health (Garfield et al.,
2006) and has been linked to men’s weight status (Garfield et al.,
2016). In a longitudinal, population-based study of 10,253 American men (Garfield et al.,
2016), those who became a father during the study experienced an increase in BMI trajectory, whereas those who remained non-fathers experienced a relative decrease over the same period. These increases may have been driven in part by changes in lifestyle health behaviors as fathers responded to shifting priorities and time commitments (Pot & Keizer,
2016). To help fathers maintain a healthy weight, targeted lifestyle interventions that meet their unique preferences and values are needed.
Suboptimal lifestyle behaviors and increasing levels of obesity in fathers may also have flow on effects to their children. For example, a longitudinal study found obesity in fathers to be associated with a four-fold increase in the risk of obesity in both sons and daughters at 18 years of age (Burke et al.,
2001). This is a major issue, as obesity becomes entrenched and around 55% of children who have obesity will still have obesity in adolescence, while 80% of adolescents with obesity go on to have obesity in adulthood (Simmonds et al.,
2016). As such, there is an urgent need to understand and address this inter-generational health risk.
It is well-established that parents play a critical role in the development of positive health behaviors in children (Golan,
2006). Specifically, parents influence physical activity and dietary behaviors through their own behavior, attitude, modeling, parenting styles and child feeding practices (Davison & Birch,
2001; Lloyd et al.,
2015; Sallis et al.,
2000). However, relatively little empirical attention has examined the unique role of fathers. To date, fathers have been largely overlooked in both family-based programs targeting children’s lifestyle behaviors (Morgan et al.,
2017) and observational research investigating optimal parenting practices for children’s physical activity and nutrition (Davison et al.,
2016). Of interest, some of the available evidence suggests fathers’ behaviors and parenting styles may be more influential on children’s weight status than mothers (Stein et al.,
2005; Wake et al.,
2007). Potential reasoning is father’s unique role in influencing physical activity, with fathers often more likely than mothers to engage in physical play (e.g., play wrestling) and to initiate co-participation in physical activity with their children (Beets et al.,
2010; Morgan et al.,
2020; Zahra et al.,
2015). In addition, fathers tend to provide a better model of sports skill performance, due to their increased opportunities and reinforcement to practice sports skills throughout life (Hallal et al.,
2012; Trost et al.,
2002).
To improve the health and wellbeing of children, there may be utility in harnessing the father-child relationship as an innovative strategy to engage fathers in family-based, lifestyle interventions. The Healthy Dads, Healthy Kids (HDHK) program was the first lifestyle program to engage fathers to improve their children’s physical activity and dietary behaviors. This program has previously demonstrated efficacy in a university-based research project delivered by qualified researchers (Morgan et al.,
2011a) and demonstrated effectiveness in a community-based trial where trained facilitators delivered the program in local primary schools (Morgan et al.,
2014). Overall, fathers and children improved their weight status, increased physical activity, and improved dietary behaviors. Importantly, a large dissemination trial of the program across a range of underserved communities revealed these results were mostly sustained at 12-month follow up (Morgan et al.,
2019a). Despite these positive findings, we need to better understand the specific mechanisms of effect through which intervention fathers impacted on their children’s physical activity, dietary behaviors, and weight status. Further, given scholars have suggested that fathers often bond with their children through physical play and lifestyle-related activities (Paquette & Dumont,
2013), it is important to explore whether participation in the program led to improvements in the father-child relationship or other family dynamics (Paquette & Dumont,
2013). Moreover, little is known about the ripple effect these changes may have on the wider family unit. Gathering insights from the whole family can help to improve overall understanding of these important questions.
