Abstract
Cardiovascular disease (CVD) is the leading cause of death both globally and in the United States. Obesity is a well-established risk factor for CVD with strong intergenerational linkages. Poor cardiovascular health and obesity tend to cluster in families due to common genetics and the shared obesogenic environment, including poor diet and low levels of activity. Previous literature consistently demonstrates the intergenerational transmission of cardiovascular risks and obesity from parent to child, especially among older children and adolescents. The transmission of obesity extends even further from maternal grandmother to young grandchildren. In order to reduce disease burden and promote health in future generations, it is imperative to understand the complexities of health risk transmission by identifying socioeconomic, intrapersonal, and interpersonal factors within an intergenerational family context that may contribute to family health behaviors and outcomes of CVD and obesity.
The current dissertation study outlines three sub-studies that encapsulate an intergenerational approach to cardiovascular health and childhood obesity prevention. Based on a review of the literature assessing intergenerational transmission of CVD risks, a majority of studies have been conducted outside the U.S., and studies that have been conducted in the U.S. have not examined Hispanic American families who are disproportionately affected by both higher rates of obesity and hypertension. Seeking to fill this gap in the literature, the first sub-study’s objectives examined: 1) The relationship between parental BMI and adolescent BMI; and 2) The relationship between parental blood pressure and adolescents’ blood pressure in a sample of Hispanic parents and adolescents (n=280) using baseline data from an obesity-focused efficacy trial. Results from a series of logistic regression models showed that parent obesity contributed to a higher likelihood of adolescents being severely obese when compared to reference groups of both overweight adolescents and obese adolescents even after controlling for adolescent lifestyle behaviors and parental education. Compared to those of normal blood pressure status, adolescents of parents with elevated blood pressure/hypertension were more likely to have elevated blood pressure even after controlling for adolescent lifestyle behaviors. Similarly, elevated blood pressure/hypertension in parents resulted in a greater likelihood of adolescents’ hypertension.
Secondly, the extant research has not explored discordant parent-adolescent pairs with regard to weight status (e.g., parent in the overweight (OW) or obese (OB) weight range and adolescent in the normal weight range; adolescent in the OW/OB weight range and parent in the normal weight range) and has largely focused on concordant intergenerational relationships for cardiovascular indicators, weight status, and lifestyle behaviors. Elucidating mechanisms that contribute to differential health behaviors and outcomes in parents and children can help in identifying risk and protective factors for future family-based intervention targets. Using baseline data from the National Cancer Institute’s Family Life, Activity, Sun, Health, and Eating (FLASHE) study on parents and adolescents (n=1,516), the second sub-study’s objectives examined: 1) Distinct concordance and discordance of parent-adolescent BMI patterns; and 2) Multiple sociodemographic, individual-level (i.e., individuals’ healthy behaviors and psychosocial factors), and family-level factors (i.e., domain-specific parenting practices and access and availability in home environment) and their associations with distinct concordance and discordance of parent-adolescent BMI patterns. To examine unique (additive) effects of all sociodemographic, individual-level, and family-level factors on distinct patterns of parent-adolescent BMI, a series of stepwise multinomial logistic regression models were run. Fathers (vs. mothers), low socioeconomic status (SES), and identifying as non-White (i.e., Hispanic, Black, or Other) were significantly associated with parent-adolescent dyads being more likely to be in either Unhealthy Discordance-does not favor parent or Unhealthy Concordance BMI pattern groups than the Healthy Concordance group, which held after adjusting for both individual-level and family-level predictors. Intrapersonal (psychosocial) factors of emotional eating and self-efficacy for physical activity (PA) were significant and strong predictors of parent-adolescent BMI patterns.
Lastly, an emerging body of literature reveals that intergenerational clustering of obesity among family members extends beyond parents, with grandparent obesity being linked to grandchild obesity. Research has shown that grandparents tend to have an adverse impact on their grandchildren’s health behaviors and weight status, despite their desire to be advocates for their grandchildren’s healthy behaviors. Thus, designing health promotive interventions to address this need may simultaneously aim to halt the transmission of obesity and CVD risk factors. Using a user-centered design approach, the third study sub-study sought to conduct formative work to inform the design of an intergenerational PA program for grandparents and grandchildren (ages of 6-12 years old) among an ethnically diverse population. Grandparent participants (n=35) completed a quantitative survey, with a subset (n=12) being invited back for in-depth qualitative interviews. The quantitative results revealed that the majority of grandparents reported mobile device proficiency, very close relationships with their grandchildren, and interest in participating in an intergenerational intervention. Four key themes emerged from the interviews as intervention considerations: 1) Enhance their existing close and loving bonds with grandchildren; 2) Consider how grandparents navigate their grandparent role with parents as gatekeepers; 3) Address challenges in keeping up with grandchildren and competing with school activities; and 4) Leverage grandchildren’s technology proficiency to improve health. An 8-week, technology-based intergenerational PA intervention for grandparents and grandchildren was developed based on these findings and is ready for pilot testing.
In summary, the findings from this dissertation study highlight the strong intergenerational relationships among parents, children, and grandparents. Future research should be focused on culturally relevant interventions that can simultaneously reduce cardiovascular disease risks among ethnically diverse families by supporting both parents and grandparents in adopting strategies that can help improve lifestyle behaviors and promote healthy lifestyle behaviors in children.