Coping with the information about the child’s weight
The information about their children being overweight came as a shock for many parents, particularly those who had previously struggled to achieve desired weight according to the growth chart. Those, whose children had always been on the heavier side, felt surprised when it was suddenly presented as a problem. The conversation awoke many feelings, and parents described it as tough to accept and difficult to hear. Many felt angry, irritated, or defensive and one dismissed the information completely. Others felt sad and one said that she went home and cried afterwards. Many highlighted the sensitivity of the subject and when parents were overweight themselves, they expressed that their own experiences made it extra sensitive and difficult to hear.
Several parents found it difficult to take the situation seriously and the health care system's perspective on overweight was described as obsolete and outdated. They described that there is too much faith in the BMI-scales and the growth charts, which they felt did not take aspects such as muscle mass into account, and therefore had too much impact in the assessment of the child. The question whether the extra weight was fat, or muscles occurred frequently, and since the overweight was not an obstacle in the children's lives, some questioned whether being overweight was actually a health concern.
He weighs a lot, yes, but is it that unhealthy in his case? Does he have that, like, unhealthy overweight that leads to, like, diseases? (Parent 6).
Some parents dismissed or questioned the information since their child was, to them, not visibly overweight, and many used alternative words to describe their children's weight status, such as big, heavy, chubby, rounded, and solid. Some parents said that children grow unevenly, and they consider it normal for a child to first gain weight and then grow taller. Many explained that their children looked like their relatives, and that it is not surprising that they have this kind of physique. They questioned whether their lifestyle habits actually could affect their children's weight situation, due to the genetic nonadjustable composition. Many also believed that the weight would resolve by itself in time.
A desire to protect the Children from the potential consequences a conversation about health and weight might lead to
The parents stated that today's cultural norms promote being as thin and fit as possible and children are affected by this both directly and indirectly. They expressed a desire to not expose their children to this and to attempt to counteract this by different means. Some avoided talking in terms such as tall, short, fat, and thin, while others used the words but without attaching any value to them. Others tried to attribute positive values to words like “fat” so it would not be considered something negative. One parent expressed that they focus on what the body can do and what it is good at instead of how it looks.
The parents did not wish to value what they eat and explained that if they discuss food with their children, it is about which food is good for you and will make you strong and healthy, not what is bad or should be avoided. As far as possible they use value-neutral words regarding food and exercise, and they avoided talking about weight and food together.
...” If you eat too much of this you will get fat”, and I was like, that isn’t something that a 3–5-year-old needs to hear about, like, even if it is true... (Parent 4)
Many parents feared that these conversations would affect the children negatively and cause eating disorders. Some parents highlighted that they are aware that being overweight is unhealthy and they understood why the CHC-nurse raised the issue. However, the fear of eating disorders and that the child would connect food and weight in a negative way was described as outweighing the risks of being overweight.
...I think that being overweight is absolutely not good, it’s harmful, but anorexia actually kills... (Parent 9)
The parents worried that the children's participation in the conversation might make them lose their self-esteem and change the way they look upon themselves and their abilities. They feared that their children would develop unhealthy body images, start thinking about their body size or start identifying as overweight.
I don’t want my little girl to start thinking about whether her body is too fat or not... (Parent 9)
One parent stated that children understand that being overweight is not considered a good thing, and most parents did not want their child to be present when addressing this subject. One parent wished that a lifestyle conversation should have been held at the child’s level of understanding. Some expressed a theoretical possibility of a child participating in this conversation, if it is done under the right conditions but most of them said that children are too young to be present.
...what made me most angry was the fact that she brought it up in front of my daughter, I mean she's 3 years old [...] children understand more than you think… (Parent 2)
Some parents worried about the future and how others would treat their children because of them being overweight. Some feared that their child would be left out or feel that they did not belong, and others were concerned that the child would suffer from mental illness and poor self-esteem. One parent said that the CHC-nurse made her aware of the risk of abuse in school, and several parents feared that being overweight would lead to the child being bullied. Parents who were overweight in their own childhood felt particularly afraid about being bullied and explained that the treatment you receive varies greatly depending on your body shape.
Feelings and thoughts about the parenting role
Feelings of guilt and shame were expressed by some parents and the situation made them question their parenting skills. They were afraid to have done something wrong or to have made the wrong decisions, and one parent expressed that this situation made her feel like they have harmed their child. Several parents explained that they always try to do what is best for their children and it felt like a failure when that was not enough. One parent shared that she struggled with being overweight herself, and always had as a goal that her children should not get there, and now when they were, it felt like a failure, and even though she knows it was not an actual failure, the sensitivity in the subject made it feel more personal than it was.