Focus groups provide an appropriate and valuable method for obtaining comprehensive information about participants’ experiences and opinions relating to a shared experience. However, only one study to date has qualitatively explored the impact of a father-child lifestyle intervention (Pollock et al.,
2020). The study obtained perspectives from fathers who participated in the Dads And Daughters Exercising and Empowered’ (DADEE) study (Morgan et al.,
2019b,
2021) and identified holistic benefits of: daughters’ social-emotional well-being, fathers’ parenting skills, the father–daughter relationship, family relationship dynamics and knowledge and understanding of gender stereotypes and gender bias. These important findings were limited to perspectives from the fathers only and the program only targeted physical activity. Other qualitative studies which have explored the impact of family-based lifestyle interventions have provided some further insights (Twiddy et al.,
2012; Watson et al.,
2021). Views obtained from parents and children participating in the GOALS study in the UK (
n = 39 children,
n = 34 parents/carers, 15% fathers) identified learning as a family, being accountable and gradual realistic goal setting as factors that facilitated behavior change (Watson et al.,
2021). Furthermore, insights from parents and children from the WATCH-IT program in the UK (
n = 23 parent-child dyads, 22% fathers) found strong family support and a good relationship with staff to facilitate successful weight management (Twiddy et al.,
2012). Despite these important insights, there was an under-representation of fathers and none of these studies obtained insights from non-participating partners to establish the wider impacts on the family.
To our knowledge, no previous study has explored the impact of a father-child lifestyle intervention by gathering perspectives from the whole family unit. Therefore, the aim of this study was to explore the broader impact of the HDHK program on the whole family (fathers, mothers and children), to help better understand how the intervention impacted on the families’ physical activity, dietary behaviors and weight status.
Results
A total of 25 fathers, 15 mothers/partners, and 41 children participated in 11 focus groups. This represented a consent rate of 76% for fathers and 45% for mothers. The fathers had a mean age of 41.9 ± 6.3 years (range 31 to 54), a mean BMI of 32.4 ± 5.1 kg/m2, and most (n = 24, 96%) lived in areas of low to middle socio-economic status. The mothers had a mean age of 38.1 ± 6.6 years (range 29 to 48; four not reported). Of the 41 children, 21 (51%) were male and the mean age was 8.2 ± 2.1 years. Overall, 56% of the children had a BMI z-score which was classified as either overweight (+1 SD) or obesity (+2 SD), respectively.
Three key themes were constructed during the thematic analysis relating to a range of perceived personal and family impacts from program involvement (Table
1). These themes included a positive impact on: (i) the father-child relationship, (ii) new family habits (e.g., lifestyle changes within the family unit) and (iii) fathers’ involvement and parenting practices (e.g., increase in fathers’ household responsibilities). In addition, each key theme encompassed several subthemes as outlined below.
Table 1
Fathers, mothers/partners’ and children’s perceived impacts of involvement in the HDHK program
Fathers | ✓ | ✓ | ✗ |
Children | ✓ | ✓ | ✓ |
Mothers/partners | ✓ | ✓ | ✓ |
Father-Child Relationships
Most fathers, mothers and children made direct reference to father-child relationship as one of the most salient outcomes of the program. For fathers, it was often the main motivation for joining the program. The ‘bonding benefit’ was mentioned mostly by fathers who felt they had largely missed quality one-on-one interaction with their children due to work commitments, or because they had several other children at home.
“It’s just the bonding, the one-on-one bonding with the kids is something I’d probably missed out on a fair bit. So that was really good for us and we’ve carried that on right through and I don’t think that’s something that will stop anytime soon.” Dad
“I feel a lot closer to the younger kids because I probably used to come home from work and sit down and it was dad’s relax time, you know, that couple of hours after you come home from work. Where now I come home and the first thing I’ll do is go to bat with them or have a wrestle or throw the ball or whatever. So for me, I’m a lot - I feel I’m a lot closer in the last maybe four to six weeks to my youngest three kids.” Dad
Similarly, many children perceived the program as a chance to spend some much needed quality one-on-one time with their dads, by engaging in fun and game-filled activities which were felt to benefit them both. “
Getting to know each other better” was a phrase commonly used. The majority of children perceived their dad as equally having gained enjoyment from spending more time with them during the program;
“I think he enjoyed spending time with me” and
“You get to have fun with your dad and you never want to stop.” In addition, half of the children felt that their fathers were now spending more time with them:
“Now he doesn’t like to be on the computer and looks for news every single time he comes from work, but now he’s like playing with us most of the time.” Child
“At home after he gets home from work he just goes straight - he gets me and my sisters and he says, come on Harry, let’s go jump on the trampoline and pass the ball. But when he didn’t come to Healthy Dads Healthy Kids, he didn’t do that.” Child
Most mothers reported a noticeable increase in the time fathers were spending with their kids, as well as an improvement in their relationship. Most perceived this to be one of the most important outcomes of the HDHK program, because of the usual scarcity of such dad-kid bonding opportunities, with this being particularly the case for father-daughter relationships, where the program had been felt to provide a common ground for interaction and bonding.
