Talking to children about weight–how is guidance for parents being used by professionals?

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Rowan Brockman, Fiona Gillison, Elisabeth Grey, Russell Jago, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6254356/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: One in five children starting primary school in England are living with overweight or obesity, rising to one in three by the end of primary school. In England, the prevalence of overweight/obesity of children is monitored through the annual National Child Measurement Programme (NCMP). Research suggests parents often lack confidence in discussing weight with their children. In 2021, evidence-based guidance was produced for parents of young children to facilitate these conversations, but it is unclear how this guidance is being promoted to parents or used by public health practitioners (PHPs). This study evaluated the implementation of parental guidance on talking to children about weight. Methods: We conducted a mixed-methods study, including a national online survey and in-depth qualitative interviews with public health practitioners working on children’s healthier lifestyles programmes in the UK. Invitations to participate were distributed via the Office of Health Improvement and Disparities (OHID) and regional and national networks. Online interviews were audio-recorded, transcribed, and analysed thematically. Survey data were descriptively reported. Results: Twenty-one participants completed the survey; twenty-four were interviewed. Practice varied between organisations with the guidance being used in NCMP letters to parents, in follow-up phone calls with parents, and in training NCMP staff and other health or education professionals. Participants valued the evidence-based guidance and its compassionate tone, feeling it gave them, and parents, confidence in addressing a sensitive topic. Some felt it was too lengthy for parents with learning disabilities or low literacy levels. Others identified a need for similar guidance for older children. Though helpful, participants acknowledged the guidance was only one small part of a necessary systems-wide approach to promoting healthy weight. Conclusions: The guidance is a useful tool but needs systematic promotion to increase use and effectiveness. Further work is warranted to develop adapted versions for other populations. obesity overweight children parents NCMP UK qualitative guidance public health weight management healthier lifestyle Figures Figure 1 Background One in five (22%) children starting primary school (aged 4–5 years) in England are living with overweight or obesity. By the end of primary school, this figure rises to over one in three (36%)( 1 ). Children in the most deprived areas are over twice as likely to live with obesity than the most affluent children ( 1 ). Children living with overweight or obesity are more likely to be bullied ( 2 ), experience low self-esteem and body dissatisfaction ( 3 ), and obesity in adulthood ( 4 ), which increases the risk of chronic disease ( 5 ). In England, the National Child Measurement Programme (NCMP) annually monitors the prevalence of overweight and obesity in Reception (4–5 years) and Year 6 (10–11 years) children across local authorities (LAs), unless parents/caregivers withdraw their child ( 6 ) (hereafter referred to as parents). In most LAs, measurement teams inform parents if their child is over- or under-weight, often providing links to further support, such as online information or details of local child weight management programmes (also known as healthier lifestyle programmes) ( 7 ). Participating in the NCMP may prompt conversations about weight which parents may find challenging. Parents fear such conversations may damage their child’s self-esteem or contribute to the development of eating disorders ( 8 , 9 ). While many parents wish to help their child maintain a healthy weight, research highlights parents lack confidence in communicating positively about weight ( 10 ), a point reiterated by the public contributors on this project. Consequently, practitioners delivering the NCMP have expressed a need for guidance for parents to assist them with these conversations ( 11 ). To address this parental need, a team of academics developed the guidance document, ‘Talking to your child about weight: A guide for parents and caregivers of children aged 4–11 years’, first published in 2021 and updated in 2023 ( 12 ). Aimed at parents of children of any weight, it seeks to increase parental confidence in handling weight-related conversations. It was developed drawing on: systematic reviews on parent communication about weight/health ( 13 ) ( 14 ); interviews with children; key message development ( 15 ); and a modified Delphi process with parents, health professionals and academics. A description of this process is available ( 16 ) and the guidance content is outlined in Box 1. Box 1: Guidance overview Talking to your child about weight: A guide for parents and caregivers of children aged 4–11 years ( 12 ) The aim of this guide is to help parents and caregivers talk with their children about weight in a positive way. It gives tips and advice on what to say and do to help children be healthy and feel good about their bodies. This guidance is for parents and caregivers of children of all shapes and sizes. Section 1: Should I talk to my child about their weight? Section 2: The whole family counts Section 3: Top tips for talking to your child about weight Section 4: How to help your child feel good about their body Section 5: What if I am struggling with my own weight? Section 6: What could I say when…? Section 7: Links to further advice and information Contents page reproduced with permission of the authors. The guidance was developed with the intention that staff involved with NCMP delivery would signpost parents to it. Feasibility research in 2021 with school nurses identified several methods and stages in the NCMP process where the guidance would be useful ( 11 ). An e-learning course was created for public health practitioners (PHPs) and other staff, to build confidence in using the guidance with parents ( 17 ). With no funding for broad dissemination, the guidance was included in a toolkit by the British Dietetic Association ( 18 , 19 ) and hosted on the University of Bath website ( 12 ). Guidance authors felt this was a pragmatic solution that could increase parents’ trust in the resource, given these were professional and academic organisations. The guidance was adopted by England’s Office for Health Improvement and Disparities (OHID) and promoted to school nurses and NCMP delivery teams through regular briefings ahead of the 2021/2022 school year. The resource was also promoted to Local Authority (LA) staff and school nurses at four regional and national OHID events between 2021–2024, and other network meetings hosted by Obesity UK (2021) and Food Active (2021/23). A link to the guidance was added to template NCMP letters in 2024. However, its promotion to NCMP leads and relevant groups has been inconsistent. Consequently, it is unclear how it is being shared with parents or used by child weight management professionals. This mixed-methods study aimed to understand if and how the guidance is currently used in child weight management services and explore barriers and facilitators to its implementation. Methods Study design We used a mixed-methods study design (survey and interviews) with practitioners working in child weight management and NCMP delivery. Participants and recruitment We recruited survey and interview participants by contacting professionals in child weight management groups and NCMP delivery. While the NCMP only runs in England, health practitioners in Wales and Scotland who run similar programmes and had received the guidance, were also eligible. We outlined the study and invited them to participate in the survey and/or interview. Participants could participate regardless of prior or current use of the guidance. Participants were contacted through multiple channels: OHID promoted the study in their February and April 2024 updates to NCMP regional leads, and regional leads shared it with local healthy weight networks. At a January 2024 OHID webinar, 345 stakeholders (LA public health teams, PHPs and school nurses) were invited to participate, with a survey link provided. The study was also shared through our own networks of those known to be familiar with or using the guidance. Participants accessed the survey via a link or contacted RB/FG to arrange an interview. Participants could also sign-up to an interview via the survey. We interviewed all participants who expressed an interest. Online Survey Data collection The online survey focused on participants’ awareness of the guidance, if/how it was used, perceived impact on parents, plans for future use, and relevance for their local population [see Additional file 1]. We also collected details of their organisation and role. The survey was open between January and April 2024. Data analysis We downloaded survey data into an Excel spreadsheet. Closed-response questions were tabulated. Free text responses were analysed qualitatively, using a coding framework (described below). When both survey and interview data came from the same LA or organisation, we compared data to identify discrepancies or additional details. Qualitative interview study Data collection Interviews were conducted online between February-May 2024. Some participants requested a joint interview with other team members due to shared roles. We used a broad topic guide focusing on similar topics to the survey [see Additional file 2]. Interviews were conducted by RB, lasted 23–62 minutes, were audio-recorded and transcribed verbatim. Data were stored on secure servers. Participants were offered a £25 voucher for their time. Data analysis Transcripts were anonymised and analysed using codebook thematic analysis ( 20 ). RB and RL independently reviewed three transcripts, noting potential codes to develop an initial coding framework. Codes were developed deductively from research questions, and inductively from participant responses. RB and RL used this framework to independently code two transcripts (using NVivo) revealing consistency in coding and interpretation. RB coded all subsequent transcripts, making additions/modifications where necessary. Codes and sub-codes were examined, compared and revised to develop three descriptive themes. Quotes are labelled as S (for survey data) and P (for interview participant). If participants provided both, we present both identifiers e.g. “S15/P08”. Ethical approval The study was approval by the University of Bath Research Ethics Committee for Biomedical Sciences (Ref: 2470-3145). Survey participants gave consent before completing the survey. We obtained verbal consent from participants before interviews. Public involvement We recruited four public contributors who were parents/carers of primary-school aged children (of any weight status) via Obesity Voices and People in Health West of England. Due to project timings, public contributors were not involved in the study design but offered perspectives on the results and contributed to the focus of the discussion. Results Survey participants Participants’ characteristics are shown in Table 1. Twenty-one participants completed the survey; all but one were female. Fifteen were employed by LAs (representing 11 different LAs); four worked for the NHS; and two