Coaching the Whole Family
Why nutrition and fitness pros need to work with moms, dads and kids togetherÔÇöand how to do it.
An adolescent with a parent who demands he "clean his plate" may lose his ability to respond to hunger cues and end up battling excess weight gain all his life.
A working parent with a spouse who prepares calorie-dense, nutrient-poor meals for family dinners will struggle to maintain a healthy eating plan. But a child who grows up in a family where both parents are highly physically active is much more likely to be active himself.
A teen raised in a family who values eating dinner together each night is more likely to eat better, perform better in school and avoid risky behaviors. And a parent who strives to provide a healthier home environment for a child recently diagnosed with obesity is apt to lose weight herself.
A growing body of research makes it clear: Families provide a powerful force in supporting—or opposing—better health behaviors. Indeed, the authors of a state-of-the-art review in a prestigious cardiology journal call families "a linchpin for cardiovascular health promotion throughout the life course" (Vedanthan et al. 2016).
Whether you work primarily with children, adolescents or adults, expanding your scope to meet the needs of the whole family is likely to improve client outcomes while enabling you to reach more people and grow your business. This article provides evidence supporting a family-level approach to fitness and nutrition coaching, and an overview of this growing opportunity for health and fitness professionals.
The Value of a Family Focus
A classic study of childhood obesity demonstrated the power of a family-level intervention to simultaneously improve the health of children and parents. In the yearlong study, researchers divided parent-child dyads into two groups. In the first, the child in each dyad received information and coaching on how to make healthful choices. In the second, the information and coaching went to the parent (Golan, Weizman & Fainaru 1999).
Here's what the study found: Making the parent the agent of change made the biggest difference in improving the health of both parent and child. Study leaders coached parents to do the following:
- Increase physical activity and decrease sedentary time.
- Reduce saturated fat intake.
- Decrease exposure to unhealthful foods.
- Apply behavioral modification.
- Practice parenting skills.
After a year, the children were healthier, and the parents had improved their health habits, lost weight and decreased their cardiovascular disease risk factors (Golan, Weizman & Fainaru 1999).
Ultimately, this study and many others after it show that when parents receive coaching and guidance on helping their children succeed, they succeed, too.
"Because parents clearly influence their children's life-styles, the health status of the parent is intricately linked to that of their children," wrote the authors of a review of family-based approaches to cardiovascular health promotion, in the Journal of the American College of Cardiology (Vedanthan et al. 2016).
Working with families provides many opportunities for intervention and coaching, including exploring how adjustments to daily routines, responsibilities, communications and emotional connections can help optimize health behaviors. In fact, just having the conversation about health can improve outcomes. One study found that families who talk openly about nutrition and physical activity are more likely to eat healthfully and stay active (Baiocchi-Wagner & Talley 2012).
Key Features of Effective Family-Based Approaches
Fitness pros understand that social support is a strong predictor of lifestyle change. For most people, no support system is more influential than family. The family systems theory, first described by psychiatrist Murray Bowen, may say it best: Individuals cannot be understood in isolation from one another; rather, they must be considered as an interconnected part of their family (Bowen 1966). Family members influence each other reciprocally, and a change in one family member can have a domino effect on everyone else. How well a family functions and the strength of connections between family members—including parent to parent, parent to child, and child to siblings—help determine how a change in one person affects other family members, for better or for worse.
Family functioning describes the structure and organization of a family and the types of interactions among family members, including how families manage daily routines, fulfill their family roles, and communicate and connect emotionally. A higher level of family functioning is associated with better nutrition, less sedentary behavior and more physical activity (Berge et al. 2013).
The General Functioning subscale (see Figure 1, "Testing How Well a Family Functions") of the McMaster Family Assessment Device provides insight into family functioning. While using this scale and exploring family dysfunction with clients are well outside the scope of the health and fitness professional (refer the family to a marriage and family therapist if such concerns arise), having a general understanding of family dynamics can help tailor a coaching intervention in the way that is most likely to improve a family's health.
Family cohesion also predicts health behaviors. Think of family cohesion as the strength of the attachment between family members combined with the degree to which they are encouraged to develop independence. Families with high cohesion are more likely to set and achieve goals, including those around health behaviors (Vedanthan et al. 2016). Adolescents from high-functioning families who have high-quality relationships with their parents exhibit better nutrition, activity and sleep behaviors, and are less likely to have excess weight or obesity (Haines et al. 2016).
The most effective family-based approaches to fitness help to enhance family functioning and cohesion. Family therapy may be outside the scope of a health and fitness professional, but you can still use family-based fitness and nutrition coaching to help parents and children adopt positive, supportive practices.
