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University of Newcastle Research Online

nova.newcastle.edu.au

Morgan Philip J., Lubans David R., Callister Robin, Okely Anthony D., Burrows Tracy L., Fletcher
Richard, Collins Clare E., 'The ‘Healthy Dads, Healthy Kids’ randomized controlled trial: Efficacy of a
healthy lifestyle program for overweight fathers and their children'
Originally published in International Journal of Obesity Vol. 35, Issue 3, p. 436-447 (2011)
Available from: http://dx.doi.org/10.1038/ijo.2010.151

Accessed from: http://hdl.handle.net/1959.13/936959

 RUNNING HEAD: Weight loss program for fathers

The ‘Healthy Dads, Healthy Kids’ randomized controlled trial: Efficacy of a healthy

lifestyle program for overweight fathers and their children

Philip J. Morgan1 PhD, David R. Lubans1 PhD, Robin Callister2 PhD, Anthony D. Okely3 PhD,

Tracy L. Burrows4 PhD, Richard Fletcher5 PhD, Clare E. Collins4 PhD

1
School of Education, Faculty of Education & Arts, University of Newcastle;
2
10 School of Biomedical Sciences and Pharmacy, Faculty of Health, University of Newcastle;
3
Faculty of Education, University of Wollongong;
4
School of Health Sciences, Faculty of Health, University of Newcastle;
5
School of Medicine and Public Health, University of Newcastle.

15 Corresponding Author:
Associate Professor Philip Morgan
School of Education
Faculty of Education and Arts
University of Newcastle
20 Callaghan NSW Australia 2308
+ 61 2 4921 7265 (PH)
+ 61 2 4921 7407 (Fax)
Philip.Morgan@newcastle.edu.au
I am happy for my email address to be published.

25 There are no conflicts of interest, financial or otherwise, for any of the authors.
* The manuscript includes 6 tables.
* The manuscript includes 2 figures.
* Word Count = 5045
This study was funded by the Hunter Medical Research Institute
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 Weight loss program for fathers

ABSTRACT

Objective: To evaluate the feasibility and efficacy of the ‘Healthy Dads, Healthy Kids’

(HDHK) program which was designed to help overweight fathers lose weight and role model

positive health behaviors to their children.

5 Design: Randomized controlled trial

Participants: Fifty-three overweight/obese men (mean [sd] age = 40.6 [7.1] years; BMI = 33.2

[3.9]) and their primary school-aged children (n =71, 54% boys; mean [sd] age = 8.2 [2.0]

years) were randomly assigned (family unit) to either (i) HDHK program (n = 26 fathers, n =

39 children) or (ii) a wait-list control group (n = 27 fathers, n = 32 children).

10 Intervention: Fathers in the 3-month program attended eight face-to-face education sessions.

Children attended three of these sessions.

Outcomes: Primary outcome was fathers’ weight. Fathers and their children were assessed at

baseline, 3- and 6-month follow-up for weight, waist circumference, BMI, blood pressure,

resting heart rate, objectively measured physical activity and self-reported dietary intake.

15 Results: Intention-to-treat analysis revealed significant between group differences at 6 months

for weight loss (P <.001), with HDHK fathers losing more weight (-7.6kg; 95% CI -9.2, -6.0; d

= .54) than control group fathers (0.0kg; 95% CI -1.4, 1.6). Significant treatment effects (P <

.05) were also found for waist circumference (d = .62), BMI (d = .53), blood pressure (d = .92),

resting heart rate (d = .60) and physical activity (d = .92) but not for dietary intake. In children,

20 significant treatment effects (P < .05) were found for physical activity (d = .74), resting heart

rate (d = .51) and dietary intake (d = .84).

Conclusion: The HDHK program resulted in significant weight loss and improved health-

related outcomes in fathers and improved eating and physical activity among children.

Targeting fathers is a novel and efficacious approach to improving health behaviours in their

25 children.

2
 Weight loss program for fathers

Keywords: weight loss, men, obesity, children, fathers, intervention

Trial Registration: Australian New Zealand Clinical Trials Registry No:

ACTRN12609000855224

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 Weight loss program for fathers

INTRODUCTION

It is well established that obesity is associated with a range of adverse physiological and

psychological health consequences (1). In Australia, two thirds of men are overweight or

obese, and these statistics are similar in many developed countries (2). Yet men are less likely

5 to attempt weight loss than women (3) and are notoriously difficult to recruit to weight loss

programs (4). In addition to the health consequences of being obese as an adult male, those

who are fathers also place their child at increased risk for obesity. Whitaker et al. (5) found that

obese children with an obese father were nearly three times more likely to remain obese as an

adult compared with those children whose father was not obese. Obesity in fathers has also

10 been found to be associated with a four-fold increase in the risk of obesity for both sons and

daughters at 18 years of age, which further increases children’s risk of various lifestyle

diseases in adulthood (6).

It is well established that parents have a critical influence on the development of positive health

15 behaviors in children (7). Parents influence the food and physical activity home environment

through their own behaviors, attitudes, modeling, parenting styles and child feeding practices

(8, 9). Studies have shown that parental eating and feeding behaviors influence the eating

habits of their children (10, 11) and physically active parents more are likely to have physically

active children (12). While there is some consensus in the literature that lifestyle interventions

20 for children should involve parents as key agents of change, systematic reviews highlight the

uncertainty around optimal strategies to target and involve parents (13, 14). Therefore, a

research priority is to evaluate the feasibility and efficacy of well-designed studies that target

parental physical activity and dietary behaviors to influence both the parent and the child.