were employed by a community interest company or social enterprise commissioned to deliver the NCMP. Participants’ job titles varied, but most worked as weight management, well-being or health improvement practitioners, community nurses, or public health/weight management service leads. Table 1 Survey and interview participants characteristics Survey participants Interview participants Total 21 24 (across 16 interviews) By organisation Local authority 15 14 NHS 4 9 Other* 2 1 By region Scotland 1 1 North East 0 0 North West 1 1 Yorkshire & the Humber 1 4 East Midlands 2 3 West Midlands 4 6 East of England 1 0 London 4 4 South East 1 0 South West 5 5 unknown 1 0 * Private provider, community interest, social enterprise. Ten participants took part in both the survey and an interview. Survey results The survey indicated the guidance was currently being used in staff training (n=6), to inform staff practice (n=6), in phone calls with parents to discuss NCMP results (n=6) or provided to parents as an electronic link in NCMP invite (n=5) or results (n=6) letters (Figure 1). No respondents reported providing printed copies of the guidance to parents. Six respondents reported the guidance had influenced their protocols, such as creating a shortened version of the guidance which was sent out with NCMP invite letters (S1/P1), sending electronic versions to families accessing specialist weight management services (S1/P1), and informing the development of a parent workshop (S11). Other reported changes included being more aware of the language they use (S12/P09), approaching weight management in a more sensitive way (S5/P03, S2/P07), and emphasizing to parents this is “a difficult topic to talk about and that they're not alone - so much so that a resource like this has been introduced. ” (S15/P08) Seventeen respondents reported currently using the guidance, and all planned to continue. Four respondents stated they did not use the guidance, having just become aware of it: three said they would use it in the future; the fourth did not comment on future plans. Interview participants Participant characteristics are shown in Table 1. Twenty-four participants were interviewed across sixteen interviews; all but one were female. Ten participants were recruited via the survey, with the remaining recruited via regional NCMP leads and study team contacts. Fourteen were employed by LAs (representing six different LAs); nine worked for the NHS; and one was employed by a community interest company. Participants’ job titles were similar to those completing the survey (described above). Interview results 1. How the guidance is currently used Interview data corroborated survey findings that the guidance was mainly used in NCMP letters, parent phone calls, and as a training resource. NCMP parent letters The guidance was often included in NCMP information sent to parents, either in the invite letter (sent to all Reception/Y6 parents) or the child’s results letter (sent out if the child is identified as over- or under-weight). Letters either included a direct link to the guidance or directed parents to the organisation’s website where they could find the link: “[It’s] linked into our NCMP letters, …and we say, ‘If you want to talk to your child about their weight, here is a resource that you can use.’” (P20) Some participants felt the guidance link should be included in the NCMP invitation letters so all families could access it. However, several NCMP organisations did not mention the guidance in their standard communications with parents. In some cases, there appeared to be an element of professional gatekeeping, with participants suggesting they were selective about which parents it would be appropriate for: “When I know a parent will be able to cope with the length of that document I will send it to them, but… I’m not going to send it to a parent where I know there’s literacy issues or that they will not sit and read a 12 [sic] page document.” (P01) (NB: the official document is 20 pages). Follow-up phone calls to parents In some regions, the guidance was used in phone calls with parents whose child had been identified as outside of the healthy weight range. The guidance was either mentioned during the call or sent to parents afterwards. As one participant explained, parents often worry about sharing the NCMP result with their child, making it a suitable time to introduce the guidance: “If a parent's not sure, should I speak to my child? … We will suggest you do what you think is best for you and your child. However, we have this [guidance], which is brilliant, that you can read through. It's got lots of ideas if you're not sure how to start that conversation.” (P19). Another found the guidance useful in starting conversations with parents and in “manag[ing] any resistance or frustration as it can be a sensitive topic” (S14/P16). Training and supporting health and education professionals Participants discussed how the guidance was used to train staff delivering the NCMP. For example, although aimed at parents, one LA used the guidance in a training session with the staff conducting the weighing and measuring in schools: “We gave it to [NCMP] staff because they were saying sometimes children can make comments when they're being weighed that they wanted to follow up on… We felt that it was only right that they were a bit more confident with how to answer those questions or with what to say and how to approach that.” (P10/S10) The same LA also developed a 90-minute stand-alone training session for parents or professionals and were currently adapting it for further audiences including for General Practitioners (GPs) and practice staff. Other participants used the guidance in their regular training update for school nurses, with one explaining she emailed it to her team saying, “If you’re speaking to a parent and they’re not sure how to talk to their children, email them this document.” (P19). Others talked about including it as a key resource for staff: “It's been [used] in the electronic resource packs… for school nurses and health and well-being assistants… should they need any help around any topic… It's in our [healthy weight folder] and people access it as and when.” (P22) Several participants had used the guidance to train staff not directly involved with the NCMP. For example, the guidance was “signposted at multiple stages in our [staff] on-boarding” (P02) in an organisation commissioned to deliver weight management services by a LA. One participant incorporated it into their training for health professionals, noting a GP had commented how it was “quite helpful to have that tool, and to have something to be able to give parents as well” (P20). Another participant had not used it with GPs yet but felt this group might benefit from it: “We get feedback from families [about] how healthy weight was raised from GPs and it’s not always positive. I think they would be a really… key group for this resource to be shared with.” (P01) It was also shared with educational professionals who, though not directly involved in delivering the NCMP, often faced weight-related conversations due to the measurements being taken in school. P15 explained they told schools about the guidance, with P16 adding: “I think it's really beneficial for those that aren't in this line of work, to have something to refer back to that they can use if they're a little bit unsure… if it's a staff member at school that's never really brought up that subject, it's really useful for them”. Staff in another LA explained they referred schools to the online e-learning module on the guidance and “encourage the schools… to have around by 50% of their staff… complete the training” (P05). Another participant mentioned sharing it with Early Years (pre-school) staff explaining, “I know it’s not aimed at that age range, but I still think it’s an important one for them to be aware about” (P09). 2. Benefits of using the guidance Participants frequently spoke of a sense of relief at discovering the guidance, and that it filled a significant gap: “I just don’t think there was anything… else like it [that] pulled [advice] together in one place.” (P01). Another participant talked about the guidance generating ‘excitement’ during staff training: “People were really keen and interested and enthusiastic about the document and thought, ‘yeah, this will be brilliant! This is just what parents need, and I'm definitely going to use it and share it.’” (P22) Participants felt reassured the guidance had been developed by academics and was therefore backed up by research evidence. This increased their confidence in recommending it to parents: “It's a no brainer, it's researched, evidence-based, and … it's just a tool that we've got in our tool bag now that we can use for ourselves, or for parents. It’s great.” (P19) The style and tone of the document was also welcomed, with one participant noting that the language fitted with their LA’s approach to weight management: “The language we're trying to use particularly around NCMP… is that it's about healthy growth at all sizes and that more compassionate, less stigmatising language. And [having] that in bold at the front of the guide really helps us to say, ‘This isn’t just for you and your family, this is all families.’” (P07) (Note: this participant is referring to page 2 of the guidance which states “This guidance is for parents and caregivers of children of all shapes and sizes.”) Importantly, many participants talked about how the guidance boosted people’s confidence in talking about a difficult and sensitive subject. One participant felt it “helped remove some of that fear ” (P07) parents have about discussing weight. Another appreciated the practical examples of what to say and how to say it: “it's good where it talks [about] you [can] try this phrase or rephrase it that way ” (P14). Several participants recognised that teachers rarely receive training on how to have these conversations and the guidance could help fill that gap: “I think it's really beneficial for those that aren't in this line of work, to have something to refer back to… if they're a little bit unsure. Because it can be quite challenging. It's challenging for us, and we've done it for years! But if it's a staff member at school that's never really brought up that subject, it's really useful for them.” (P16) Even school health assistants conducting phone calls with parents may not have received training and again the guidance proved useful: “It was a really useful… because it’s exactly what we needed for the phone calls. Because hardly any of us have had training in how to raise the issue of weight because it’s been quite a taboo subject… it was useful to be able to share what wording to use.” (P21) 3. Limitations of the guidance While feedback on the guidance was overwhelmingly positive, participants identified some features which might limit the accessibility of the guidance for particular groups. The guidance is 20 pages, which some participants felt was too long for parents with low literacy levels: “When you think that a lot of our children who are of an unhealthy weight, they come from deprived backgrounds, where there is low level literacy skills, parents will struggle then to access it.” (P05) In response, one participant reported developing a shortened version for “parents who will not be able to read that entire document” (P01/S01). Others felt it might need to be adapted for use with parents with learning disabilities. One participant explained