Issue: 2015, Vol 1, No 3, Pages 84–119

Growing up not out: The HENRY approach to preventing childhood obesity

Kim Roberts

Kim Roberts
Chief Executive of HENRY

Traditionally – and this is still true in many parts of the world, where infant mortality rates are high – weight gain was seen as an indicator of good growth and increased likelihood of survival. This perception runs so deep that not only are parents proud when their baby gains weight, but also there remains a widespread assumption that fat babies slim down once they start walking, with many healthcare professionals unaware that this is often no longer true.

In today’s obesogenic environment, a change of attitude is urgently needed. Rapid weight gain and obesity in the early months of life are linked to the development of long-term obesity (Baird et al, 2005). Most excess weight in children is gained before a child is 5 years old (Gardner et al, 2009), with some signs that the critical period is under the age of 2 years (Harrington et al, 2010). Once established, obesity is extremely difficult to reverse (James, 2008), and treatment of obesity in childhood and adolescence is very often unsuccessful, with high rates of relapse even when weight loss has been achieved (Epstein et al, 1998).

This is the bad news. The good news is that it is easier to prevent or reverse obesity early in life, when parents are most receptive to help and support, and when children are forming enduring food preferences and eating and activity habits (Skouteris et al, 2011).

HENRY (Health, Exercise, Nutrition for the Really Young) was developed in 2007 in response to an identified need for a preventive initiative rooted in the research evidence about the risk and protective factors for child obesity (Rudolf et al, 2010). Now a national charity, HENRY is widely commissioned by public health departments as a child obesity intervention focused on children aged 0–5 years and their families. Promising outcomes based on service evaluation (Willis et al, 2014) have resulted in an implementation optimisation study and pilot cluster randomised controlled trial being recently funded by the National Institute for Health Research (reference CDF-2014-07-052).

This article describes the unique HENRY approach to a healthy start in life and what we have learned about effective early intervention to prevent obesity.

The HENRY approach

Those involved in public health are all too aware that simply providing nutritional and activity guidance is unlikely to result in behaviour change, especially for families dealing with multiple challenges in their lives associated with socioeconomic deprivation. HENRY’s founders, Professor Mary Rudolf, a paediatrician and expert in child growth, and Candida Hunt, a parenting educator and behaviour change specialist, brought together their complementary knowledge and skills to create an innovative and multi-layered approach which recognises that the messenger is as important as the message. Content and process (see Table 1) go hand in hand to communicate key research-based messages for a healthy start in life (Rudolf, 2010) in a way that maximises the likelihood of positive change and builds family resilience.

Figure 1

Embedding the HENRY approach in local partnerships

As the causes of child obesity are complex, effective prevention requires an ecological approach, providing support for behaviour change and a healthy start in life within each system around the child, as shown in .

Figure 1

Over the past 8 years, HENRY has established ongoing partnerships with local public health departments, NHS Trusts and children’s services across England and Wales to embed a systemic model that includes workforce development, family programmes and community-based peer support. Over 10 000 practitioners have been trained in the HENRY approach and over 5000 parents have taken part in family programmes, with a current completion rate of 72% (defined as attending at least five of eight sessions; Willis et al, 2015).

Support for parents to enable them to adopt a healthy family lifestyle

The 8-week HENRY family programme is delivered as part of universal services in children’s centres in disadvantaged areas in 36 Local Authorities. Group sessions are either delivered by local healthcare and early-years practitioners who have been trained by HENRY or they are directly delivered by HENRY staff. A targeted one-to-one equivalent is offered to families in need of more intensive support, for instance if there is already concern about a child’s weight.

The programme content integrates the key elements of a healthy family lifestyle shown in Table 1. A distinctive element of HENRY is its focus on parenting, emotional wellbeing and whole-family lifestyle as a foundation for enabling young children to develop healthy food preferences and eating and activity habits right from the start. Parental modelling and an authoritative parenting style that fosters loving parent–child relationships whilst enabling parents to hold firm boundaries both have a major influence on, for example, young children learning to enjoy vegetables or on how much television they watch. Equally, helping parents to use alternatives to food to comfort or reward their children is important because of the emotional associations of energy-dense food – when is the last time you overheard a parent in a supermarket promising their child a carrot on the way home for being so helpful?