25

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 Weight loss program for fathers

However, family-based interventions have mostly engaged mothers (13). Fathers have not been

exclusively targeted and their influence on children’s physical activity and eating behaviour is

commonly overlooked. A number of studies have demonstrated the relationship between

mothers’ health and behaviors and their children’s well-being but the specific influence of

5 fathers on their children has only recently been examined (15). Wake et al. (16) demonstrated

that it was the parenting styles and behaviors of fathers, and not mothers, that predicted

preschool children’s overweight status. Similarly, Stein et al. found that fathers’ parenting

style predicted better maintenance of weight loss in obese children (17). Although a body of

evidence is accumulating relating to the role of the father in a child’s development, there is a

10 paucity of experimental research on the impact of fathers on children’s physical activity and

dietary habits (15).

The primary aim of this RCT was to evaluate the feasibility and efficacy of a program that

targeted overweight/obese fathers to lose weight, and in turn act as role models to promote

15 positive physical activity and eating behaviors for their children. We hypothesized that health

outcomes and behaviors of both fathers and children would improve in the intervention group

when compared to a wait-list control group at 6-month follow-up. The design, conduct and

reporting of this study adhered to the Consolidated Standards of Reporting Trials (CONSORT)

guidelines (18).

20 METHODS

Participants

Overweight or obese (BMI between 25 and 40kg/m2 ) men with a child aged between 5 and 12

years of age (i.e. primary school age) were recruited from the local community via media

releases, school newsletters and paid advertisements in local newspapers in August/September

25 2008. Men were screened for eligibility via telephone. Ineligibility criteria included a history of

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 Weight loss program for fathers

major medical problems such as heart disease in the last five years, diabetes, orthopaedic or

joint problems that would be a barrier to physical activity, recent weight loss of ≥4.5kg, or

taking medications that might affect body weight. Fathers with a child with extreme obesity

(BMI z-score > 4) were also excluded. All fathers needed to have Internet access and were

5 asked to not participate in other weight loss programs during the study. Fathers completed a

pre-exercise risk assessment screening questionnaire (19) and provided written informed

consent, as well as child assent. Ethics approval was obtained from the University of

Newcastle Human Research Ethics Committee.

Study design

10 Participants were randomly allocated to one of two groups: the ‘Healthy Dads, Healthy Kids’

(HDHK) program or a wait-list control group. Based on 80% power to detect a significant

weight loss difference between groups of 3kg, assuming SD = 5 (P = 0.05, two-sided) a sample

size of 18 fathers for each group was needed at 6 months. Assuming a 20% attrition rate, a total

sample of 44 subjects was required. The random allocation sequence was generated by a

15 computer-based random number-producing algorithm in block lengths of six to ensure an equal

chance of allocation to each group. To ensure concealment, the sequence was generated by a

statistician and given to the project manager. Randomization was completed by a researcher

who was not involved in the assessment of participants and the allocation sequence was

concealed when enrolling participants.

20

Outcome measures were obtained from all participants at baseline (October, 2008) and at 3-

months (February, 2009) and 6-months (May, 2009) from baseline. Measurements were taken

in the Human Performance Laboratory at the University of Newcastle (Australia) using the

same instruments at each time point. Participants were blind to group allocation at baseline

25 assessment. Once baseline assessments were completed, participants received a sealed

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 Weight loss program for fathers

envelope with a note advising their group allocation. Assessors were instructed to not ask

questions that might reveal the participants’ group allocation at follow-up assessments.

Although it was our intention to blind assessors at follow up, it was not possible to keep

assessors completely blinded as there were a few cases of treatment group families (and in

5 particular, children) mentioning aspects of their program involvement or wearing their program

t-shirts to follow-up assessment sessions. The wait-list control group received no information

or intervention before attending the 3- and 6-month follow- up assessment sessions.

The HDHK program

The 3-month HDHK program involved fathers attending eight face-to-face group sessions (75

10 minutes each) starting in October 2008. Five group sessions were for fathers only, and were

delivered by one of the male researchers (PJM) at the University of Newcastle. Three of the

group sessions were practical and involved both fathers and children participating together.

These were conducted at the University recreation centre and delivered by two of the male

researchers (PJM and DRL), both qualified teachers with expertise in physical education.

15 The total program contact time was 600 minutes. The program aims were to help fathers

achieve their weight loss goals, become healthy role models, and promote healthy behaviors

for their children. Table 1 details the specific HDHK program content, intervention strategies

and alignment with theoretical constructs using the taxonomy of behavior change strategies

identified by Abraham and Michie (20).

20

The HDHK program was based on Bandura’s Social Cognitive Theory (SCT) (21) and Family

Systems Theory (FST) (22) . Key SCT variables were targeted and operationalized including

self-efficacy, outcome expectations, self-monitoring, goal setting, perceived facilitators and

barriers to changes, role modeling and social support. FST postulates a complex theoretical

25 framework of reciprocal relationships among family members. That is, when a parent changes

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 Weight loss program for fathers

his or her physical activity and dietary behaviours this will be reflected in the child’s behavior

(23). HDHK aimed to provide fathers with the education and skills important for long-term

behavior change. The fathers were provided with evidence-based information about reducing

health risks and behavior change and encouraged to model more appropriate health behaviors

5 as key decision makers in family units. HDHK taught fathers about the importance of spending

quality time with their children and used healthy eating and physical activity as the medium to

engage fathers with their children.

The physical activity sessions for fathers emphasized modeling, reinforcing and providing

10 opportunities and removing barriers for physical activity. The four major focus areas of the

father/child physical activity sessions were (i) fundamental movement skills, (ii) rough and

tumble play (iii) health-related fitness, and (iv) fun and active games.

The nutrition components of the sessions were developed by Accredited Practicing Dietitians

15 (CEC & TLB) and modeled on a previous successful intervention (24). Sessions on healthy

eating for families focused on various aspects of parental influence on children’s dietary intake

incorporating Satter’s (25) ‘trust’ paradigm, which suggests parents should supply healthy

foods and a supportive eating environment and children can decide when and how much to eat.