they might provide these parents with the whole document but would direct them to “snippets of the guidance [that]… would work for the family,” adding the conversation would need to be “tailored… to what their understanding would be” (P14). Additionally, some participants suggested more could be done to make the guidance culturally inclusive: “We have a vast diversity of languages in the borough and lots of our families have a fairly low level of English… so we felt that maybe it could be translated into some key languages …Also some of the imagery wasn't always reflective of our population.” (P13) Several participants suggested there was a pressing need for similar guidance parents of teenagers who may be particularly worried about the sensitivities of discussing weight with their children. “If I was to have one ask it would be that the next iteration is targeted at the 13 to 18 age group… [that] would be really powerful, particularly because there’s a lot of misconceptions and … conflicting evidence about the risks of talking to teenagers about weight and the concerns that it generates eating disorders.” (P02) More complex issues about the utility of the guidance were raised by other participants. One participant noted that while a step in the right direction, the guidance on its own was unlikely to change much: “There’s lots of reasons as to why parents wouldn’t want to talk about healthy weight with their kids. And I think the guidance is a really useful tool but I’m not necessarily sure just by looking at that in isolation that would make too much of a difference.” (P01) Several participants also noted in the context of significant deprivation, discussions around weight simply weren’t a priority for many families: “I’ve given it to parents for them to kind of take away and have a little read but… healthy eating and exercise comes bottom of the list when they’ve got so much on their plate… it’s all those barriers and all those struggles that they’re having and the money issues … [It’s] all those other areas… that need to be addressed first.” (P09) Another felt the guidance was useful but was unsure how it could adequately counter the negative framings encountered in society more generally: “Whilst [the guidance is] absolutely great, how do you manage that against the alternative messages that children and families are getting...[in] social media, marketing, films?” (P18) This concern for consistent messaging was echoed by other participants who felt all the professionals a family might encounter needed to use the same approach: “For me it's about making sure that all the messaging that goes out to families is coordinated… so that families are receiving the same information from various different sources.” (P20) This participant went on to consider whether parents – particularly those in the most challenging circumstances - could or should be asked to address an issue which she felt was a systemic and environmental issue: “There's a huge assumption that every parent has the ability and capability to be able to have that conversation in an appropriate and compassionate way with their child…. It puts a lot of responsibility on the parent when actually we deeply believe it's a system issue and environmental issue…” (P20) Discussion This study explored the implementation of a parental guidance document on talking to young children (4-11yrs) about weight. Some organisations provided parents with a link to the guidance via NCMP letters or referred to it in follow-up phone calls. It was also used in training and support for health and education professionals, including GPs and teachers. Participants were positive about the guidance, noting it ‘filled a gap’ by providing an evidence-based and tonally-sensitive document which increased their own and parents’ confidence in addressing a sensitive issue. Potential limitations of the guidance that may prevent wider implementation included its suitability for those with lower literacy levels, the need for additional parental (and professional) guidance on discussing weight with adolescents, and recognition that the guidance was just one small part of a much-needed systems-wide approach to tackling overweight and obesity. The study was planned as a mixed-methods evaluation of implementation but, despite a varied recruitment approach endorsed by OHID, recruitment to the survey was low (N=21) compared with a previous NCMP survey that received responses from 92 LAs (7). This limits our ability to assess the uptake of the guidance among LAs across the country. Of the responses we received, though some reported the guidance had been integrated into their practice pathways, other responses and informal feedback from study team members indicated low levels of awareness and use of the guidance in practice. This was not anticipated as the guidance had been introduced to local NCMP leads in a series of events from summer 2021 onwards and was included in the 2023/24 NCMP parent letter template which was launched at a well-attended event (N=345 PHPs) in January 2024. Additionally, the authors had worked directly with numerous LAs to support its use. Notably, some areas where staff had engagement with the accompanying e-learning module (N=12 requesting a completion certificate) did not respond to the survey, suggesting it did not always reach those most familiar with the guidance. High staff turnover within public health teams (21) may have meant that information was not passed on or retained beyond the initial PHP who received the guidance. Among survey respondents and interviewees, the guidance was considered useful and relevant, feeling it provided something new and supported their practice. This aligns with and extends initial pilot findings (11), and supports the need to extend implementation of the guidance at scale. Participants considered the guidance trustworthy, reassured by its clear link to an evidence base. While OHID guidance (22) is available for healthcare professionals in the form of a ‘conversation framework’ for talking to parents about the NCMP (issued 2019, updated 2023) this does not provide guidance on talking to children and is not suitable for sharing with parents. It was notable no participants referred to this partner guidance document in the present study, despite its availability since 2019, suggesting they lack awareness of this resource too. Barriers to using the guidance included its accessibility for families facing greater deprivation, from ethnic minority cultural backgrounds or with lower educational levels. Some PHPs did not share the guidance with those they felt would find it hard to access, resulting in a two-tier system. Given the perceived lack of inclusivity differentially influenced PHP practice in sharing the guidance with parents, this raises concerns about the potential to widen health inequalities which should be explored further. Our public contributors felt increasing access to the guidance in these more marginalised communities should be a specific priority for commissioners. Participants recognised the tension between helping parents to address children’s weight while avoiding feelings of blame. Providing the guidance to all parents, regardless of their child’s weight, may help reduce perceptions of stigma. Participants mostly endorsed this approach, noting the guidance is relevant for all parents, as even healthy weight children may worry about their weight or encounter potentially harmful weight-related content online. In past work (11), parents and school nurses suggested introducing the guidance in advance of the NCMP, giving parents time to address their own and their child’s emotional responses and concerns about the measurement process. However, parents may not find it relevant until they receive specific information about their child (11). This suggests use of the guidance may be enhanced by both embedding it into invitation letters and operational guidance to reduce gatekeeping on the part of practitioners, as well as making it available widely available to parents and health, social care and education practitioners working with children and families. Many interviewees found the guidance useful for other elements of their role, such as in children’s weight management services, and in links with schools and primary care, ensuring a common approach and language. Individuals are more likely to trust and adopt advice from health and care professionals when it is consistent (23), endorsing a case for wider distribution to professionals beyond the NCMP. In a recent study with GPs in Ireland, the guidance was perceived as useful in overcoming barriers to talking to families about children’s weight, avoiding stigma, and providing a framework for conversations (24). They also identified a need for advice to be consistent across multi-disciplinary teams. Our findings also suggest school staff may benefit from the resource, with our public contributors emphasising the importance of this group due to their daily interaction with children and because NCMP measurements take place within schools. Limitations Despite sending the survey out via multiple routes on several occasions, the response rate was low. Consequently, we cannot determine the extent of the guidance’s implementation across NCMP-delivery organisations, though the low response rate may suggest low levels of awareness. Furthermore, as those not using or unaware of the guidance did not volunteer for interviews, we cannot provide insights into the broader barriers to awareness and implementation. Given the limited number of participants, we were unable to sample to ensure geographical and occupational variation. There were no survey or interview participants from the North-East of England, and no interview participants from the East of England and the Southeast. Additionally, we are aware that the findings reflect a UK-based programme, and further research should look at similar measurement programmes in Europe (25), as well as non-mandated measurement experiences in the US (26), Canada (27) and Australia (28). Finally, survey/interview participation depended on who we reached within organisations, with responses inevitably influenced by factors like role, time in position, and personal views, as well as reflecting organisational approach. In some areas where we knew the guidance had been used extensively, staff changes meant we were unable to capture past implementation practices through our methods. Some participants referred to procedures or training suggesting the guidance had been adopted within standard practice, however, others responded based on their own experience and use, rather than representing policy within a given organisation. Recommendations The findings of this study and past work (11) indicate the guidance is useful, credible and relevant to professionals and parents, and fills a gap that is not met by other resources. This is further illustrated in those areas where staff had used the guidance to develop their own training, and initiatives involving schools and parents. However, the potential impact of the guidance is limited by lack of awareness, embedding into core processes and application to other groups. We therefore recommend: Stronger endorsement and branding of the guidance by OHID to allow systematic distribution and integration into operational guidance. Sharing best practice on how the guidance could be used e.g. in training for NCMP staff, multi-disciplinary teams and school staff; providing links in both the invitation and