The programme aims to be fun and interactive, and satisfaction and retention rates indicate it is popular with parents. Analysis of data from 144 programmes delivered between January 2012 and February 2014 showed that, of 1100 parents who enrolled or attended a taster session, 788 (72%) attended at least five of eight sessions. Matched pre-post questionnaires were available from 624 (79%) of those parents who completed the programme. Of these, 596 (96%) reported that they felt great (71%) or good (25%) about the programme and 516 (83%) reported that they would definitely recommend the programme to others (Willis et al, 2015). A strengths-based and solution-focused approach is integral to the delivery style, building confidence and motivation and helping parents move from “I can’t...” to “How will I…?”

Positive self-reported changes include the following (Willis et al, 2014):
- Increased consumption of fruit, vegetables and water, and reduced consumption of energy-dense foods and sugary drinks in both adults and children.
- More frequent family meal times.
-Reduced screen time.
-Increased physical activity for the whole family.

At a follow-up focus group conducted as part of a national service evaluation, one parent described the impact of the programme:

“I thought it would feel like school but it doesn’t. No-one tells you what to do, you learn for yourself and from the others in the group. HENRY is a real eye opener – it’s turned our life round and we are much healthier now. My son is an only child so I’ve realised I need to eat with him and eat healthier foods – who else is he going to copy?”

Workforce development: Moving from problem to solution

Health practitioners are uniquely placed to provide timely, skilled support to parents at the start of a child’s life. Worryingly, however, research suggests that the majority of practitioners do not feel comfortable raising sensitive weight and lifestyle issues with parents – and even when they do, they do not consider it to be effective (Edmunds et al, 2007; Redsell et al, 2013). Practitioners who are themselves struggling with their weight are even less likely to start conversations about lifestyle issues with parents, which, given that the obesity profile of NHS staff mirrors that of the general population, compounds the risk of missing crucial opportunities to intervene early.

To address this risk, HENRY 2-day training courses (see Figure 2) equip practitioners with the skills, knowledge and confidence to help parents adopt a healthy family lifestyle right from the start, and to respond effectively to signs of rapid weight gain and obesity in infants and young children.

Figure 1

Many practitioners coming to HENRY training talk about the frustration of working with “resistant” parents who believe they are fine the way they are. In the words of one health visitor describing her work with the mother of an obese 3-year-old: “I sit there giving her advice and I know she’s not going to follow any of it”. By adopting the HENRY approach, practitioners find they are able to get alongside parents and do more listening than talking, using their expertise to ask the right questions rather than provide the right answers. The results are often transformational: building relationships based on respect and empathy and starting with a parent’s strengths creates the conditions for change, enabling parents to reflect on their family lifestyle non-defensively and decide their own goals for change and how they are going to achieve them.

A longitudinal study demonstrated that this brief 2-day HENRY training has a long-term, profound impact on practitioners’ professional and personal lives, increasing their confidence and skills to tackle lifestyle change, with benefits sustained up to 5 years after completing training (Brown et al, 2013). Research also indicates that the training results in positive changes to children’s centres’ policies and practice, including provision of age-appropriate portion sizes and healthy snacks and strengthened team working (Willis et al, 2012).