Sessions focused on promoting a ‘do as I do’ and not a ‘do as I say’ philosophy and making

20 small changes, building on initial success and setting up a home environment where

sustainable healthy family eating patterns could be established. The dietary component focused

on a covert parenting style to facilitate better dietary choices in children’s intake (26).

Although mothers did not attend sessions, fathers were encouraged to enhance social support

25 for their child’s efforts and consider strategies to involve mothers. The face-to-face sessions

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 Weight loss program for fathers

were supplemented by resources including a physical activity handbook, a weight loss

handbook for men, a program folder with session outlines and an online component. Fathers

were instructed to access a publicly accessible and free website Calorie KingTM

(www.calorieking.com.au) and to self-monitor their weight, exercise and dietary intake during

5 the program, a strategy successfully used in a previous study with overweight/obese men (27).

Men also weighed in at the beginning of each session and recorded their body weight on a

chart at the front of their program folders.

Outcome measures

Baseline assessments were taken 1-2 weeks before the program started. Assessors were trained

10 by the same experienced researcher and for anthropometric measurements used the protocols

prescribed by the International Society for the Advancement of Kinanthropometry (28). The

primary outcome measure was change in body weight of the fathers (kg and percent change

from baseline) at 6-month follow-up. Weight was measured with fathers wearing light

clothing, without shoes on a digital scale to 0.1kg (model CH-150kp, A&D Mercury Pty Ltd,

15 Australia). A similar protocol was followed to record children’s weight.

Secondary outcomes for fathers and children

BMI: Height was measured to 0.1 cm using the stretch stature method and a stadiometer

(VR High Speed Counter) (Harpenden/Holtain, Mentone Education Centre, Morrabin,

20 Victoria). BMI was calculated using the standard equation (weight [kg]/height[m]2 ). Height

and weight were recorded twice and the average of the two measures reported. For children,

height and weight were used to calculate BMI (kg/m2 ) and age- and sex-adjusted standardized

scores (z-scores) based upon the UK reference data (29) and LMS methods (30). International

Obesity Task Force cut points were used to determine overweight or obesity (31).

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 Weight loss program for fathers

Waist circumference: Waist circumference was measured at two points (i) level with

the umbilicus and (ii) at the narrowest point. Each measurement was recorded with a non-

extensible steel tape (KDSF10-02, KDS Corporation, Osaka, Japan). Two measures were taken

and if the measures differed by more than one centimetre, a third was recorded. The average of

5 the measures was reported and a waist z-score calculated for children (32).

Blood Pressure and Resting Heart Rate (RHR): Systolic and diastolic blood pressures

were measured using a NISSEI/DS-105E digital electronic blood pressure monitor (Nihon

Seimitsu Sokki Co. Ltd., Gunma, Japan) under standardized procedures. Participants were

seated for at least five minutes before blood pressure and RHR was recorded. Blood pressure

10 and RHR were measured three times and the average of the three measures was reported.

Physical activity: Yamax SW700 pedometers (Yamax Corporation, Kumamoto City,

Japan) were used to objectively measure physical activity. Participants were asked to wear

pedometers for seven consecutive days and keep to their normal routine. At baseline

assessments, participants were instructed on how to attach the pedometers (at the waist on the

15 right hand side) and asked to remove the pedometers only when sleeping, when the pedometer

might get wet (e.g. swimming, showering) or during contact sports. At the end of the day

participants were instructed to record their steps and reset their pedometers to zero. Once seven

days of monitoring had been completed, participants were instructed to place the pedometer

and record sheet in the prepaid envelope provided and return to the research team. Participants

20 were included in all analyses if they had completed at least four weekdays of pedometer

monitoring and one weekend day. Physical activity variability for the seven day monitoring

period was explored using intraclass correlation coefficients (ICCs). The ICC (95% confidence

intervals) for mean steps/day for fathers was .83 (.74 to .89) for seven days and for children

was .79 (.70 to .86) for seven days.

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 Weight loss program for fathers

Dietary intake: For fathers, dietary intake was measured using the Dietary

Questionnaire for Epidemiological Studies (DQES) Version 2, Food Frequency Questionnaire

(FFQ) from the Cancer Council Victoria (33). It provides a detailed summary of food intake

(34) and was developed specifically for use in Australian adults by the Cancer Council of

5 Victoria and both the development of the questionnaire (35) and its validation have been

reported previously (36). Fathers total energy intake was calculated at each time point. For

children, their mothers completed the Australian Child and Adolescent Eating Survey

(ACAES), a 137-item semi-quantitative FFQ developed and validated for use with Australian

children, aged 10 to 16 years (37). ACAES has also been validated for younger children aged

10 5-9 years for parent-reported fruit and vegetable intake using plasma carotenoid concentrations

(38). Children’s dietary intake was adjusted relative to body weight and kJ/kg reported. At 3-

and 6-month assessments, participants and mothers were instructed to report on the previous 3-

month dietary intake.

Additional information

15 Socio-demographic information: Age and socioeconomic status (SES) data were

collected. SES was based on postal code of residence using the Index of Relative

Socioeconomic Advantage and Disadvantage from the Australian Bureau of Statistics census-

based Socio-Economic Indexes for Areas (SEIFA) (39).

Process evaluation

20 The feasibility of the program was evaluated using a number of metrics including recruitment

(achievement of target sample size), retention (retention rates at 6-month follow-up) and

attendance (at program sessions). Fathers also completed a 43-item process questionnaire to

determine level of satisfaction with the program. Questions were focused on the timing of the

program, self-monitoring, quality of instructors, quality of the program, impact of the program

25 on behaviours, impact of the program on the family, use of the website, social support, and

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 Weight loss program for fathers

levels of overall satisfaction. A 5-point Likert scale anchored from (1) strongly disagree to (5)

strongly agree was used. Adherence to self-monitoring was determined by total number of

daily diet entries, total number of daily exercise entries and total number of weekly weigh-ins

which were calculated from website usage data.