results letters; and within phone conversations with families. Adapting the guidance for different groups, including families with lower literacy levels (shorter or pictorial forms), different languages and for families with learning disabilities. Generating guidance for parents of adolescents with age-appropriate additional content and framing. Further research to explore the impact of the guidance on parents and children, and if/how it promotes children’s wellbeing and healthy weight (16). Conclusion Public health professionals viewed guidance for parents on talking to children about weight as useful for staff training and engaging with families. However, the guidance had not yet been embedded within core NCMP procedures and participants reported some limitations to wider implementation. Wider sharing of the guidance is needed to embed it within a system-wide approach to supporting children’s healthy weight. Abbreviations GP General Practitioner (also known as Family Doctor) LA Local Authority (Local government responsible for proving a wider range of services including public health provision.) NCMP National Child Measurement Programme NHS National Health Service OHID Office of Health Improvement and Disparities PHP Public Health Practitioner PPI Patient and Public Involvement Declarations Ethics approval and consent to participate The university of Bath’s Research Ethics Committee for Biomedical Sciences gave ethical approval for this study (Ref: 2470-3145). Participants gave informed verbal consent before participating in the interviews. Consent for publication Not applicable. Availability of data and materials Data from this study are stored at https://data.bris.ac.uk/data/ and are available under ‘controlled access’. Requests for use will be referred to the University of Bristol Data Access Committee for approval before data can be shared under a data sharing agreement. Competing interests The authors declare that they have no competing interests. Funding This research was funded by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West). The views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Authors' contributions The project was conceived by FG and EG. All authors contributed to the design of the study. RL oversaw the project. RB conducted interviews and analysed the data. RB, RL and FG produced the first draft of the manuscript. All authors contributed to the revisions of the manuscript including intellectual content and approved the submitted version. Acknowledgements We thank all the participants for their time and thoughtful discussions with us. We are grateful for the contributions of our PPI contributors, Elaine Tidswell, Lauren Wheeler, John Halliwell and Ed Brooks, supported by our PPI co-ordinator, Lucy Condon. References NHS England. National Child Measurement Programme, England, 2023/24 School Year. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/national-child-measurement-programme/2023-24-school-year; 2024. Cheng S, Kaminga AC, Liu Q, Wu F, Wang Z, Wang X, et al. Association between weight status and bullying experiences among children and adolescents in schools: An updated meta-analysis. Child Abuse & Neglect. 2022;134:105833. Moradi M, Mozaffari H, Askari M, Azadbakht L. Association between overweight/obesity with depression, anxiety, low self-esteem, and body dissatisfaction in children and adolescents: a systematic review and meta-analysis of observational studies. Critical Reviews in Food Science and Nutrition. 2021;62(2):555-70. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta‐analysis. Obesity reviews. 2016;17(2):95-107. Llewellyn A, Simmonds M, Owen CG, Woolacott N. Childhood obesity as a predictor of morbidity in adulthood: a systematic review and meta‐analysis. Obesity reviews. 2016;17(1):56-67. NHS England. National Child Measurement Programme. Available from: https://digital.nhs.uk/services/national-child-measurement-programme/. Čadek M, Flint SW, Tench R. Delivery of the National Child Measurement Programme in England. Public Health Nutrition. 2021;24(6):1177-84. Statham J, Mooney A, Boddy J, Cage M. Taking stock: A rapid review of the National Child Measurement Programme. 2011. Gillison F, Beck F, Lewitt J. Exploring the basis for parents’ negative reactions to being informed that their child is overweight. Public health nutrition. 2014;17(5):987-97. Ames H, Mosdøl A, Blaasvær N, Nøkleby H, Berg R, Langøien L. Communication of children’s weight status: what is effective and what are the children’s and parents’ experiences and preferences? A mixed methods systematic review. BMC Public Health. 2020;20:1-22. Baber F, Gillison FB, Grey EB. The acceptability of evidence-informed guidance for parents in talking to their children about weight. BMC Public Health. 2023;23(1):1357. Gillison F, Grey E, Chater A, Atkinson L, Gahagan A. Talking to your child about weight: A guide for parents and caregivers of children aged 4-11 years. Available from: https://www.bath.ac.uk/guides/talking-to-your-child-about-weight/; 2023. Gillison FB, Lorenc AB, Sleddens EF, Williams SL, Atkinson L. Can it be harmful for parents to talk to their child about their weight? A meta-analysis. Preventive medicine. 2016;93:135-46. Grey E, Atkinson L, Chater A, Gahagan A, Tran A, Gillison FB. A systematic review of the evidence on the effect of parental communication about health and health behaviours on children's health and wellbeing. Preventive Medicine. 2022;159:107043. Gillison FB, Grey EB, McConnell HE, Sebire SJ. Using narrative messages to improve parents' experience of learning that a child has overweight. British Journal of Child Health. 2020;1(5):220-30. Gillison FB, Grey EB, Baber F, Chater A, Atkinson L, Gahagan A. The systematic development of guidance for parents on talking to children of primary school age about weight. BMC Public Health. 2023;23(1):1704. University of Bath. Using the resource ‘Talking to your child about weight’: A training session for professionals. British Dietetics Association. Childhood Obesity Toolkit. Available from: https://www.bda.uk.com/specialist-groups-and-branches/paediatric-specialist-group/childhood-obesity-toolkit.html. British Dietetics Association. Leading Conversations. Available from: https://www.bda.uk.com/specialist-groups-and-branches/paediatric-specialist-group/childhood-obesity-toolkit/leading-conversations.html. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019;11(4):589-97. Royal Society for Public Health. The public health workforce: struggling to recruit and retain... but still delivering. Available from: https://www.rsph.org.uk/about-us/news/the-public-health-workforce-voicing-their-concerns-on-recruitment-and-retention.html; 2022. GOV.UK. National Child Measurement Programme: conversation framework. A conversation framework for talking to parents about the National Child Measurement Programme (NCMP). Available from: https://www.gov.uk/government/publications/national-child-measurement-programme-conversation-framework; 2019 (updated 2023). World Health Organization. WHO Strategic Communications Framework for effective communications. Available from: https://www.who.int/docs/default-source/documents/communicating-for-health/communication-framework.pdf; 2017. Twoomey. Exploring the acceptability and modes of use of new evidence-informed guidance for parents on talking to children about weight. MSc dissertation: University of Bath; 2024. WHO. WHO European Childhood Obesity Surveillance Initiative (COSI). Available from: https://www.who.int/europe/initiatives/who-european-childhood-obesity-surveillance-initiative-(cosi). Thompson HR, Madsen KA. The Report Card on BMI Report Cards. Current Obesity Reports. 2017;6(2):163-7. Government of Canada. Canadian Community Health Survey. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/food-nutrition-surveillance/health-nutrition-surveys/canadian-community-health-survey-cchs.html. Australian Institute of Health and Welfare. Australia's children. Available from: https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/overweight-obesity; 2022. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.docx Additionalfile2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6254356","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":431316433,"identity":"91a5b04f-27e2-4738-b9c3-4c781c7fb366","order_by":0,"name":"Rowan 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10:17:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1018588,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6254356/v1/eb95d25b-62cc-424e-814d-0fa96b8c8096.pdf"},{"id":78945695,"identity":"8b64adb7-0e5c-4451-938d-7fcf53ea4eb9","added_by":"auto","created_at":"2025-03-21 07:52:53","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":21500,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6254356/v1/09b82d67c2e4dfaeecc3e063.docx"},{"id":78945694,"identity":"f4aa2730-9c7f-4417-affe-07a07dd7d0b5","added_by":"auto","created_at":"2025-03-21 07:52:53","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":19809,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6254356/v1/3a4be5bf3d506d3836916564.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTalking to children about weight–how is guidance for parents being used by professionals?\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eOne in five (22%) children starting primary school (aged 4\u0026ndash;5 years) in England are living with overweight or obesity. By the end of primary school, this figure rises to over one in three (36%)(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Children in the most deprived areas are over twice as likely to live with obesity than the most affluent children (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Children living with overweight or obesity are more likely to be bullied (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), experience low self-esteem and body dissatisfaction (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and obesity in adulthood (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), which increases the risk of chronic disease (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn England, the National Child Measurement Programme (NCMP) annually monitors the prevalence of overweight and obesity in Reception (4\u0026ndash;5 years) and Year 6 (10\u0026ndash;11 years) children across local authorities (LAs), unless parents/caregivers withdraw their child (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) (hereafter referred to as parents). In most LAs, measurement teams inform parents if their child is over- or under-weight, often providing links to further support, such as online information or details of local child weight management programmes (also known as healthier lifestyle programmes) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipating in the NCMP may prompt conversations about weight which parents may find challenging. Parents fear such conversations may damage their child\u0026rsquo;s self-esteem or contribute to the development of eating disorders (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). While many parents wish to help their child maintain a healthy weight, research highlights parents lack confidence in communicating positively about weight (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), a point reiterated by the public contributors on this project. Consequently, practitioners delivering the NCMP have expressed a need for guidance for parents to assist them with these conversations (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo address this parental need, a team of academics developed the guidance document, \u0026lsquo;Talking to your child about weight: A guide for parents and caregivers of children aged 4\u0026ndash;11 years\u0026rsquo;, first published in 2021 and updated in 2023 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Aimed at parents of children of any weight, it seeks to increase parental confidence in handling weight-related conversations. It was developed drawing on: systematic reviews on parent communication about weight/health (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e); interviews with children; key message development (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e); and a modified Delphi process with parents, health professionals and academics. A description of this process is available (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and the guidance content is outlined in Box 1.