Sample description
Of the 28 parents who received the inquiry letter, five declined to participate and six parents did not reply. Thus, 17 parents (12 mothers and five fathers) of 17 children were interviewed. Data saturation was reached, and the sample size also met established criteria for saturation in thematic analysis studies [31]. The interviews lasted an average of 34 min (18 – 48 min). Twelve parents had a university degree and three had a foreign origin, the mean age was 40.0 years (min–max 31.5 – 48.1 years). The children’s mean age was 4.8 years (min–max 3.0 to 6.9 years), and the majority were girls (12 girls and 5 boys). All children were classified as either having overweight (seven children) or obesity (10 children), and weight status (mean body mass index standard deviation score, BMI SDS) 2.4 (SD 0.6, min–max 1.5 to 3.9) was calculated using international age and sex specific reference data [32]. Mean BMI SDS for girls was 2.4 (SD 0.7, min–max 1.6 to 3.9) and for boys 2.5 (SD 0.6, min–max 1.5 to 3.1).
The thematic analysis resulted in two main themes: ‘Receiving the overweight/obesity diagnosis’ and ‘Parenting a child with a formal diagnosis of overweight/obesity’. Theme 1 had two subthemes and Theme 2 had three subthemes, see Fig. 1.
Theme 1. Receiving the overweight/obesity diagnosis
When parents were first informed by a CHC nurse about their child’s weight, they experienced this as upsetting. However, depending on how the conversation proceeded, it either fostered an alliance between the parent and the nurse, encouraging parents to reflect and develop insights about the child’s and the family’s needs (subtheme Conversations that empower), or felt limited, uncomfortable, or belittling, triggering frustration and even anger (subtheme Conversations that provoke resistance).
Conversations that empower
Most parents felt it was appropriate and important for CHC nurses to initiate conversations about their child’s weight, even if it was difficult to hear and difficult to handle. Several said it was an advantage that the child’s weight was acknowledged early. Parents who did not receive information about their child’s weight when their child was younger said they wished the nurse had raised the issue earlier.
Of these parents, some described their conversations with CHC nurses as particularly positive. These parents said they felt listened to and that the conversation was a dialogue, with parents given the opportunity and time to ask questions. Compared to previous conversations with the CHC nurse about other health topics, many parents felt more involved in conversations about the child’s weight. Pre-existing rapport between parents and CHC nurses helped facilitate weight-related conversations. One mother said that previous serious conversations she had had with the CHC nurses created a trusting relationship, making it easier to talk about the child’s weight. Key to the conversation, this mother said, was the nurse’s non-judgmental attitude:
“It [the conversation] was not judgmental, it was not a lecture, it was not stressful, but I was still taken seriously, and we talked about it [the weight] properly, but there were no pointed comments. I never felt like "oh my goodness, she thinks I’m the world’s worst parent because I might have an overweight child", it was nothing like that.” (Mother, Interview a)
Parents identified the CHC nurses’ sensitive and validating language as an important part of conveying a non-judgmental attitude. For example, a parent said they felt reassured when, after expressing their worries and asking a question, the CHC nurse prefaced her reply with “these are common reactions and feelings, and it is common to feel that way” (Father, Interview c). Likewise, in cases where the child was present when the nurse initiated the weight-related conversation, the parents felt it was important that the nurse normalized the situation for the child, using neutral and non-alarming language:
“She gave our daughter something to play with and told her that “we adults are going to talk a little”, I thought she told us in a very smooth manner but also very … in the serious situation, listen[ed] and asked if we were surprised over it [the daughter’s weight] and if there was something regarding her weight that we had thought about.” (Mother, Interview d)
The same mother also described how the nurse spoke sensitively, in order to prevent the child from fully understanding what had been discussed:
“… she [the nurse] was aware not to talk about this in such a way that our daughter understood exactly what it was about, and she sort of suggested that we should take [the information home], to land [settle/take this information in], to talk a little at home and then have a meeting, a phone call together, … we could quickly agree on that.” (Mother, Interview d)
In some cases, the child took active part in the conversation, but the focus was then on healthy habits rather than weight. Parents said that when nurses kept the conversation at the child’s level and engaged with the child, this could be a positive experience:
“She [the child] can give feedback on what we have done and what we have talked about, it has been very good actually, and I’ve never experienced that she [the child] felt … bad about it, but it has been at her level, and it has been just right and not pushed too much either.” (Mother, Interview e)
Parents said that conversations where the nurse invited them to reflect on their child’s and family’s situation and needs were particularly constructive, with the nurse offering an empathetic ‘outsider’ voice. For example, one mother recollected:
“I also remember that one of the first [conversations], like, when she had stated that ‘I see that a lot has happened in the last year' and asked me ‘what are your reflections, … have you reflected on this [weight change] during this year?’, she kind of invited me to think and land [settle/take this information in].” (Mother, Interview d)
When being told about their child’s weight, some parents said the use of the child’s weight chart in the conversation helped to dedramatize but at the same time capture the seriousness of the conversation:
“… [it became] very visual with this graph and that (the nurse said) "then you see it [the child weight development] very clearly here, but we will follow up …". So, I think it got us to notice [the child’s increased weight status] in a very good professional way.” (Mother, Interview d)
Several parents said the conversation with the nurse led to further dialogue at home, cooperation with their partners and behavior changes. In families where parents disagreed about the child’s weight being a problem, the conversations with CHC nurses could lead to consensus-building between the parents: “… it started a very good dialogue between me and my husband about this and how we both act in different situations and what can trigger what …, so it started a very good conversation in the family” (Mother, Interview d).