5 Analysis

Analyses were performed using PASW Statistics 17 (SPSS Inc. Chicago, IL). Data are

presented as mean (SD) for continuous variables and counts (percentages) for categorical

variables. All variables were examined to determine whether they satisfied normality criteria.

Characteristics of completers versus dropouts were tested using independent t tests for

10 continuous variables and chi-squared (χ2 ) tests for categorical variables. The significance level

was set at 0.05 for all analyses. Analyses were performed separately for fathers and children

and included all randomized participants. Linear mixed models were fitted with an

unstructured covariance structure for all primary and secondary outcomes. Differences of

means and 95% confidence intervals (CIs) were determined using the linear mixed models.

15

Mixed models were used to assess all outcomes for the impact of group (Intervention and

control), time (treated as categorical with levels baseline, 3-months and 6-months) and the

group-by-time interaction, these three terms forming the base model. This approach was

preferred to using baseline scores as covariates, as the baseline scores for subjects who dropped

20 out at 3-months and/or 6-months were retained consistent with an intention-to-treat (ITT)

analysis. Mixed models are more robust to the biases of missing data, and provide better

control of Type 1 and Type 2 errors than last observation carried forward (LOCF) ANOVA

(40). Similarly, imputation methods such as LOCF or baseline carried forward may bias results

towards the null in obesity trials where untreated overweight men are likely to increase their

25 weight. Age, SES and sex of the child were examined as covariates to see if they contributed

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 Weight loss program for fathers

significantly to the models. If a covariate was significant, two-way interactions with time and

treatment were also examined and all significant terms were added to the final model to adjust

the results for these effects. Effect sizes were determined using Cohen’s d (41) and calculated

using mean differences and the pooled standard deviation of the group (d = M1 - M2 / σpooled).

5 Effect sizes were interpreted as small (d = .20), medium (d = .50) or large (d = .80) (41).

RESULTS

Participant flow

Figure 1 illustrates the flow of participants through the trial. A total of 107 men responded to

the HDHK recruitment materials with most participants recruited in response to notices placed

10 in school newsletters. Seventy men were eligible for the study but 17 men were not

randomized as no consent was received. In total, 53 overweight or obese fathers and their

children (n = 71) attended baseline assessments and were randomized by family unit, resulting

in an overall recruitment rate of 50%. In terms of retention, measurements were obtained for

83% of the sample at 3- and 6-months (n = 44). There was no difference in retention between

15 the HDHK and control groups at 3- (χ2 = 1.1, df = 1, P = .30) or 6-months (χ2 = 3.1, df = 1, P =

.08). All randomized participants with baseline data (n = 53 fathers, n = 71 children) were

analysed for outcomes at 3- and 6-months. There were no significant differences (P >.05) in

baseline characteristics between those lost to follow-up and those retained at 6-months for

weight or any of the secondary outcomes for fathers or children.

20 Baseline data

Table 2 presents the baseline characteristics of the fathers. Fathers’ mean (SD) age was 40.6

years (7.1) and mean BMI was 33.2 (3.9). Mean weight and waist circumference were 105.9kg

(13.5) and 111.2cm (10.0), respectively with 77.4% of the sample considered obese (BMI>30).

Table 3 presents baseline characteristics of the children (53.5% boys). Mean (SD) age for the

25 children was 8.2 (2.0) years and mean BMI z-score was 0.7(1.2) with 19.7% and 9.9% of the

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 Weight loss program for fathers

sample overweight or obese, respectively. There were no baseline differences between men

randomized to the HDHK or control groups; however, it appeared that children in the control

group were more likely to be overweight/obese.

Change in primary outcome for fathers

5 Figure 2 shows the mean change in absolute body weight by treatment group. There was a

significant treatment effect for change in weight at 3- and 6-month follow-up (P < .001; d =

.54) (see Table 4 also). Weight loss as a percentage of baseline weight was also calculated at 3-

and 6-months and there was a significant difference in percentage weight loss between groups

(P < .001). Mean percentage weight loss in the HDHK group was 6.4% at 3 months and 7.4%

10 at 6 months. Mean percentage weight loss in the control group was 0.3% at 3 months and 0.2%

at 6 months. At 6 months, 85% of men in the HDHK group had lost more than 5% of their

baseline weight.

Change in secondary outcomes for fathers

Significant treatment effects were found from baseline to 3 and 6 months for waist

15 circumference (umbilicus) (P < .001); waist circumference (narrowest point) (P < .001); BMI

(P < .001); systolic (P = .01) and diastolic (P = .04) blood pressure; resting heart rate (P = .01);

and mean steps/day (P = .002). Medium-to-large effect sizes (range from d = .53 - .92) were

found for all secondary outcomes. While there was a significant time effect for kJ intake (P <

.001), no group-by-time effect was found (P >.05).

20 Change in outcomes for children

Results for outcome variables for children are displayed in Table 5. There were significant

group-by-time differences for mean steps/day (P < .001; d = .74), resting heart rate (P = .01; d

= .51) and kJ/kg (P = .01, d = .74) at 3- and 6-months. There were no significant between

group differences for blood pressure (P >.05). Anthropometric data are also provided in Table

25 5. No significant group differences were found for waist z-score or BMI z-score (both P > .05).