\u003c/p\u003e \u003cp\u003eBox 1: Guidance overview\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTalking to your child about weight: A guide for parents and caregivers of children aged 4\u0026ndash;11 years\u003c/b\u003e (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe aim of this guide is to help parents and caregivers talk with their children about weight in a positive way. It gives tips and advice on what to say and do to help children be healthy and feel good about their bodies.\u003c/p\u003e \u003cp\u003eThis guidance is for parents and caregivers of children of all shapes and sizes.\u003c/p\u003e \u003cp\u003e\u003cb\u003eSection 1: Should I talk to my child about their weight?\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSection 2: The whole family counts\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSection 3: Top tips for talking to your child about weight\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSection 4: How to help your child feel good about their body\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSection 5: What if I am struggling with my own weight?\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSection 6: What could I say when\u0026hellip;?\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eSection 7: Links to further advice and information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cem\u003e Contents page reproduced with permission of the authors.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe guidance was developed with the intention that staff involved with NCMP delivery would signpost parents to it. Feasibility research in 2021 with school nurses identified several methods and stages in the NCMP process where the guidance would be useful (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). An e-learning course was created for public health practitioners (PHPs) and other staff, to build confidence in using the guidance with parents (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). With no funding for broad dissemination, the guidance was included in a toolkit by the British Dietetic Association (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and hosted on the University of Bath website (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Guidance authors felt this was a pragmatic solution that could increase parents\u0026rsquo; trust in the resource, given these were professional and academic organisations.\u003c/p\u003e \u003cp\u003eThe guidance was adopted by England\u0026rsquo;s Office for Health Improvement and Disparities (OHID) and promoted to school nurses and NCMP delivery teams through regular briefings ahead of the 2021/2022 school year. The resource was also promoted to Local Authority (LA) staff and school nurses at four regional and national OHID events between 2021\u0026ndash;2024, and other network meetings hosted by Obesity UK (2021) and Food Active (2021/23). A link to the guidance was added to template NCMP letters in 2024. However, its promotion to NCMP leads and relevant groups has been inconsistent. Consequently, it is unclear how it is being shared with parents or used by child weight management professionals.\u003c/p\u003e \u003cp\u003eThis mixed-methods study aimed to understand if and how the guidance is currently used in child weight management services and explore barriers and facilitators to its implementation.\u003c/p\u003e "},{"header":"Methods","content":"\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eWe used a mixed-methods study design (survey and interviews) with practitioners working in child weight management and NCMP delivery.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and recruitment\u003c/h2\u003e \u003cp\u003eWe recruited survey and interview participants by contacting professionals in child weight management groups and NCMP delivery. While the NCMP only runs in England, health practitioners in Wales and Scotland who run similar programmes and had received the guidance, were also eligible. We outlined the study and invited them to participate in the survey and/or interview. Participants could participate regardless of prior or current use of the guidance.\u003c/p\u003e \u003cp\u003eParticipants were contacted through multiple channels: OHID promoted the study in their February and April 2024 updates to NCMP regional leads, and regional leads shared it with local healthy weight networks. At a January 2024 OHID webinar, 345 stakeholders (LA public health teams, PHPs and school nurses) were invited to participate, with a survey link provided. The study was also shared through our own networks of those known to be familiar with or using the guidance.\u003c/p\u003e \u003cp\u003eParticipants accessed the survey via a link or contacted RB/FG to arrange an interview. Participants could also sign-up to an interview via the survey. We interviewed all participants who expressed an interest.\u003c/p\u003e \u003cp\u003eOnline Survey\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe online survey focused on participants\u0026rsquo; awareness of the guidance, if/how it was used, perceived impact on parents, plans for future use, and relevance for their local population [see Additional file 1]. We also collected details of their organisation and role. The survey was open between January and April 2024.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe downloaded survey data into an Excel spreadsheet. Closed-response questions were tabulated. Free text responses were analysed qualitatively, using a coding framework (described below). When both survey and interview data came from the same LA or organisation, we compared data to identify discrepancies or additional details.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative interview study\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eInterviews were conducted online between February-May 2024. Some participants requested a joint interview with other team members due to shared roles. We used a broad topic guide focusing on similar topics to the survey [see Additional file 2]. Interviews were conducted by RB, lasted 23\u0026ndash;62 minutes, were audio-recorded and transcribed verbatim. Data were stored on secure servers. Participants were offered a \u0026pound;25 voucher for their time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eTranscripts were anonymised and analysed using codebook thematic analysis (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). RB and RL independently reviewed three transcripts, noting potential codes to develop an initial coding framework. Codes were developed deductively from research questions, and inductively from participant responses. RB and RL used this framework to independently code two transcripts (using NVivo) revealing consistency in coding and interpretation. RB coded all subsequent transcripts, making additions/modifications where necessary. Codes and sub-codes were examined, compared and revised to develop three descriptive themes.\u003c/p\u003e \u003cp\u003eQuotes are labelled as S (for survey data) and P (for interview participant). If participants provided both, we present both identifiers e.g. \u0026ldquo;S15/P08\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e\u003ch3\u003eEthical approval\u003c/h3\u003e\n\u003cp\u003eThe study was approval by the University of Bath Research Ethics Committee for Biomedical Sciences (Ref: 2470-3145). Survey participants gave consent before completing the survey. We obtained verbal consent from participants before interviews.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003ePublic involvement\u003c/h3\u003e\n\u003cp\u003eWe recruited four public contributors who were parents/carers of primary-school aged children (of any weight status) via Obesity Voices and People in Health West of England. Due to project timings, public contributors were not involved in the study design but offered perspectives on the results and contributed to the focus of the discussion.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003eSurvey participants\u003c/h3\u003e\n\u003cp\u003eParticipants\u0026rsquo; characteristics are shown in Table 1. Twenty-one participants completed the survey; all but one were female. Fifteen were employed by LAs (representing 11 different LAs); four worked for the NHS; and two were employed by a community interest company or social enterprise commissioned to deliver the NCMP. Participants\u0026rsquo; job titles varied, but most worked as weight management, well-being or health improvement practitioners, community nurses, or public health/weight management service leads.\u003c/p\u003e\n\u003ch3\u003eTable 1 Survey and interview participants characteristics\u003c/h3\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"415\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvey participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;(across 16 interviews)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBy organisation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eLocal authority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eNHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eOther*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBy region\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eScotland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eNorth East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eNorth West\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eYorkshire \u0026amp; the Humber\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eEast Midlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eWest Midlands\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eEast of England\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eLondon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eSouth East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eSouth West\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50.3614%;\"\u003e\n \u003cp\u003eunknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 28.4337%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 21.2048%;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e* Private provider, community interest, social enterprise. Ten participants took part in both the survey and an interview.\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eSurvey results\u003c/h3\u003e\n\u003cp\u003eThe survey indicated the guidance was currently being used in staff training (n=6), to inform staff practice (n=6), in phone calls with parents to discuss NCMP results (n=6) or provided to parents as an electronic link in NCMP invite (n=5) or results (n=6) letters (Figure 1). No respondents reported providing printed copies of the guidance to parents.