“I find him with the kids instead of sitting down watching TV or playing a game or something like that.” Mum
“I think the kids have really, really enjoyed doing this with their dad. I think it’s been really good for them and to go out and leave me because that just doesn’t happen ever. I’m taking one of them or all of or it just never happens that he leaves the house with all three kids and I’m in the house on my own. It’s such a rare thing so I think that’s been really good for their relationships.” Mum
New Family Habits
Most fathers commented on the positive way in which their children involved in the program had embraced the concepts, from food changes to physical activities, and carried those through to the home environment. Specifically, the children continually motivated their dads to participate, bringing about lifestyle changes within the family unit above what would take place with only the parent attending.
“Well for me, it started off just as a more one-on-one time with [child] because of - with four - I’m backwards and forwards from work. Basically, he knew that every Wednesday night he had me for this period of time for himself. Then that’s actually rolled on to all the kids because they’re interactive as far as ‘let’s do the courses’ or ‘let’s do the obstacle challenges’ or whatever else is now rolled in through the other three as well.” Dad
For many, the games learnt through the program were becoming part of family routine (e.g., “sock wrestle” or “backyard obstacle course”). Many fathers talked about how their child would now often invite them to join in physical activities and physical play. This was corroborated by the children;
“We set a little circuit up at home and they always come and say, time to do the circuit dad.” Dad
“My daughter quite regularly now wants to have sock wrestles and stuff when we go home” Dad
“I find the kids come to me a lot more to play and do things now. Like they would just play together, now they actually say dad, let’s go out, we’re kicking a ball or dad, we’re going to go jump on the trampoline and yeah, so it gets me up and motivated too” Dad
“Ever since we’ve come here, we’ve made sure we’ve taken care of dad and made him a healthier lunch and played more games with him than we used to.” Child
Furthermore, most fathers talked of simple but fundamental changes to family choices, such as eating dinner without the TV on, going for regular walks or other physical activity as a whole family. Many of the fathers and mothers talked of the family having increased focus on, and motivation to, engage in healthy behaviors; as well as benefits in terms of a newly established patterns and awareness of healthy and unhealthy food and nutrition.
“It’s made a big difference to our family’s nutrition. I think we spend a lot more time wandering in [the supermarket] at the fruit and veg section, getting the nice things. They think, oh what can we get to go with this salad instead of going to the meat section or the bakery section and said, ah we’ll just grab this to go with that. I think the main focus now is the salad and the vegetables which is from this program.” Dad
“I like the fact that my husband hasn’t eaten a family block of chocolate most nights of the week. But I hate the fact that I can’t do it either. So we’re more aware of what we have in the household at the moment, as far as food goes. So therefore if you do feel like that naughty snack, there’s not an option to have it. It’s got to be a healthy one at the moment. It’s been really good.” Mum
Many fathers talked about the strategies and knowledge they had gained to enable improved planning of their diet such as making healthier lunch choices, opting for healthier take-away options, reading food labels as well as a more astute understanding of, and attention to, the intake-output balance (e.g., daily kilojoule [kJ] requirements to maintain a healthy weight). For example;
“…at the end of the day I sort of had this little picture in my head of hey I’m 9500 kJ [2270 calories] today and I’ve actually had 6500 kJ [1553 calories], you know those sorts of things.” Dad
Other new strategies commonly adopted were reducing portion size, “surfing the urge” (tuning into hunger cues and avoiding unnecessary snacking), choosing healthier snacks, and limiting screen time for themselves and their children. Furthermore, most fathers and mothers talked of engaging in opportunistic physical activity, which was perceived to be largely initiated by the fathers (e.g., getting up earlier to go for a walk or playing with kids after work).