Conversations that provoke resistance
Some parents felt their CHC nurse lacked enough knowledge to facilitate in-depth discussions about the child’s weight development. These parents said their nurse initiated weight conversations but provided inadequate information, could not answer their questions, and did not provide sufficient explanations. One mother said the CHC nurse said her daughter was “two above the curve” (Mother, Interview l) on the weight chart but provided no further explanation. The mother had to ask, “What does it mean? Is it dangerous? Should I do something?” and said that “[i]f I had not asked such questions, she might not have said more than that she is two lines above the curve” (Mother, Interview l). Other parents said the nurse provided information they already knew, feeling, consequently, that they were not being listened to and that the nurse did not understand the family’s needs and requests for support. As one father explained, “The only thing that conversation was really about was that he was not allowed to eat too much sugar and he had to be more active outdoors. Yeah, no shit! That was too basic. That, we have already managed to figure out” (Father, Interview i). Along similar lines, a mother said, “…there is a lot of focus on sweets … as soon as you talk about weight … [but] you feel that there are other things too” (Mother, Interview m).
Some parents described a lack of commitment on the part of the nurse and felt that addressing the child’s weight was a process that they themselves started and pushed. In these cases, the nurse had not seen the child’s weight as a problem in the same way the parents did, and the parents felt the nurse did not take their concerns seriously. For example, one father expressed a concern that , saying that “… if we raise the question when we are at the CHC then she [the nurse] says. ‘Yes but try to think about eating a lot of vegetables’ … you see, there has been no more [guidance] than that.” (Father, Interview b).
In contrast, other parents said they experienced the weight conversation repeatedly, which led them to feel accused and attacked every time they visited the CHC. One father said:
“If I can be blunt, it feels stupefying [the conversations at CHC]. You go in there and someone points with their finger “no, no” [the way you would say to a child], … that’s what it feels like … that you are a fool and a complete idiot that has let your child become fat …” (Father, Interview i)
Another parent described the weight conversation as making her feel both helplessness and defensive:
“And then there was a nurse there … who simply said, ‘he is super overweight and obese, and this is diabetes and there is no hope’, like. … So, of course that’s not nice to hear and you get offended and then you become defensive because it’s your child and such, but above all, there were no broader hints [discussions] about how big he really was. Or why he’s so big. It was just blindly looking at this number, like.” (Mother, Interview e)
Across the interviews, parents preferred for weight-related conversations to take place when the child was not present, and some explained they wanted to protect their children from these conversations as they were still so young. When children were present during these conversations, parents felt it prevented them from “talking freely” (Mother, Interview j). In some cases, parents felt the conversation made their child realize that their weight and appearance were being discussed. The father quoted above also reported that a weight-related conversation triggered body image concerns in his young son:
“When he was drawing [during a visit to the CHC] … He was there busy drawing and then [he asked] ‘Dad, should I not do this? Did I do something wrong?’, Like something like that. And then when we got home; ‘But Dad, what is it with my stomach?’ ... So that, yes, really completely wrong!” (Father, Interview i)
Several parents left the CHC visits feeling failure and regret, burdened by the sense they had made mistakes and feeling powerless to change the situation. One father described asking himself: “Should you have done something else when [the child] was two? But yes, I do not know, it is easy to be wise in hindsight … You can feel this as a small failure … in some way, in terms of… what eating habits you give to the child.” (Father, Interview j).
Notably, feeling a lingering sense of failure was a problem unique to weight-related conversations, as the same parents said they had different experiences in visits where other topics were discussed. One parent described the difference involved:
“… regarding the more general topics such as vaccines and how the breastfeeding works … then I have felt more involved … but this might be because there I haven’t had any problems if I compare to this weight discussion, where I feel it is a little rock that gnaws somewhere.” (Mother, Interview h)
Theme 2. Parenting a child with a formal diagnosis of overweight/obesity
After their children were diagnosed with overweight or obesity at the CHC, parents experienced numerous challenges. These included managing their own feelings and concerns (subtheme Fear of transferring weight anxiety), dealing with others’ reactions (subtheme Involve family and manage surroundings) and asking for and receiving support from health care professionals (subtheme Obtain support from health care professionals).