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Six respondents reported the guidance had influenced their protocols, such as creating a shortened version of the guidance which was sent out with NCMP invite letters (S1/P1), sending electronic versions to families accessing specialist weight management services (S1/P1), and informing the development of a parent workshop (S11). Other reported changes included being more aware of the language they use (S12/P09), approaching weight management in a more sensitive way (S5/P03, S2/P07), and emphasizing to parents this is \u003cem\u003e\u0026ldquo;a difficult topic to talk about and that they\u0026apos;re not alone - so much so that a resource like this has been introduced.\u003c/em\u003e\u0026rdquo; (S15/P08)\u003c/p\u003e\n\u003cp\u003eSeventeen respondents reported currently using the guidance, and all planned to continue. Four respondents stated they did not use the guidance, having just become aware of it: three said they would use it in the future; the fourth did not comment on future plans.\u003c/p\u003e\n\u003cp\u003eInterview participants\u003c/p\u003e\n\u003cp\u003eParticipant characteristics are shown in Table 1. Twenty-four participants were interviewed across sixteen interviews; all but one were female. Ten participants were recruited via the survey, with the remaining recruited via regional NCMP leads and study team contacts. Fourteen were employed by LAs (representing six different LAs); nine worked for the NHS; and one was employed by a community interest company. Participants\u0026rsquo; job titles were similar to those completing the survey (described above).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterview results\u003c/p\u003e\n\u003ch2\u003e1. How the guidance is currently used\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eInterview data corroborated survey findings that the guidance was mainly used in NCMP letters, parent phone calls, and as a training resource.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eNCMP parent letters\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe guidance was often included in NCMP information sent to parents, either in the invite letter (sent to all Reception/Y6 parents) or the child\u0026rsquo;s results letter (sent out if the child is identified as over- or under-weight). Letters either included a direct link to the guidance or directed parents to the organisation\u0026rsquo;s website where they could find the link:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;[It\u0026rsquo;s] linked into our NCMP letters, \u0026hellip;and we say, \u0026lsquo;If you want to talk to your child about their weight, here is a resource that you can use.\u0026rsquo;\u0026rdquo; (P20)\u003c/p\u003e\n\u003cp\u003eSome participants felt the guidance link should be included in the NCMP invitation letters so all families could access it. However, several NCMP organisations did not mention the guidance in their standard communications with parents. In some cases, there appeared to be an element of professional gatekeeping, with participants suggesting they were selective about which parents it would be appropriate for:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When I know a parent will be able to cope with the length of that document I will send it to them, but\u0026hellip; I\u0026rsquo;m not going to send it to a parent where I know there\u0026rsquo;s literacy issues or that they will not sit and read a 12 [sic] page document.\u0026rdquo; (P01) (NB: the official document is 20 pages).\u003c/p\u003e\n\u003ch3\u003eFollow-up phone calls to parents\u003c/h3\u003e\n\u003cp\u003eIn some regions, the guidance was used in phone calls with parents whose child had been identified as outside of the healthy weight range. The guidance was either mentioned during the call or sent to parents afterwards. As one participant explained, parents often worry about sharing the NCMP result with their child, making it a suitable time to introduce the guidance:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If a parent\u0026apos;s not sure, should I speak to my child? \u0026hellip; We will suggest you do what you think is best for you and your child. However, we have this [guidance], which is brilliant, that you can read through. It\u0026apos;s got lots of ideas if you\u0026apos;re not sure how to start that conversation.\u0026rdquo; (P19).\u003c/p\u003e\n\u003ch3\u003eAnother found the guidance useful in starting conversations with parents and in \u0026ldquo;manag[ing] any resistance or frustration as it can be a sensitive topic\u0026rdquo; (S14/P16).\u0026nbsp;\u003c/h3\u003e\n\u003ch3\u003eTraining and supporting health and education professionals\u003c/h3\u003e\n\u003cp\u003eParticipants discussed how the guidance was used to train staff delivering the NCMP. For example, although aimed at parents, one LA used the guidance in a training session with the staff conducting the weighing and measuring in schools:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We gave it to [NCMP] staff because they were saying sometimes children can make comments when they\u0026apos;re being weighed that they wanted to follow up on\u0026hellip; We felt that it was only right that they were a bit more confident with how to answer those questions or with what to say and how to approach that.\u0026rdquo; (P10/S10)\u003c/p\u003e\n\u003cp\u003eThe same LA also developed a 90-minute stand-alone training session for parents or professionals and were currently adapting it for further audiences including for General Practitioners (GPs) and practice staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther participants used the guidance in their regular training update for school nurses, with one explaining she emailed it to her team saying, \u003cem\u003e\u0026ldquo;If you\u0026rsquo;re speaking to a parent and they\u0026rsquo;re not sure how to talk to their children, email them this document.\u0026rdquo;\u003c/em\u003e (P19). Others talked about including it as a key resource for staff:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It\u0026apos;s been [used] in the electronic resource packs\u0026hellip; for school nurses and health and well-being assistants\u0026hellip; should they need any help around any topic\u0026hellip; It\u0026apos;s in our [healthy weight folder] and people access it as and when.\u0026rdquo; (P22)\u003c/p\u003e\n\u003cp\u003eSeveral participants had used the guidance to train staff not directly involved with the NCMP. For example, the guidance was \u003cem\u003e\u0026ldquo;signposted at multiple stages in our [staff] on-boarding\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P02)\u003cem\u003e\u0026nbsp;\u003c/em\u003ein an organisation commissioned to deliver weight management services by a LA.\u0026nbsp;One participant incorporated it into their training for health professionals, noting a GP had commented how it was\u0026nbsp;\u003cem\u003e\u0026ldquo;quite helpful to have that tool, and to have something to be able to give parents as well\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P20). Another participant had not used it with GPs yet but felt this group might benefit from it:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We get feedback from families [about] how healthy weight was raised from GPs and it\u0026rsquo;s not always positive. I think they would be a really\u0026hellip; key group for this resource to be shared with.\u0026rdquo; (P01)\u003c/p\u003e\n\u003cp\u003eIt was also shared with educational professionals who, though not directly involved in delivering the NCMP, often faced weight-related conversations due to the measurements being taken in school. P15 explained they told schools about the guidance, with P16 adding:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think it\u0026apos;s really beneficial for those that aren\u0026apos;t in this line of work, to have something to refer back to that they can use if they\u0026apos;re a little bit unsure\u0026hellip; if it\u0026apos;s a staff member at school that\u0026apos;s never really brought up that subject, it\u0026apos;s really useful for them\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStaff in another LA explained they referred schools to the online e-learning module on the guidance and \u003cem\u003e\u0026ldquo;encourage the schools\u0026hellip; to have around by 50% of their staff\u0026hellip; complete the training\u0026rdquo;\u003c/em\u003e (P05). Another participant mentioned sharing it with Early Years (pre-school) staff explaining, \u003cem\u003e\u0026ldquo;I know it\u0026rsquo;s not aimed at that age range, but I still think it\u0026rsquo;s an important one for them to be aware about\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P09).\u003c/p\u003e\n\u003ch2\u003e2. Benefits of using the guidance\u003c/h2\u003e\n\u003cp\u003eParticipants frequently spoke of a sense of relief at discovering the guidance, and that it filled a significant gap: \u003cem\u003e\u0026ldquo;I just don\u0026rsquo;t think there was anything\u0026hellip; else like it [that] pulled [advice] together in one place.\u0026rdquo;\u003c/em\u003e (P01). Another participant talked about the guidance generating \u0026lsquo;excitement\u0026rsquo; during staff training:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;People were really keen and interested and enthusiastic about the document and thought, \u0026lsquo;yeah, this will be brilliant! This is just what parents need, and I\u0026apos;m definitely going to use it and share it.\u0026rsquo;\u0026rdquo; (P22)\u003c/p\u003e\n\u003cp\u003eParticipants felt reassured the guidance had been developed by academics and was therefore backed up by research evidence. This increased their confidence in recommending it to parents:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It\u0026apos;s a no brainer, it\u0026apos;s researched, evidence-based, and \u0026hellip; it\u0026apos;s just a tool that we\u0026apos;ve got in our tool bag now that we can use for ourselves, or for parents. It\u0026rsquo;s great.\u0026rdquo; (P19)\u003c/p\u003e\n\u003cp\u003eThe style and tone of the document was also welcomed, with one participant noting that the language fitted with their LA\u0026rsquo;s approach to weight management:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The language we\u0026apos;re trying to use particularly around NCMP\u0026hellip; is that it\u0026apos;s about healthy growth at all sizes and that more compassionate, less stigmatising language. And [having] that in bold at the front of the guide really helps us to say, \u0026lsquo;This isn\u0026rsquo;t just for you and your family, this is all families.\u0026rsquo;\u0026rdquo; (P07)\u003c/p\u003e\n\u003cp\u003e(Note: this participant is referring to page 2 of the guidance which states \u0026ldquo;This guidance is for parents and caregivers of children of all shapes and sizes.