“My wife and I and our young fellow will go for a walk and for that hour that we’re walking, like, we’re talking and doing stuff and that’s not focussing on a screen and we’re finding that like every Sunday morning now it’s a regular thing, we just go for a big long walk somewhere and couple of afternoons we take the dogs for a walk and it’s just stuff that we didn’t do before as a little unit. It’s really good.” Dad
“It’s been the physical activities. My husband will reluctantly come for a walk with us before whereas now it’s ‘let’s go for a walk’.” Mum
The notable changes in the fathers were clearly observed by the children. The majority of children perceived their fathers as generally more active (e.g.,
“he’s been doing lots of exercise” and “he’s a lot fitter”), replacing screen time with physical activity time (“
my dad has stopped being so focused on TV and the computer and the iPad and he’s come out and he’s played with us”) and eating more healthy food (
“he eats healthy and it’s good“), while others made direct reference to their father having lost weight:
“Before dad came to Healthy Dads, Healthy Kids you could see a bit of a belly under his shirt but since he’s come back he is much changed and he is much healthier and can run better.” Child
“He’s lost some weight and he has muscles”. Child
“His body shape’s changed and he’s lost weight and he also gets to know some activities that he can do to exercise now.” Child
While some mothers reported their partners’ new enthusiasm relating to diet and exercise to be somewhat overwhelming, the majority reported the new
‘dad as a health instructor’ as a very positive change for the family.
“Definitely my husband tends to be a bit more aware of what’s going on around him now that he’s taking more interest in the program and what the program is teaching him. He’s trying to teach that to all of us as well, so he’s become the instructor himself. Yeah, we try and humour him as much as we can and go along with it.” Mum
While many mothers reported having attempted to initiate changes to family diet and routines in the past, they felt that the information and initiatives provided through the HDHK program had been more readily accepted and taken on board by their partners and children, due to it coming from an “outside authority”.
“I think sometimes if all the information comes from me, it’s not always accepted or that I’m the ‘know it all’. So, if it comes from somebody else, in research and comes through them, then he’s a bit more accepting of it. So yes, I did like that he took on that responsibility and it wasn’t mine.” Mum
For some fathers, the program had increased quality time spent together which had effects extending to the entire family unit and facilitated family bonding… “it definitely brought the family closer”.
Fathers’ Involvement and Parenting Practices
Most mums talked of their partners having taken on more chores and other household responsibilities since their involvement in the program. In particular, the fathers had been instrumental in implementing new household rules relating to screen time and improved family awareness relating to nutrition and healthy eating. For many, these new attitudes had positively changed the dynamics of the household. Most mothers voiced their appreciation of their partners’ new involvement and interest in family health and diet. This had been particularly evident around meal planning, food shopping, packing kids’ and fathers’ lunches etc where responsibilities in the past, had fallen on the mothers. The fathers’‘ newfound skills such as assessing the nutritional value of foods selected was felt as a welcome change. Some mums also perceived the program as having facilitated an overall increase in their partners’ involvement in parenting. A few perceived the main outcome of the program being the fathers’ renewed enthusiasm to make a difference.
“So much of the food and healthy eating responsibility is the mother’s responsibility and the dads aren’t always willing partners coming along with it. It’s nice to have the dads reading labels and realising what they’re putting in their mouths. So I love that aspect of it.” Mum
The fathers’ increased involvement and positive influence on parenting were also mentioned by some children, particularly around their fathers’ becoming more helpful around the home (“he’s been helping around the house more”) and generally being in a better mood (“he has changed because he has got nicer”).
Most mums indicated that the program had given their partners a better understanding of the issues faced by mothers, ensuring that they both now were standing united and
“being on the same page” when it came to family choices.
“As a mother, a lot of the things that he was coming home and saying and sharing with me, sort of had an idea anyway. Because you always put your children’s nutrition first and what not. But with having him on board, it was reinforcing those behaviours that need to be there, as far as eating and things like that go. As far as computer time, television time, and just exercise in general. So it was good to have him on board, him informed and on the same page.” Mum
“The kids now know if you ask mum or dad, the answer is going to be the same…” Mum
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