10 Ways to Help Families Change
Family-based fitness and nutrition coaching is a relationship where an expert on behavior change, family dynamics, nutrition and physical activity works with individuals and families to optimize health and well-being.
To date, there is no standardized training to help health and fitness pros meet this growing need. Nevertheless, you can deploy the 10 strategies outlined below to play a powerful role in helping families work together to improve their health.
1. Learn Motivational Interviewing
Motivational interviewing is a conversational approach that coaches use to help people "talk themselves into change" and build a sense of self-efficacy. This approach uses open-ended questions, reflective listening, affirmations and summarizing to develop a person's "change talk"—statements that encourage behavior change.
For example, a mom might say, "I know I need to be more active to set a good example for my daughter, but it is so hard to make time for it." A coach using motivational interviewing could respond with a reflective statement, such as, "Even though time is tight, you want your daughter to see you 'walking the talk.'" If the mom says, "Yes, I do," the coach might ask, "What would that look like?" This prompts the mom to find her own solutions, which builds her self-efficacy (her belief that she can change despite the barriers).
2. Help Families Talk About Healthy Behaviors
When possible, engage all family members in a discussion of nutrition and physical activity. For example, you might ask, "On a grading scale of F to A-plus, how healthy is your home?" Follow up by asking why they gave that grade rather than a lower one (e.g., "Why give a B and not a C?"). This helps the family members identify things that are going well.
Then ask what it would take to improve the grade, and how other family members could help. Identify barriers and find ways to overcome them. This guided conversation helps people open up on their health behaviors.
3. Learn Children's Ages and Stages
As children develop, opportunities emerge at different times to promote healthful nutrition and activity. A good understanding of normal childhood development creates opportunities to help parents tailor an intervention to their children's places in specific life stages. Table 1 ("Family Fitness Coaching by Age and Stage") highlights nutrition and activity targets at each stage.
4. Coach Parents on Refining Their Approach
One study identifies four major approaches to parenting: authoritarian, authoritative, permissive and neglectful (see Figure 2, "Parenting Style and Cardiovascular Health Pro-motoion"). These approaches are classified across two domains: warmth and responsiveness, and control and/or demandingness. Research clearly indicates that an authoritative approach leads to the best outcomes, for health and overall (Vedanthan et al. 2016).
Help parents figure out how to adopt a more authoritative style. For example, one authoritative approach to the home food environment relies on a clear division of responsibilities (ESI 2005): Parents decide which foods are in the home, when to offer them, and where. Ideally, parents stock the home with healthy foods, offer balanced meals, and require that meals and snack times (for everyone) occur at the kitchen or dining room table. Then, the children choose what to eat from available options (so the kids are not forced to eat certain foods) and decide how much (so they learn to trust their internal hunger and fullness cues).
5. Help Parents Set Health Goals
Studies suggest many parents underestimate their children's weight and overestimate the nutritional quality of their diets and their levels of physical activity (Vedanthan et al. 2016). The best way to gauge what's really going on is to help parents monitor their own nutrition and physical activity and those of their children (ideally for at least a 3-day period, including 2 weekdays and 1 weekend day). They may also consider reviewing a child's growth chart with a pediatrician to best understand the child's current status.
This information is a useful starting point for establishing nutrition and activity goals based on dietary and activity guidelines (such as the USDA's Dietary Guidelines and the U.S. Department of Health's Physical Activity Guidelines) that are tailored to the individual family.
6. Encourage Modeling
Parents are potent role models for their children. Possibly the most effective way for parents to raise healthy, active kids is to be healthy and active themselves. Studies indicate that children follow their parents' cues on how to eat, portion control, table manners, eating rituals, social interactions at mealtime and timing of meals.
Making family meals a priority enables parents to be positive role models, which is associated with health-related, educational and social benefits for children and decreased risk-taking in teens (Vedanthan et al. 2016). Children and teens also model their parents' physical activity (and sedentary) behaviors. Having at least one physically active parent increases the odds that kids will be active. At the same time, sedentary parents who watch a lot of television encourage their kids to embrace similar behavior (Vedanthan et al. 2016).
7. Make the Healthy Choice the Easy Choice
If home is a healthy, active environment, family members will by default be healthy and active. If home is not that environment, healthy behaviors will be much more difficult to maintain. Thus, making healthful foods readily available and unhealthful foods hard to get makes it easier for everybody to choose healthy foods. Eating at home more often (cooking most meals) supports healthier nutritional status, as does minimizing consumption of snacks and processed foods.