\u0026rdquo;)\u003c/p\u003e\n\u003cp\u003eImportantly, many participants talked about how the guidance boosted people\u0026rsquo;s confidence in talking about a difficult and sensitive subject. One participant felt it \u003cem\u003e\u0026ldquo;helped remove some of that fear\u003c/em\u003e\u0026rdquo; (P07) parents have about discussing weight. Another appreciated the practical examples of what to say and how to say it: \u003cem\u003e\u0026ldquo;it\u0026apos;s good where it talks [about] you [can] try this phrase or rephrase it that way\u003c/em\u003e\u0026rdquo; (P14). Several participants recognised that teachers rarely receive training on how to have these conversations and the guidance could help fill that gap:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think it\u0026apos;s really beneficial for those that aren\u0026apos;t in this line of work, to have something to refer back to\u0026hellip; if they\u0026apos;re a little bit unsure. Because it can be quite challenging. It\u0026apos;s challenging for us, and we\u0026apos;ve done it for years! But if it\u0026apos;s a staff member at school that\u0026apos;s never really brought up that subject, it\u0026apos;s really useful for them.\u0026rdquo; (P16)\u003c/p\u003e\n\u003cp\u003eEven school health assistants conducting phone calls with parents may not have received training and again the guidance proved useful:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It was a really useful\u0026hellip; because it\u0026rsquo;s exactly what we needed for the phone calls. Because hardly any of us have had training in how to raise the issue of weight because it\u0026rsquo;s been quite a taboo subject\u0026hellip; it was useful to be able to share what wording to use.\u0026rdquo; (P21)\u003c/p\u003e\n\u003ch2\u003e3. Limitations of the guidance\u003c/h2\u003e\n\u003cp\u003eWhile feedback on the guidance was overwhelmingly positive, participants identified some features which might limit the accessibility of the guidance for particular groups. The guidance is 20 pages, which some participants felt was too long for parents with low literacy levels:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When you think that a lot of our children who are of an unhealthy weight, they come from deprived backgrounds, where there is low level literacy skills, parents will struggle then to access it.\u0026rdquo; (P05)\u003c/p\u003e\n\u003cp\u003eIn response, one participant reported developing a shortened version for \u0026ldquo;parents who will not be able to read that entire document\u0026rdquo; (P01/S01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOthers felt it might need to be adapted for use with parents with learning disabilities. One participant explained they might provide these parents with the whole document but would direct them to \u003cem\u003e\u0026ldquo;snippets of the guidance [that]\u0026hellip; would work for the family,\u0026rdquo;\u003c/em\u003e adding the conversation would need to be \u003cem\u003e\u0026ldquo;tailored\u0026hellip; to what their understanding would be\u0026rdquo;\u003c/em\u003e (P14). Additionally, some participants suggested more could be done to make the guidance culturally inclusive:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;We have a vast diversity of languages in the borough and lots of our families have a fairly low level of English\u0026hellip; so we felt that maybe it could be translated into some key languages \u0026hellip;Also some of the imagery wasn\u0026apos;t always reflective of our population.\u0026rdquo; (P13)\u003c/p\u003e\n\u003cp\u003eSeveral participants suggested there was a pressing need for similar guidance parents of teenagers who may be particularly worried about the sensitivities of discussing weight with their children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If I was to have one ask it would be that the next iteration is targeted at the 13 to 18 age group\u0026hellip; [that] would be really powerful, particularly because there\u0026rsquo;s a lot of misconceptions and \u0026hellip; conflicting evidence about the risks of talking to teenagers about weight and the concerns that it generates eating disorders.\u0026rdquo; (P02)\u003c/p\u003e\n\u003cp\u003eMore complex issues about the utility of the guidance were raised by other participants. One participant noted that while a step in the right direction, the guidance on its own was unlikely to change much:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There\u0026rsquo;s lots of reasons as to why parents wouldn\u0026rsquo;t want to talk about healthy weight with their kids. And I think the guidance is a really useful tool but I\u0026rsquo;m not necessarily sure just by looking at that in isolation that would make too much of a difference.\u0026rdquo; (P01)\u003c/p\u003e\n\u003cp\u003eSeveral participants also noted in the context of significant deprivation, discussions around weight simply weren\u0026rsquo;t a priority for many families:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I\u0026rsquo;ve given it to parents for them to kind of take away and have a little read but\u0026hellip; healthy eating and exercise comes bottom of the list when they\u0026rsquo;ve got so much on their plate\u0026hellip; it\u0026rsquo;s all those barriers and all those struggles that they\u0026rsquo;re having and the money issues \u0026hellip; [It\u0026rsquo;s] all those other areas\u0026hellip; that need to be addressed first.\u0026rdquo; (P09)\u003c/p\u003e\n\u003cp\u003eAnother felt the guidance was useful but was unsure how it could adequately counter the negative framings encountered in society more generally:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Whilst [the guidance is] absolutely great, how do you manage that against the alternative messages that children and families are getting...[in] social media, marketing, films?\u0026rdquo; (P18)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis concern for consistent messaging was echoed by other participants who felt all the professionals a family might encounter needed to use the same approach: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;For me it\u0026apos;s about making sure that all the messaging that goes out to families is coordinated\u0026hellip; so that families are receiving the same information from various different sources.\u0026rdquo; (P20)\u003c/p\u003e\n\u003cp\u003eThis participant went on to consider whether parents \u0026ndash; particularly those in the most challenging circumstances - could or should be asked to address an issue which she felt was a systemic and environmental issue: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There\u0026apos;s a huge assumption that every parent has the ability and capability to be able to have that conversation in an appropriate and compassionate way with their child\u0026hellip;. It puts a lot of responsibility on the parent when actually we deeply believe it\u0026apos;s a system issue and environmental issue\u0026hellip;\u0026rdquo; (P20)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the implementation of a parental guidance document on talking to young children (4-11yrs) about weight. Some organisations provided parents with a link to the guidance via NCMP letters or referred to it in follow-up phone calls. It was also used in training and support for health and education professionals, including GPs and teachers. Participants were positive about the guidance, noting it \u0026lsquo;filled a gap\u0026rsquo; by providing an evidence-based and tonally-sensitive document which increased their own and parents\u0026rsquo; confidence in addressing a sensitive issue. Potential limitations of the guidance that may prevent wider implementation included its suitability for those with lower literacy levels, the need for additional parental (and professional) guidance on discussing weight with adolescents, and recognition that the guidance was just one small part of a much-needed systems-wide approach to tackling overweight and obesity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was planned as a mixed-methods evaluation of implementation but, despite a varied recruitment approach endorsed by OHID, recruitment to the survey was low (N=21) compared with a previous NCMP survey that received responses from 92 LAs (7). \u0026nbsp;This limits our ability to assess the uptake of the guidance among LAs across the country. Of the responses we received, though some reported the guidance had been integrated into their practice pathways, other responses and informal feedback from study team members indicated low levels of awareness and use of the guidance in practice. This was not anticipated as the guidance had been introduced to local NCMP leads in a series of events from summer 2021 onwards and was included in the 2023/24 NCMP parent letter template which was launched at a well-attended event (N=345 PHPs) in January 2024. Additionally, the authors had worked directly with numerous LAs to support its use. Notably, some areas where staff had engagement with the accompanying e-learning module (N=12 requesting a completion certificate) did not respond to the survey, suggesting it did not always reach those most familiar with the guidance.\u0026nbsp;High staff turnover within public health teams\u0026nbsp;(21)\u0026nbsp;may have meant that information was not passed on or retained beyond the initial PHP who received the guidance.\u003c/p\u003e\n\u003cp\u003eAmong survey respondents and interviewees, the guidance was considered useful and relevant, feeling it provided something new and supported their practice. This aligns with and extends initial pilot findings (11), and supports the need to extend implementation of the guidance at scale. Participants considered the guidance trustworthy, reassured by its clear link to an evidence base. While\u0026nbsp;OHID guidance\u0026nbsp;(22)\u0026nbsp;is available for healthcare professionals in the form of a \u0026lsquo;conversation framework\u0026rsquo; for talking to parents about the NCMP (issued 2019, updated 2023) this does not provide guidance on talking to \u003cem\u003echildren\u0026nbsp;\u003c/em\u003eand is not suitable for sharing with parents. It was notable no participants referred to this partner guidance document in the present study, despite its availability since 2019, suggesting\u0026nbsp;they lack awareness of this resource too.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBarriers to using the guidance included its\u0026nbsp;accessibility for families facing greater deprivation, from ethnic minority cultural backgrounds or with lower educational levels. Some PHPs did not share the guidance with those they felt would find it hard to access, resulting in a two-tier system. Given the perceived lack of inclusivity differentially influenced PHP practice in sharing the guidance with parents, this raises concerns about the potential to widen health inequalities which should be explored further. Our public contributors felt increasing access to the guidance in these more marginalised communities should be a specific priority for commissioners.\u003c/p\u003e\n\u003cp\u003eParticipants recognised the tension between helping parents to address children\u0026rsquo;s weight while avoiding feelings of blame. Providing the guidance to all parents, regardless of their child\u0026rsquo;s weight, may help reduce perceptions of stigma. Participants mostly endorsed this approach, noting the guidance is relevant for all parents, as even healthy weight children may worry about their weight or encounter potentially harmful weight-related content online. In past work (11), parents and school nurses suggested introducing the guidance in advance of the NCMP, giving parents time to address their own and their child\u0026rsquo;s emotional responses and concerns about the measurement process. However, parents may not find it relevant until they receive specific information about their child (11). This suggests use of the guidance may be enhanced by both embedding it into invitation letters and operational guidance to reduce gatekeeping on the part of practitioners, as well as making it available widely available to parents and health, social care and education practitioners working with children and families.