The impact of the training is illustrated in the words of a health visitor who described the impact of the 2-day training on her practice:

“HENRY training has helped me to do a better job as a health visitor. Before the training, when I met a family where I had concerns about weight and lifestyle habits I didn’t feel confident in how to handle the conversation and I tended to ask them if they knew about their child’s nutritional needs and then direct them to a load of nutritional information. I knew it wasn’t particularly effective as I would see the same families coming back with their next child a couple of years later and it was obvious they weren’t living a healthy family lifestyle.
“The HENRY training was a revelation. It gave me the insights and skills I needed to help me have a conversation with parents that actually works. It has also given me amazing techniques that I can use with other issues families may be experiencing.
“I put HENRY into practice straight away. On my very first visit the HENRY techniques worked wonderfully. Mum opened up as we explored her concerns together using the HENRY resources and then it was lovely to see her having a go with some new ideas there and then with her toddler – and to see them working. I saw the family again recently and mum, toddler and baby are all doing really well.”

Reaching the not-yet-reached: Changing communities

The association between poverty and obesity (Health and Social Care Information Centre [HSCIC], 2013) means that effective early intervention needs to overcome barriers experienced by different socioeconomic and ethnic groups in accessing preventive health services. HENRY has developed a range of peer support models, working with parents as agents of change within their own local communities and building resilience to the obesogenic environment.

These peer support models aim to overcome barriers in both reaching and engaging parents, as well as providing tailored and culturally acceptable support. Trained volunteers who speak the appropriate languages lead community-based activities to provide a stepping stone to joining a local HENRY programme and to help families maintain changes they made whilst attending the programme, as well as offering more intensive and structured one-to-one support to vulnerable families.

The HENRY vision: Successes and challenges

Our evidence-based and systemic approach to helping babies and young children have a healthy start in life over the past 8 years has given us confidence that it is possible to turn lives around – if families get skilled and sensitive support early enough. Although definitive conclusions about impact will not be possible until the results of the randomised controlled trial are available, National Child Measurement Programme data suggest that a coherent strategy to tackle child obesity in the early years can make a real difference. In Leeds, where HENRY is embedded in the city-wide obesity strategy and every healthcare and early-years practitioner has been HENRY-trained, obesity rates at Reception Year have fallen across the city from 10.3% to 8.7% over a 5-year period, during which time national trends have remained almost static. Very encouragingly, the gap between obesity rates at age 5 in the least deprived and most deprived areas of Leeds is narrowing, with obesity rates dropping from 13.8% to 10.9% in the most deprived areas over the 5 years (Burkhardt, 2013).

We know from what parents tell us, and from independent service evaluation, that families completing the HENRY programme make significant improvements to their lifestyle, including healthier eating across the whole family, increased activity levels and increased parenting efficacy, and that these are maintained at follow-up (Willis et al, 2014). Analysis of data from a sample of 601 parents who attended the HENRY programme between January 2012 and February 2014 showed an increase in the number of times a day their children ate fruit and vegetables (Willis et al, 2015). At the beginning of the programme, parents reported that just 22% of their children were eating fruit and vegetables five times a day, similar to the national average (National Obesity Observatory, 2012). By the end, this had risen to 44%. Furthermore, HENRY’s emphasis on enhancing the skills, knowledge and confidence of healthcare and early-years practitioners has resulted in wider benefits to professional practice, children’s centre policies and practitioners’ own lifestyles (Willis et al, 2012; Brown et al, 2013).

Figure 1

Concluding remarks

The start of life is a crucial window of opportunity, both to protect children from the emotional and physical consequences of obesity, and to reduce the burden on the NHS of obesity-related illness. Continued pressure on public spending means that making the most of this window of opportunity to achieve maximum and long-term value and efficiency for every pound spent has never been more important.

The positive impact of HENRY’s holistic approach on family lifestyle, as well as children’s food consumption and activity levels, suggests that prevention in the early years can make a real difference. Demonstrating return on investment in prevention is notoriously difficult, and we welcome the opportunity of the National Institute for Health Research-funded trial to further national and international understanding of the long-term impact of investment at the start of life.

Further information

More information about HENRY is available at: www.henry.org.uk

Contact details

Tackling child obesity requires a whole system approach. The author would welcome the opportunity to discuss the work of HENRY in more depth with others involved in promoting a healthy start in life and can be contacted at: kim.roberts@henry.org.uk


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