All but one parent expressed that they felt judged and criticized in their parenthood and one parent explained that every health check-up the child goes to feels like an assessment of you as a parent, and if something is not perfect it feels like criticism.
…I think that the instinctive feeling is, or was for me at least, that I did not do a good job, and she judged me for that. (Parent 9)
Some felt like the CHC-nurse jumped to conclusions regarding their habits and assumed that they did something wrong. Some said that the CHC-nurse showed no interest in what kind of lifestyle habits they had, and instead instantly pointed out what to do differently, which made them feel accused. Those presumptions were unwarranted for those who had never met that CHC-nurse before.
It was the first time she met us, and sure, she does not know at all… then maybe you should not just assume that people eat junk food and sit still… (Parent 9).
The parents not only expressed feelings of being judged by the healthcare system, but also a fear that other people would question how they took care of their children and what habits they had.
...it feels like people think you give them candy every day, and just eat unhealthy food and never exercise (Parent 1)
One parent expressed that it is easy to have opinions about what other parents do, but when you find yourself in the same situation, it is not as simple as it seems.
Some parents felt divided since they were responsible for their children's habits and therefore causing the problem and were now responsible to put it right. It was perceived as against the parental instinct to limit the child's food intake, and it felt difficult to justify this to the children. One parent felt conflicted since others had difficulties getting their children to eat at all while she cannot give her child more food when he asks for it. For those who were separated from the other parent, it felt difficult to respond to questions about the child's food and eating habits since they could not speak for the other parent. Many wished the other parent should have been contacted as well, even those cohabitating, since it was described as hard to pass on information and advice, especially if the parents had different opinions on what is right for the child.
The relationship with the nurse influenced the experience
The parents highlighted the importance of respectful healthcare encounters and to establish a good relationship with their CHC-nurse. Those who felt they were treated nicely found it easier to handle the situation while parents who had a bad experience wished for more support. Many expressed that the CHC-nurse was insensitive and plump while telling them about the child's being overweight, and some perceived the CHC-nurse as harsh and insensitive which made them feel as if they were caught off guard. Encouragement was described as important, and one parent said that it would have been nice to hear calming and reassuring words. Those who did receive reassurance such as ‘it will probably even out’ said that even though it was comforting to hear, it felt like the CHC-nurse mitigated the problem or was afraid of stepping on her toes. Some parents expressed that the CHC-nurse seemed uncomfortable and had difficulties raising the subject, which made the conversation feel awkward.
A neutral and matter-of-fact approach was appreciated by the parents, and it was preferred when the nurse was calm and educational. It felt positive when she showed understanding for the sensitivity of the subject and the CHC-nurse's responsiveness made it easier to receive the message. Sensitivity and humility were requested by most parents, and one described the CHC-nurse as not empathetic at all, which made her wish for better treatment.
Whether the parents trusted the CHC-nurse or not was described as significant for the outcome of the conversation, and their trust was affected by the advice they got. Non-evidence-based advice affected their faith in the CHC-nurse in a negative way, and one parent found it questionable when they got advice to make more unlikable food to try to get their child to eat less.
One parent expressed lots of faith in her CHC-nurse which affected the situation positively, and even though it was a delicate situation it was not perceived as a negative experience. She explained that they had the same CHC-nurse since the child was born which had created a trusting relationship between them, and if someone else had given the information, it would not have been received in the same way.
...she [the CHC-nurse] really understands the problem in a different way[...] it feels like, the doctors who come at these check-ups who just go in and point[...] it doesn't get personal then, it's like this "okay you're talking about a chart, but I'm talking about my child", it's a bit different. (Parent 8)
It was described as difficult to have the conversation with a CHC-nurse they did not trust. One parent shared that she mistrusted the CHC-nurse since there was a history of being forgotten or double booked, and the room was empty and cold and there were no toys, so the child wanted to leave. Others lacked trust since they never met that CHC-nurse before, and one parent described that she felt unwanted during the entire appointment as the CHC-nurse sighed heavily in relation to every moment of the check-up.
What support the parents were offered from the CHC-nurse varied greatly, some received dietary advice, follow-ups and lots of information regarding being overweight while others got none at all. It was perceived in different ways since some did not want any information at all while others wished for more. It was also described as difficult to receive advice on what measures to take while still being in shock. Some did not want either advice or follow-ups, although many were offered extra weight checks or a referral to an obesity unit, which they had different opinions on. Some went there with their children while others felt it was an overreaction from the CHC-nurse.
...that we would get a follow-up, because it could also be something medically wrong. Like this, yes, but it's also pulling the trigger all at once... (Parent 2)