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 Weight loss program for fathers

Process evaluation

We were able to recruit our target sample size and retain 83% of participants at 6-month

follow-up. Participants attended 81% of the HDHK sessions. A detailed account of the process

evaluation scores are presented in Table 6. Fathers believed the timing and structure of the

5 program was appropriate, and that the quality of the program, instructors, and resources was

high. Fathers also perceived that the program affected their lifestyles, and the behavior of other

family members. The overall satisfaction score was very high. In terms of adherence to self-

monitoring, the mean (SD) number of diet and exercise entries to the Calorie KingT M website

by HDHK group participants was 46 (65) and 31(49) respectively with an average of 14 (12)

10 weight check-ins over the 3-month period. Significant correlations were found between percent

weight loss at 6 months and number of days of diet intake entries (r = .62, P = .004), number of

daily exercise entries (r = .74, P < .001) and number of weekly weight check-ins (r = .55 P =

.012).

DISCUSSION

15 Approximately 85% of fathers in the ‘Healthy Dads, Healthy Kids’ (HDHK) group achieved a

clinically important (42) sustained weight loss of >5% of their body weight. HDHK also

resulted in a significant treatment effect in mens’ waist circumference, blood pressure, resting

heart rate and physical activity with medium-to- large intervention effect sizes. Importantly,

fathers maintained improvements from 3- to 6-months, despite no contact between researchers

20 and participants. The weight loss findings are greater than many studies in men reported in the

literature (27, 43). The web-based self-monitoring of diet, exercise and weight were strongly

related to weight loss, which supports previous studies that have identified the importance of

these behaviors to weight loss (44), and compliance rates with the self-monitoring were similar

to other weight loss studies (45). In addition, children in the HDHK group also significantly

25 improved their physical activity levels, reduced their resting heart rate and decreased their

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 Weight loss program for fathers

kilojoule intake relative to the control group, with improvements also maintained at 6-month

follow-up.

Research has demonstrated that parents shape children’s lifestyle behavioral patterns by their

5 own behaviors (i.e. role modelling) and by activity and eating-related parenting practices (8),

although only a small number of studies have examined paternal influences separately. The

significant improvements in health-related outcomes and physical activity for fathers may be

attributed to the fact that fathers were instructed and encouraged to role model these healthy

behaviors for their children and this is likely to have acted as an additional source of

10 motivation. Similarly, children were also taught to role model and encourage their fathers to

adopt healthy behaviours. According to Bandura (46), this reciprocal reinforcement between

family members is particularly important when changing and sustaining new behaviors. That

is, both fathers and children mutually reinforced healthier behaviors.

15 The HDHK program is the first study to exclusively target overweight fathers to improve their

weight profile, physical activity and dietary behaviours in order to positively influence the

physical activity and eating behaviors of their children. This study represents an important

contribution to the field of family interventions as it has demonstrated behavioral changes in

children following weight loss in overweight fathers. To date, studies of family-based lifestyle

20 interventions have mainly targeted parents and/or mothers of obese children. When both

children and parents have been targeted, weight loss outcomes for children usually improve

(47, 48). Results have been equivocal for programs that have also targeted parental and child

weight loss (13). Importantly, relative to previous family-based interventions, the HDHK

program was relatively low dose with many published studies detailing interventions with a

25 substantially greater number of sessions and total contact time compared to HDHK (13).

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 Weight loss program for fathers

The HDHK program was unique in that it was designed to engage fathers as key agents of

behavior change in their families. We hypothesised that in losing weight, fathers would be

more likely to role model positive health behaviors and create healthier home environments for

5 their children. While there was no significant intervention effect for dietary intake for fathers,

men in the HDHK group still decreased their dietary intake by more than 3 000kJ per day and

given the large standard deviation for fathers kJ intake this is likely to have been underpowered

to detect a significant group effect for this secondary outcome. This was equal to an effect size

of d = .69.

10

The increased physical activity levels and lower resting heart rate, represented by medium-to-

large effect sizes, seen in children indicate the effectiveness of the strategies used to improve

physical activity and fitness levels. The interactive sessions focused on teaching fathers and

children the importance of physical activity to improve physical fitness, fundamental motor

15 skills, rough and tumble play and fun and active games. Fathers were encouraged to spend time

each day with their children engaged in physical activities that targeted these components. For

example, sessions focused on the development and practice of object control fundamental

motor skills, given the established importance of these types of basic sports skills to future

physical activity participation (49) and fitness (50). The development of physical fitness

20 through vigorous intensity active play at home was also encouraged as recent evidence has

shown the independent health benefits of both cardiorespiratory and muscular fitness (51, 52),

which may explain the improvements in resting heart rates of both fathers and children.

Recent reviews have demonstrated that parental modelling of physical activity is associated

25 with child physical activity (53) and that parental exercise is associated with children’s sports

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 Weight loss program for fathers

participation and fitness (54). But there is limited evidence for the effectiveness of family-

based interventions to increase physical activity among children (55, 56). Of only six studies

that included direct contact with parents to increase child physical activity, findings were

mixed and generally studies have been of poor quality, not used objective measures of physical

5 activity, and been equivocal about the best way to engage parents (56).

We also found a significant treatment effect for dietary intake for children which supports

research showing modelling of healthy eating by parents influence children’s dietary intake

(10). The reduction in kJ / kg for children reported by mothers at 6-month follow-up,

10 particularly the magnitude relative to the control group, provides support that families in the

program have modified their eating habits in a sustainable way. This is important and reporting

by the mothers is likely to have reduced reporting bias relative to having fathers report for their

children. This provides further evidence that the fathers have effectively facilitated transfer of

dietary information to the family environment to a level that has impacted positively on their

15 children’s intake. We did not find a significant treatment effect for children’s anthropometric

data but this is not surprising as 80% of the intervention group were a healthy weight at

baseline.

