Science Spotlight with Dr. Keeley Pratt
March is National Nutrition Month, a time to emphasize the importance of informed food choices that support overall health. From your research on family dynamics and weight management, what are some of the most influential ways that families shape lifelong eating habits?
Given the existing (and rising) rates of obesity, half of US adults report pursuing some type of weight loss through changing eating habits and behaviors, and often in some type of organized program or medical treatment. The most evidence-based and robust treatment options available for weight loss and maintenance target youth and adults’ dietary and physical activity behaviors through medical weight management programs, metabolic and bariatric surgery (MBS), and more recently anti-obesity medications (i.e., GLP-1s). However, treatment has proven challenging for both youth and adults to initially lose weight and maintain their weight loss long-term.
While eating habit change occurs at the individual level, some family and household environments make healthy behavioral changes easier than others. Familial support and positive family relationships are two key features that can help or hinder the adoption of healthy behaviors. We have produced evidence detailing that impaired family functioning (i.e., unhealthy family interactions and family environment), challenging romantic partners, and unsupportive family members negatively affect behavior change and weight loss among adults in treatment. Given the strong evidence that patients with obesity are likely to be part of families in which one or multiple members also have obesity, obesity is commonly understood as a family-level condition, and one that is intergenerationally passed down in families both through genetics and modifiable eating patterns and dynamics.
When approaching the topic of eating habits with families, both in research and clinical work, we are curious about how families “learned to eat” and established their eating routines. Our research and others have identified that for children, this is often done through parental modeling of eating habits, routines, and behaviors in which children observe and fit into the existing food-related norms of their parents. These behaviors and habits often become so routine, predictable even, that when one family member deviates from this routine- say by trying to adopt more healthy eating habits- they can be met with resistance from other family members because this is a threat to their existing status quo. The challenge then for scholars/scientists like me, is to (1) address underlying family dynamics (i.e., negative communication, chaos, limited support) that prevent the adoption of healthy eating habits, and (2) finding ways that the overall family or household can change their eating habits to establish healthier routines to benefit the identified patient and the entire family.
What common challenges to families face when trying to create a healthy eating environment and what are effective ways to overcome these challenges?
One of the most common challenges we see is that the overall family environment, including eating habits and routines, has become established over time and has become “automatic”. It’s not uncommon for children and adults to be on autopilot when it comes to what they eat, when they eat it, and the context around their eating (i.e., in front of screens, etc.). Breaking these normative routines can be a challenge, especially when one family member may be trying to change their eating habits and other family members are not supportive. For the family member who is trying to change their eating habits, the presence of temptation foods in the home and food-related routines that don’t always offer healthy alternatives can make change more difficult. While they may be able to change their individual eating habits in the short term, long-term maintenance of these changes will be more difficult if the family and household environment does not change. To address this challenge, we have to determine how receptive the identified patient’s family members are to household-level changes, like limiting temptation foods in the home and establishing new routines around healthy eating habits. For parents, this often involves offering healthy foods in the home and modeling. For couples, this may involve finding new ways to connect around eating routines that offer healthy alternatives, like cooking a meal together at home or eating out at restaurants with healthy alternatives.
What are the biggest challenges you face when studying the role of family dynamics in weight management and food choices, and how do you navigate these challenges?
The most significant barrier we face is when families have underlying challenging family dynamics, and those dynamics require more intensive intervention. For example, when families have high levels of stress and conflict, changing eating habits may not be able to be the priority. Instead, addressing existing conflict may need to happen prior to trying to change routines and behaviors around eating. We call this first and second-order change. First-order change happens when a family member changes their individual eating behavior; whereas second-order change is when the family changes their structure or dynamic so that all family members can change their eating habits and routines. For some patients, first-order change may be more feasible if there is underlying family conflict that families may be resistant to address. In this case, the patient may be able to change their individual behavior, but long-term maintenance is unlikely without the environment changing. For other patients, second-order change is feasible especially when the existing family dynamics are healthy and supportive for new eating habits and routines to be established.
An interdisciplinary research approach can be essential for understanding and addressing weight management and nutrition. Who are your primary collaborators?
I am fortunate to have an extensive network of collaborates both with the OSU Comprehensive Center for Adult Weight Management Metabolic and Bariatric Surgery (Drs. Sabrena Noria, Bradley Needleman, Stacy Brethauer, Ashleigh Pona, and Kris Dilley) and at Nationwide Children’s Hospital Center for Healthy Weight and Nutrition (Drs. Steve Cook, Amrik Khalsa, Eileen Chaves, and Alexis Tindall). I also collaborate with OSU’s Center for Urban and Regional Analysis (CURA) to research social determinants of health affecting adult and pediatric weight management outcomes. Given the complexity of obesity and behavior change, the only way to comprehensively assess/research and treat patients and their families is with a multidisciplinary team. Ultimately, these groups of collaborators ensure that the research I am doing positively affects patient outcomes in treatment while also potentially preventing future obesity-related challenges for additional family members in the home.
With the growing use of GLP-1 agonists for weight management, how you do you see these medications fitting into a family-based, interdisciplinary approach to obesity treatment?
Popular media has called attention to potential benefits and challenges arising in couples and families in which an adult is utilizing an anti-obesity medication (AOMs). Given that the majority of adults taking AOMs tend to be female and of an age where they may be parents, considering the role of the family in the adherence to AOMs and adoption of healthy behaviors is needed. Further, as romantic partners, parents, and children reside in the same household and share similar habits and routines, healthy eating changes that the parent initiates may have a positive effect on their child, even preventing obesity or slowing down the rate of weight gain, mitigating a future health concern for their child. There is some evidence to suggest that there are short-term positive ripple effects to children’s diet and weight status following a parents’ bariatric surgery which may extend to patients’ family members from AOM therapy. Alternatively, if parents are taking an AOM in the absence of adopting healthy eating behaviors, children may observe that their parent is losing weight and eating less but not improving the nutritional quality of their food. This highlights a potential concern about what message children may receive from their parent’s weight loss. Recent reports highlight a high percentage of those prescribed GLP-1s are no longer taking them at one year, creating an ebb and flow of weight cycling that children observe. Our research noted the increased risk in children of parents in weight management and who undergo metabolic and bariatric surgery with respect to weight control practices, where children were more likely to adopt the same weight control practices of their parent. A broader focus on the family and AOM management is needed, not only to identify unanticipated negative side effects, such as disordered eating, but to maximize treatment effectiveness by increasing family support for eating habit change, and to positively influence the ripple effect to additional family members.