Likewise, having many opportunities for physical activity, and access (e.g., transportation) needed to participate, will lead to more active families. Family members should share a behavioral environment that enables self-efficacy for change, self-regulation, role modeling and eating practices.
8. Emphasize Quality-Time Activities
In the stresses of daily life, people have a tough time finding enough time and energy to strengthen family cohesion. However, making a concerted effort to do this improves family functioning, which in turn optimizes the health and well-being of all family members.
Help parents identify opportunities to spend quality time with their children—and each other—to nurture familial bonds. Whether it is giving a baby massage to an infant, reading to a young child, walking together as a family, enjoying a parent date night, taking a trip to the farmer's market, participating in a Zumba® class with a child in middle school, camping one-on-one with a teen—or engaging in any other activity, small or large—quality time spent together, engaged in healthful activities, yields big gains.
9. Help Families Cope With Stress
Families under significant stress face a higher risk of developing unhealthy habits. For example, a parent whose response to stress includes eating or vegging out in front of the television may have difficulty discouraging a child from doing the same. Financial stresses can prompt marital discord, which can affect meal planning, physical activity, family communication and parenting quality. Maternal depression can be devastating for the mother as well as the health and well-being of her children.
Help clients identify common stressors and the impact of their response to stress on the family. Talk about strategies for reducing or eliminating stressors. Then problem-solve together to find productive ways to respond if a stressor returns. When it does, ask what happened (did the client adopt the new response or the old one, or some variation of the two?), and figure out how to improve for next time.
10. Urge Families to Be Active Together
As experts on physical activity, fitness pros are in the best position to advocate for more opportunities for families to be active together. Challenge gyms and fitness centers to rethink their approach to children's access and to encourage more child- and family-friendly policies. Brainstorm ways to offer new classes, programs and activities that will meet the needs of all clients and their families. Lead a culture shift to a more inclusive, family-centered approach to fitness and activity.
While family-based fitness and nutrition programming may be a relatively new focus for many fitness professionals, several trailblazers have created programs that apply these principles effectively (see the sidebar, "Family-Based Coaching Programs"). The increasing recognition of family-driven programs gives health and fitness professionals opportunities to improve the lives of children and parents for generations to come.
Increasing numbers of individuals, organizations and university researchers are investing in programs rooted in family approaches to improving nutrition and physical activity. Here's a sampling of these programs:
MEND (Mind, Exercise, Nutrition, Do It!) Foundation. Operating in communities throughout the country, MEND deploys a twice-weekly, 10-week-long group intervention for families with children aged 7ÔÇô13 at risk for obesity. MEND includes parent coaching sessions; nutrition and activity lessons that aim to increase knowledge, change attitudes and ultimately build skills to change behaviors; and age-appropriate physical activities. MEND is led by trained behavior-change coaches and fitness leaders. Online at www.mendfoundation.org.
Fit4Mom. What started as Stroller Strides® in 2001, after founder and fitness professional Lisa Drux
Baiocchi-Wagner, E.A., & Talley, A.E. 2012. The role of family communication in individual health attitudes and behaviors concerning diet and physical activity. Health Communication, 28 (2),193-205.
Berge, J., et al. 2013. Family functioning: Associations with weight status, eating behaviours, and physical activity in adolescents. Journal of Adolescent Health, 52 (3), 351-57.
Bowen, M. 1966. The use of family theory in clinical practice. Comprehensive Psychiatry, 7 (5), 345-74.
Epstein, N.B., Baldwin, L.M., & Bishop, D.S. 1983. The McMaster Family Assessment Device. Journal of Marital and Family Therapy, 9 (2), 171-80.
ESI (Ellyn Satter Institute). 2005. Ellyn SatterÔÇÖs Division of Responsibility with Activity. Accessed Aug. 11, 2016. http://ellynsatterinstitute.org/dor/divisionofresponsibilityinactivity.php.
Golan, M., Weizman, A., & Fainaru, M. 1999. Impact of treatment for childhood obesity on parental risk factors for cardiovascular disease. Preventive Medicine, 29 (6, Part. 1), 519-26.
Haines, J., et al. 2016. Family functioning and quality of parent-adolescent relationship: Cross-sectional associations with adolescent weight-related behaviors and weight status. International Journal of Behavioral Nutrition and Physical Activity, 13 (1), 68-80.
Vedanthan, R., et al. 2016. Family-based approaches to cardiovascular health promotion. Journal of the American College of Cardiology, 67 (14), 1725-37.