The feasibility of the HDHK program was also demonstrated as we were able to successfully

20 recruit fathers and retain them in the program. Furthermore, the high attendance levels and high

levels of overall satisfaction relating to structure, content and instruction suggest that the

HDHK program is a feasible and efficacious approach to weight loss among overweight

fathers. A lifestyle program that can recruit and engage men, and achieve clinically important

weight loss and improved health behaviors of children at the same time may be a more cost

25 effective approach than separate interventions.

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 Weight loss program for fathers

The idea that children’s health can be promoted through engaging fathers is not yet a strongly

held view in public health policy, health promotion, medicine or family service (15), which

tend to focus on mother’s involvement as critical; this approach is described as ‘mothercentric’

5 (15). There is evidence of the positive influence of father engagement on children’s social,

behavioural and psychological outcomes (57), and our findings provide further support for

health-related interventions that target fathers. There is an urgent need for strategies to reduce

obesity in men and improve the lifestyle behaviors of children. The HDHK program worked

exclusively with fathers and targeted overall family changes, highlighting the generalizability

10 of this approach with children of varying ages and weight profiles.

Our study addressed many of the weaknesses identified in the literature (13, 55, 58), and its

strengths included: a randomized design, high retention rate, intention-to-treat analysis,

theoretically-based framework, and follow-up assessments three months after the immediate

15 post-intervention assessment. There were some study limitations which need to be noted. The

physical activity assessment may contribute to some reactivity, as both groups of participants

were required to monitor and record their physical activity in a log book over a period of one

week. However, the majority of weight loss interventions use self-report measures of physical

activity, which are more susceptible to social desirability bias and the evidence for reactivity is

20 inconclusive (59). Use of the FFQ as a dietary assessment tool may be associated with a

reporting bias, which would manifest as systematic rather than random error and additionally

there could be a training effect which could mask some of the between groups changes.

Future research could explore the capacity of father-focused programs to engage mothers and

25 examine any change in maternal health-related behaviours to further our understanding of the

19
 Weight loss program for fathers

broader familial influences of such programs. Further, while SES was examined as a covariate,

only data on area-level SES were collected and other more sensitive measures such as

education level and income could be examined in future studies. Finally, the intervention was

delivered by highly qualified staff with expertise in physical education. There is a need to test

5 the HDHK program in larger effectiveness trials to determine the impact of the program

delivered by trained community-based facilitators and with longer-term follow-up.

Conclusion

A program targeting overweight fathers was effective in achieving statistically and clinically

10 important weight loss in men that was sustained up to 6 months. The HDHK program also

increased physical activity-related outcomes and decreased total energy intake in children in

response to paternal role modelling. Future family-based programs should consider how best to

include and engage fathers and mothers in obesity treatment and prevention interventions to

optimise the effectiveness of programs in reducing obesity-related risk factors long term.

15

20
 Weight loss program for fathers

ACKNOWLEDGMENTS

This study was funded by the Hunter Medical Research Institute and the Gastronomic Lunch.

We would like to thank project manager James Bray and are also grateful for the help of

5 research assistants Elroy Aguiar, Garbrielle Quick and Sam Biver. We thank all study

participants. We would also like to thank NUSport for their support and Dr Janet Warren for

her revision of the manuscript.

CONFLICT OF INTEREST

10

The author(s) declare that they have no competing interests.

21
 Weight loss program for fathers

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levels with pedometers? Pediatric Exercise Science 2002; 14: 56-63.

28
 Weight loss program for fathers

Table 1: HDHK program content and alignment with theoretical constructs

Session Session SCT

Session detail Behavior change techniques
no. focus construct
* Program rationale
* Importance of fathers and their * Provide information about behavior
influence on children health link * Outcome
* Energy balance and weight * Prompt self-monitoring of behaviors expectations
1 ‘Weight loss
loss * Prompt specific goal setting * Social support
for men’
* 9 Weight loss tips for men * Information on consequences * Self-efficacy
(Dads)
* Website use for eating and * Prompt intention formation * Intentions
activity diaries * Provide instruction

* Provide information about behavior

* Obesogenic environments
health link * Outcome
‘Raising active * PA levels, trends and benefits
* Model or demonstrate the behavior expectations
2 children in an * PA recommendations
* Prompt specific goal setting * Self-efficacy
inactive world’ * PA goals for Dads
* Barrier identification * Social support
(Dads) * Ideas for fitness/ activity at
* Prompt self-monitoring of PA
home
* Plan social support or social change
‘Ready to * Rough and Tumble Play * Model or demonstrate the behavior
* Self-efficacy
rumble with * Fun Fitness circuits * General encouragement
3 * Social support
Dad’ * Fun and active games * Provide instruction
(Dads & Kids) * Graded tasks
* Healthy eating benefits
* Provide instruction
‘Healthy * Food based guidelines * Outcome
* Prompt identification as a role model
eating for * Role of fathers in healthy expectations
4 * Prompt review of goals
families – home eating environments * Self-efficacy
* Prompt barrier identification
Dads matter’ * Authoritative feeding practices * Intentions
* Plan social support or social change
(Dads) * Reading food labels * Social support

* Planning meals
* Australian Guide to Healthy * Provide information about behavior
‘Sustaining Eating health link * Social support
5 healthy eating * Recommended daily intakes * Prompt review of behavioral goals * Self-efficacy
at home’ * Why we eat food? * Relapse prevention * Outcome
(Dads) * Support and strategies for * Problem solving expectations
successful dietary changes and
relapse prevention
‘Fitness, fun
and
fundamental * FMS skills circuit * Model or demonstrate the behavior
6 * Social support
movement * Rough and Tumble activities * Prompt identification as a role model
* Self-efficacy
skills’ * Partner fitness challenges * General encouragement
(Dads & Kids)