Fear of transferring weight anxiety
Most parents described being shocked when CHC nurses used words like overweight or obesity to describe their child’s weight status. These words triggered parents’ anxiety both about their child’s weight and about their own parenting and followed parents in the conversation’s aftermath. The CHC conversation was often followed by a larger focus on the child’s weight in different situations – in other healthcare settings, at home, with grandparents and at pre/school. For parents, this emergence of ‘weight talk’ was accompanied by fears of triggering or transferring weight anxiety to their young children. One parent said that “if you talk weight then I do not think, never, that the children should hear it … it is so emotionally charged for the adults and then it becomes emotionally charged for the children and it automatically becomes something negative.” (Mother, Interview l).
Parents were particularly worried that conversations about overweight would lead children to develop an unhealthy relationship with food and negative body image, especially as some children were already aware that they were bigger than their friends. One mother explained:
“This thought has really hit me, if we talk, in front of the daughter, about a high weight and being chubby, how does that stay in her head when she is 10?” (Mother, Interview h)
In addition, parents worried that talking about food might cause the child to feel guilty in eating situations. This made it challenging for parents to talk about lifestyle changes, though they felt it was still important to encourage healthy eating:
“You always have a fear of this … that it [conversations about weight] will cause an unhealthy … view of the whole thing … when you are four years old, you register so much. … At the same time, it is always good to have this little talk … about what is healthy … that you [the child] hear it from someone else too.” (Mother, Interview f)
Some parents had a complicated relationship with food themselves. As children, they were subject to talk about weight and weight loss in their family of origin, which they had experienced as negative. One mother said she worried her daughter might inherit her eating disorder if exposed to weight talk:
“I do not want her to walk the same path [as I] … I remember when people talked about me as chubby ... when I was little, it was the only thing that etched itself in my head … then you have that extra challenge that you yourself remember what it was like. Yes. And that’s why I’m so damn scared she’s going to hear anything negative that it stays with her for the rest of her life.” (Mother, Interview q)
In parenting a child with a higher weight, several parents stressed how important it was to talk about being healthy, teach their children how to make healthy choices and avoid talking about weight: “… We do not talk about her weight with her … but we work on not eating sweets for the sake of her teeth and so on. That you exercise to become strong. We do not talk about how to look and so on, not yet” (Mother, Interview c).
Some parents raised the issue of the stigma attached to obesity. They worried that addressing their child’s overweight in a way that the child could perceive as negative, would make the child overly critical towards their own body and lead to an eating disorder.
“… You don’t want him to get eating disorders either. So, it’s all about, like, how do you handle that? After all, it’s a young child, how can you get something to last ... how can you help him with this without it going the other way, so to speak.” (Father, Interview j)
Some parents said they spoke with preschool staff about the child’s weight. However, the staff did not always see the child’s weight or eating as a problem. Sometimes it was difficult for the preschool staff to limit tactfully the child’s food intake, and some parents felt their child was treated as different from other children. These parents worried about how being treated differently affected their children and expressed concern that the children would be teased, as some children had already been exposed to negative comments from friends.
“So, she may not even have thought about it [being treated differently], but … it’s probably just a matter of time. There was someone in the kindergarten who had said that she had a big belly or something like that ... so I’m thinking there will be more of that.” (Mother, Interview l)
Involve family and manage surroundings
After the CHC conversation, parents began sharing their child’s diagnosis of overweight or obesity with family and friends. Almost all parents said their child’s grandparents wondered aloud if their grandchild was truly overweight. Many parents felt these comments were insensitive. For some, this was an added conflict in an already strained relationship with the child’s grandparents and they preferred to restrict their involvement, while others chose to keep grandparents at arm’s length as they worried about their parenting being criticized. However, notwithstanding initial disagreements about the child’s weight, many parents said they were supported by their parents and relatives. For example, one mother said: “… they [the family] took it very strongly, was my experience … and said like ‘yes, but of course we will support you by thinking about this too’.” (Mother, Interview d).
Several parents mentioned they disagreed with their child’s other parent regarding the child’s weight, and some parents felt they had been left alone with the responsibility. Some even felt discouraged by the other parent in trying to enact lifestyle changes. In some families, one parent expressed doubts about whether the child was truly overweight, suggesting it was only a CHC perception. This imbalance in the family, where one parent was more engaged than the other, was a cause of arguments and disagreements in the family.