* The benefits of strength * Provide information about behavior * Outcome

‘Playing
7 training health link expectations
strong’
* Strength training exercises * Model or demonstrate the behavior * Social support
(Dads & Kids)
* Rough and tumble activities * Prompt identification as a role model * Self-efficacy
* Ball and game skills * General encouragement
* Program revision
‘Games show * Group based trivia competition * Model or demonstrate the behavior
* Self-efficacy
8 and Healthy with practical challenges to * Prompt review of behavioral goals
* Intentions
BBQ’ reinforce PA messages (fitness, * Problem solving
* Social support
(Dads) FMS etc.) * Post-program goal setting

Abbreviations: SCT – Social Cognitive Theory; FMS – fundamental movement skill; WL – weight loss; PA – physical
activity

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 Weight loss program for fathers

Table 2: Baseline characteristics of men randomized to the intervention and control

groups

Control HDHK program Total

Characteristics
(n = 26) (n = 27) (N = 53)
Mean (SD) Mean (SD) Mean (SD)
Age (years) 40.3 7.5 40.9 6.7 40.6 7.1
a
SES , n (%)
1-2 (lowest) 0 0.0 1 3.7 1 1.9
3-4 1 3.8 4 14.8 5 9.4
5-6 12 46.2 10 37.0 22 41.5
7-8 10 38.5 9 33.3 19 35.8
9-10 (highest) 3 11.5 3 11.1 6 11.3
Weight (kg) 105.0 13.4 106.7 13.7 105.9 13.5
Height (m) 1.78 0.07 1.79 0.06 1.79 0.06
BMI (kg/m2) 33.1 4.1 33.3 3.7 33.2 3.9
BMI Category
Overweight, n (%) 7 26.9% 5 18.5% 12 22.6%
Obese, n (%) 19 73.1% 22 81.5% 41 77.4%
Waist (Umb) (cm) 111.1 9.7 111.2 10.5 111.2 10.0
Waist (Narrow) (cm) 104.4 7.8 104.7 8.9 104.5 8.3
Systolic blood pressure (mmHg) 134 16 134 11 134 13
Diastolic blood pressure (mmHg) 87 11 88 8 87 10
Resting heart rate (BPM) 78 11 75 10 76 10
Physical activity (steps/day)b 8028 2559 8521 2745 8285 2643
c
Dietary intake (kJ/day) 12759 4132 11792 3587 12256 3849

Abbreviations: HDHK = Healthy Dads, Healthy Kids; BMI = Body Mass Index; SES = socioeconomic status;
Umb = umbilicus measurement; BPM = beats per minute; kJ = kilojoules.
a
Socioeconomic status by population decile for SEIFA Index of Relative Socio-economic Advantage and
Disadvantage
b
n = 25 (Control); n = 27 (Intervention); N = 52 (Total)
c
n = 24 (Control); n = 26 (Intervention); N = 50 (Total)

30
 Weight loss program for fathers

Table 3: Baseline characteristics of children randomized to the intervention and control

groups

Control HDHK program Total

Characteristics
(n = 32) (n = 39) (N = 71)
Mean (SD) Mean (SD) Mean (SD)
Age (years) 7.9 1.9 8.4 2.1 8.2 2.0
Sex, n(%) Male 56.3% Male 51.3% Male 53.5%
Weight (kg) 34.9 14.8 33.0 12.9 33.8 13.7
Height (m) 1.32 0.14 1.34 0.14 1.33 0.14
2
BMI (kg/m ) 19.1 4.5 17.6 3.3 18.3 3.9
BMI z-score 1.0 1.3 0.3 1.0 0.7 1.2
BMI Category
Healthy weight, n (%) 19 59.4 31 79.5 50 70.4
Overweight, n (%) 7 21.9 7 17.9 14 19.7
Obese, n (%) 6 18.8 1 2.6 7 9.9
Waist (Umb) (cm) 64.8 14.1 61.4 13.1 62.9 13.6
Waist (Narrow) (cm) 60.7 11.0 57.7 9.5 59.1 10.2
Waist z-score .8 1.5 .1 1.4 0.5 1.5
Systolic blood pressure (mmHg) 103 10 100 8 102 9
Diastolic blood pressure (mmHg) 64 9 64 9 64 9
Resting heart rate (BPM) 85 11 85 9 85 10
a
Physical activity (steps/day) 11084 3184 11171 2719 11132 2915
b*
Dietary intake (kJ/kg/day) 312 131 363 140 339 137

Abbreviations: HDHK = Healthy Dads, Healthy Kids; BMI = Body Mass Index; SES = socioeconomic status;
UM = umbilicus measurement; BPM = beats per minute; kJ = kilojoules; kg = kilograms; g = grams.
a
n = 31 (Control); n = 38 (Intervention); N = 69 (Total)
b
n = 25 (Control); n = 27 (Intervention); N = 52 (Total)
* reported by mothers (for eldest child if more than one child enrolled)

31
 Weight loss program for fathers

Table 4: Changes in outcome variables for fathers by treatment group from baseline to 3-
and 6-months and differences in outcomes among the treatment groups at 3- and 6-
months (ITT analysis) (n=53)*

Treatment group
Group * Effect
† Time
Mean change from Baseline (95% CI) S ize

Control HDHK program Mean difference (Cohen

Outcome Mth between groups P
(n = 26) (n = 27) ’s d)
(95% CI)§
3 -0.4 (-1.9, 1.1) -6.7 (-8.2, -5.1)
Weight (kg)* 6 0.0 (-1.4, 1.6) -7.6 (-9.2, -6.0) 7.6 (5.4, 9.9) <.001 .54
3 -0.5 (-2.3, 1.4) -6.2 (-8.2, -4.3)
Waist (Umb)
(cm)* 6 -0.7 (-2.4, 1.1) -7.5 (-9.4, -5.7) 6.9 (4.3, 9.5) <.001 .62
3 1.0 (-0.6, 2.6) -4.4 (-6.0, -2.7)
Waist (Narrow)
(cm) 6 1.2 (-0.5, 2.8) -5.5 (-7.3, -3.7) 6.6 (4.2, 9.1) <.001 .67
3 0.0 (-0.5, 0.5) -1.8 (-2.4, -1.3)
BMI (kg/m2 )* 6 0.0 (-0.5, 0.4) -2.3 (-2.8, -1.8) 2.3 (1.5, 3.0) <.001 .53
3 -3 (-7, 2) -9 (-13, -4)
Systolic blood
pressure (mmHg) 6 3 (-2, 8) -9 (-14, -3) 12 (4, 19) .01 .92
3 1 (-3, 5) -5 (-9, -1)
Diastolic blood
pressure (mmHg) 6 4 (-1, 8) -5 (-9, -0) 8 (2, 15) .04 .82
3 -2 (-6, 1) -9 (-13, -6)
Resting heart rate
(BPM)* 6 -3 (-6, 1) -11 (-15, -7) 8 (2, 14) .01 .66
3 -39 (-1080, 1002) 2178 (1074, 3281)
Physical activity
(mean steps/day)a 6 -710 (-2010, 591) 2837 (1448, 4225) -3546 (-5449, -1643) .002 .91
3 -2031 (-3514, -548) -2857 (-4400, -1315)
Dietary Intake
(total daily kJ) 6 -973 (-3212, 1266) -3270 (-5490, -1050) 2297 (-856, 5450) .350 .69

Abbreviations: Mth = Month; Umb = Umbilicus; BMI = body mass index; BPM = beats per minute; kJ = kilojoules
a
n = 52
†
Time differences were calculated as (3 month – baseline) and (6 month – baseline)
§
Between group differences at 6 months
* Adjusted for age

32
 Weight loss program for fathers

Table 5: Changes in outcome variables for children by treatment group from baseline to 3- and 6-
months and differences in outcomes among the treatment groups at 3- and 6-months (ITT
analysis)*

Treatment group
Group Effect
Mean change from Baseline
* Time S ize
(95% CI) †

Control HDHK program Mean difference (Cohen’s

Outcome M onth between groups P
(n = 32 ) (n = 39) d)
(95% CI)§
3 0.0 (-0.1, 0.1) -0.0 (-0.1, 0.1)
BMI z-score
6 0.1 (-0.1, 0.2) -0.0 (-0.1, 0.1) 0.1 (-0.1, 0.2) .74 .09
3 0.3 (0.1, 0.5) 0.2 (-0.0, 0.5)
Waist z-score
6 0.2 (-0.0, 0.4) -0.1 (-0.3, 0.2) 0.3 (-0.0, 0.6) .17 .22
Systolic blood 3 -2 (-5, 0) -4 (-6, -1)
pressure (mmHg)** 6 -1 (-4, 1) -4 (-7, -2) 3 (-1, 7) .26 .40
Diastolic blood 3 -4 (-7, -0) -3 (-6, -0)
pressure (mmHg)* 6 -2 (-5, 1) -3 (-6, -0) 1 (-3, 6) .69 .13
Resting heart rate 3 3 (-1, 7) -4 (-8, -1)
(BPM) 6 -1 (-4, 3) -6 (-9, -3) 5 (1, 10) .01 .51
Physical activity 3 -763 (-1600, 74) 465 (-331, 1261)
a
(mean steps/day) 6 -828 (-1700, 42) 1499 (665, 2322) -2327 (-3531, -1122) <.001 .74
Dietary Intake 3 -18 (-55, 19) -37 (-77, 3)
b
(kJ/kg) 6 -1 (-39, 37) -88 (-128, -48) 87 (32, 143) .01 .84
Abbreviations: Umb = Umbilicus; BMI = body mass index; BPM = beats per minute; kJ = kilojoules; kg = kilograms
†
Time differences were calculated as (3 month – baseline) and (6 month – baseline)
§
Between group differences at 6 months
a
n = 69
* Adjusted for age; ** Adjusted for age and sex
b
reported by mothers (for eldest child if more than one child enrolled)

33
 Weight loss program for fathers

Table 6: Overall satisfaction and perceptions of impact for fathers

Construct (n = number of Example item Mean

items) (SD)
Program structure and timing
‘The number of sessions was appropriate’ 4.1 (0.5)
(n=3)

Quality of instructors (n=4) ‘The instructors had a high level of knowledge’ 4.9 (0.2)

Quality of program (n=3) ‘The content of the program was interesting’ 4.6 (0.5)

Impact on family (n=6) ‘HDHK has impacted positively on the whole family’ 4.0 (0.4)

Resources (n=2) ‘The physical activity handbook was useful’ 4.4 (0.5)

Website satisfaction (n=3) ‘The website was easy to use’ 4.2 (0.7)

Adherence to self-monitoring
‘I now keep a record of my physical activity’ 3.7 (0.7)
(n=5)

‘HDHK program provided me with enough support to

Program support (n=3) 4.3 (0.8)
help me lose weight’

Overall satisfaction (n=3) ‘I enjoyed the HDHK program’ 4.8 (0.4)

1 = Strongly Disagree; 2 = Disagree; 3 = Neutral; 4 = Agree; 5 = Strongly Agree

34
 Weight loss program for fathers

Figure 1: Participant flow through the trial and analysed for the primary outcome
(Fathers’ weight [kg])

Figure 2: Mean change in weight at 3 months and 6 months after baseline for fathers in
both groups (n = 53). P > 0.05 for between group comparisons. Error bars represent 95%
confidence intervals (intention-to-treat analysis)

35