“… it has felt a little hard that you have to work, like, yourself and be that tough one who always has to slow down [the eating], say no and stop a little when there is “fika” [coffee break that often involves a snack such as cake, a biscuit or a sandwich] and so on.” (Mother, Interview c)
The parents’ own childhood experiences of overweight and obesity sometimes led to different perceptions in the family of how serious the child’s weight problem was; in some cases, while one parent with a personal history of childhood overweight felt the problem was serious, the other dismissed it. Parents also described how the child’s diagnosis led them to look at their everyday lives differently, and how it affected the family’s life. One mother said: “… now you feel like you are double checking, have we really, like, been outdoors and been properly physically active? It becomes like a family matter …” (Mother, Interview f).
To obtain support from others outside the family, parents had to initiate weight conversations. However, some parents felt ambivalence and guilty when speaking to friends and relatives about their children’s overweight:
“…when I brought it [the child having obesity] up with my friends, then it really felt awful to say that about a young child … I do not know, I am very ambivalent, because I think that on the one hand; let children be … I never want anyone to say anything about my child's body in front of her and, on the other hand, I feel … it is very important to be aware and keep track of the situation and all that.” (Mother, Interview l)
In other cases, parents tried to avoid these conversations as they felt embarrassed and worried that people may judge their parenting. This was part of a wider social silence around childhood obesity, as one father described: “I think people dare not say anything there either. … it is sensitive, when it comes to someone’s children … the question that is raised is always … ‘Are you a bad parent or not?’.” (Father, Interview i).
Obtain support from health care professionals
Following the CHC conversation, parents felt they needed to know not only ‘what’ they could do for their children, but also ‘how’ to do it. What is considered healthy food and what is an appropriate portion size for a toddler? How and where do you set the limit? For this, parents said they needed ongoing support and advice from health care professionals: “… we requested, like, support for us parents. How do we think about food, how do we think about exercise?… like a sounding board and information support for us parents.” (Mother, Interview d).
Parents also said they wanted to connect with other parents of children with overweight or obesity. One mother explained that: “… I think you kind of get more inspired and more motivated by talking with someone who perhaps has older children who … how they have done and what they did and what they thought was good and bad and stuff like that …” (Mother, Interview k).
The parents described it as much more difficult than they thought it would be to handle the child’s weight. After being informed about their child’s weight status, a particular challenge parents faced was managing their child’s eating behavior, for example, coping with a child who often asks for and talks about food.
“Because (the child) does not really have a problem with eating unhealthy foods, she only eats too much, of regular food ... So, it's not … that I give her too … or inappropriate food ... The thing is that it’s too much, she's hungry all the .... she does not feel full, I think.” (Mother, Interview q)
Although parents were aware of these behaviors before the CHC conversation, the conversation conveyed the seriousness of the child’s weight status, prompting parents to feel they needed to manage their child’s weight better. Parents described constantly thinking about steering the child away from food situations and finding ways to reward and do activities with the child without food being involved. However, parents described everyday weight management as challenging, with very limited support from health care professionals.
Without adequate professional support, parents said their child’s rapid weight gain was especially difficult to handle.
“At the four-year visit then, it was just ‘oh my god what are we going to do now so that he does not get childhood diabetes’. Yes, it was just terrified panic with me and his mom, like. Yes, and then it was the next talk with the dietitian, then we almost just got angry about how meaningless it was.” (Father, Interview i)
Some parents were frustrated by not achieving the desired result after all the changes they had implemented in the child’s lifestyle. They wanted more support and access to useful tools to move forward. Several reflected on how it can be so difficult to do right, even when you know what is healthy and what is not.
“We know what is healthy and unhealthy, we do not think McDonald’s is good for our children, but the problem is that (pause) why do we not live according to that? If we know that we have children with problems, if we know this is bad for the kids, why don't we do it right then?” (Mother, Interview l)
Following the CHC conversation, some parents turned to additional professionals for support. For example, one parent contacted a family therapist with good knowledge of weight problems. However, several parents said they had been to see a dietician but left the visit feeling disappointed and frustrated as they had expected more help. The information they had received, often regarding what is healthy food, was already known to them. The parents instead requested support in how to handle a hungry child. One mother described:
“I do not know what support to ask for either, we have talked [with the CHC nurse] have talked about a referral to a dietitian too, but I feel it is a bit tricky, because then it is like that you… I can feel that you are being taken for a fool, that you do not know how to eat properly ...” (Mother, Interview m)
Despite these disappointments, parents were motivated to enact change, and several said they took every opportunity to receive support. One mother emphasized it was a parent’s responsibility to accept the help offered: “oh my goodness I have an overweight child, it is very dangerous, and she will have lots of problems in life—I do everything I can for that not to happen and it is my responsibility”. (Mother, Interview l). Along similar lines, another mother said: “We must listen to the help we can get” (Mother, Interview f).