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany interviewees found the guidance useful for other elements of their role, such as in children\u0026rsquo;s weight management services, and in links with schools and primary care, ensuring a common approach and language. Individuals are more likely to trust and adopt advice from health and care professionals when it is consistent (23), endorsing a case for wider distribution to professionals beyond the NCMP. In a recent study with GPs in Ireland, the guidance was perceived as useful in overcoming barriers to talking to families about children\u0026rsquo;s weight, avoiding stigma, and providing a framework for conversations (24). They also identified a need for advice to be consistent across multi-disciplinary teams. Our findings also suggest school staff may benefit from the resource, with our public contributors emphasising the importance of this group due to their daily interaction with children and because NCMP measurements take place within schools.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eDespite sending the survey out via multiple routes on several occasions, the response rate was low. Consequently, we cannot determine the extent of the guidance\u0026rsquo;s implementation across NCMP-delivery organisations, though the low response rate may suggest low levels of awareness. Furthermore, as those not using or unaware of the guidance did not volunteer for interviews, we cannot provide insights into the broader barriers to awareness and implementation. Given the limited number of participants, we were unable to sample to ensure geographical and occupational variation. There were no survey or interview participants from the North-East of England, and no interview participants from the East of England and the Southeast. Additionally, we are aware that the findings reflect a UK-based programme, and further research should look at similar measurement programmes in Europe (25), as well as non-mandated measurement experiences in the US (26), Canada (27) and Australia (28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, survey/interview participation depended on who we reached within organisations, with responses inevitably influenced by factors like role, time in position, and personal views, as well as reflecting organisational approach. In some areas where we knew the guidance had been used extensively, staff changes meant we were unable to capture past implementation practices through our methods. Some participants referred to procedures or training suggesting the guidance had been adopted within standard practice, however, others responded based on their own experience and use, rather than representing policy within a given organisation.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eRecommendations\u003c/h3\u003e\n\u003cp\u003eThe findings of this study and past work (11) indicate the guidance is useful, credible and relevant to professionals and parents, and fills a gap that is not met by other resources. This is further illustrated in those areas where staff had used the guidance to develop their own training, and initiatives involving schools and parents. However, the potential impact of the guidance is limited by lack of awareness, embedding into core processes and application to other groups. We therefore recommend: \u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eStronger endorsement and branding of the guidance by OHID to allow systematic distribution and integration into operational guidance.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSharing best practice on how the guidance could be used e.g. in training for NCMP staff, multi-disciplinary teams and school staff; providing links in both the invitation and results letters; and within phone conversations with families.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAdapting the guidance for different groups, including families with lower literacy levels (shorter or pictorial forms), different languages and for families with learning disabilities.\u003c/li\u003e\n \u003cli\u003eGenerating guidance for parents of adolescents with age-appropriate additional content and framing.\u003c/li\u003e\n \u003cli\u003eFurther research to explore the impact of the guidance on parents and children, and if/how it promotes children\u0026rsquo;s wellbeing and healthy weight (16). \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePublic health professionals viewed guidance for parents on talking to children about weight as useful for staff training and engaging with families. However, the guidance had not yet been embedded within core NCMP procedures and participants reported some limitations to wider implementation. Wider sharing of the guidance is needed to embed it within a system-wide approach to supporting children\u0026rsquo;s healthy weight.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003eGP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;General Practitioner (also known as Family Doctor)\u003c/p\u003e\n\u003cp\u003eLA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Local Authority (Local government responsible for proving a wider range of services including public health provision.)\u003c/p\u003e\n\u003cp\u003eNCMP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Child Measurement Programme\u003c/p\u003e\n\u003cp\u003eNHS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;National Health Service\u003c/p\u003e\n\u003cp\u003eOHID\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Office of Health Improvement and Disparities\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePHP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Public Health Practitioner\u003c/p\u003e\n\u003cp\u003ePPI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Patient and Public Involvement\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe university of Bath\u0026rsquo;s Research Ethics Committee for Biomedical Sciences gave ethical approval for this study (Ref: 2470-3145). Participants gave informed verbal consent before participating in the interviews.\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eData from this study are stored at https://data.bris.ac.uk/data/ and are available under \u0026lsquo;controlled access\u0026rsquo;. Requests for use will be referred to the University of Bristol Data Access Committee for approval before data can be shared under a data sharing agreement.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003e\u003cspan lang=\"EN-GB\"\u003eThis research was funded by the National Institute for Health and Care Research Applied Research Collaboration West (NIHR ARC West).\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eThe views expressed in this article are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026apos; contributions\u003c/h3\u003e\n\u003cp\u003eThe project was conceived by FG and EG. All authors contributed to the design of the study. RL oversaw the project. RB conducted interviews and analysed the data. RB, RL and FG produced the first draft of the manuscript. All authors contributed to the revisions of the manuscript including intellectual content and approved the submitted version.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eWe thank all the participants for their time and thoughtful discussions with us. We are grateful for the contributions of our PPI contributors, Elaine Tidswell, Lauren Wheeler, John Halliwell and Ed Brooks, supported by our PPI co-ordinator, Lucy Condon.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNHS England. National Child Measurement Programme, England, 2023/24 School Year. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/national-child-measurement-programme/2023-24-school-year; 2024.\u003c/li\u003e\n\u003cli\u003eCheng S, Kaminga AC, Liu Q, Wu F, Wang Z, Wang X, et al. Association between weight status and bullying experiences among children and adolescents in schools: An updated meta-analysis. Child Abuse \u0026amp; Neglect. 2022;134:105833.\u003c/li\u003e\n\u003cli\u003eMoradi M, Mozaffari H, Askari M, Azadbakht L. Association between overweight/obesity with depression, anxiety, low self-esteem, and body dissatisfaction in children and adolescents: a systematic review and meta-analysis of observational studies. Critical Reviews in Food Science and Nutrition. 2021;62(2):555-70.\u003c/li\u003e\n\u003cli\u003eSimmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta‐analysis. Obesity reviews. 2016;17(2):95-107.\u003c/li\u003e\n\u003cli\u003eLlewellyn A, Simmonds M, Owen CG, Woolacott N. Childhood obesity as a predictor of morbidity in adulthood: a systematic review and meta‐analysis. Obesity reviews. 2016;17(1):56-67.\u003c/li\u003e\n\u003cli\u003eNHS England. National Child Measurement Programme. Available from: https://digital.nhs.uk/services/national-child-measurement-programme/.\u003c/li\u003e\n\u003cli\u003eČadek M, Flint SW, Tench R. Delivery of the National Child Measurement Programme in England. Public Health Nutrition. 2021;24(6):1177-84.\u003c/li\u003e\n\u003cli\u003eStatham J, Mooney A, Boddy J, Cage M. Taking stock: A rapid review of the National Child Measurement Programme. 2011.\u003c/li\u003e\n\u003cli\u003eGillison F, Beck F, Lewitt J. Exploring the basis for parents\u0026rsquo; negative reactions to being informed that their child is overweight. Public health nutrition. 2014;17(5):987-97.\u003c/li\u003e\n\u003cli\u003eAmes H, Mosd\u0026oslash;l A, Blaasv\u0026aelig;r N, N\u0026oslash;kleby H, Berg R, Lang\u0026oslash;ien L. Communication of children\u0026rsquo;s weight status: what is effective and what are the children\u0026rsquo;s and parents\u0026rsquo; experiences and preferences? A mixed methods systematic review. BMC Public Health. 2020;20:1-22.\u003c/li\u003e\n\u003cli\u003eBaber F, Gillison FB, Grey EB. The acceptability of evidence-informed guidance for parents in talking to their children about weight. BMC Public Health. 2023;23(1):1357.\u003c/li\u003e\n\u003cli\u003eGillison F, Grey E, Chater A, Atkinson L, Gahagan A. Talking to your child about weight: A guide for parents and caregivers of children aged 4-11 years. Available from: https://www.bath.ac.uk/guides/talking-to-your-child-about-weight/; 2023.\u003c/li\u003e\n\u003cli\u003eGillison FB, Lorenc AB, Sleddens EF, Williams SL, Atkinson L. Can it be harmful for parents to talk to their child about their weight? A meta-analysis. Preventive medicine. 2016;93:135-46.\u003c/li\u003e\n\u003cli\u003eGrey E, Atkinson L, Chater A, Gahagan A, Tran A, Gillison FB. A systematic review of the evidence on the effect of parental communication about health and health behaviours on children\u0026apos;s health and wellbeing. Preventive Medicine. 2022;159:107043.\u003c/li\u003e\n\u003cli\u003eGillison FB, Grey EB, McConnell HE, Sebire SJ. Using narrative messages to improve parents\u0026apos; experience of learning that a child has overweight. British Journal of Child Health. 2020;1(5):220-30.\u003c/li\u003e\n\u003cli\u003eGillison FB, Grey EB, Baber F, Chater A, Atkinson L, Gahagan A. The systematic development of guidance for parents on talking to children of primary school age about weight. BMC Public Health. 2023;23(1):1704.\u003c/li\u003e\n\u003cli\u003eUniversity of Bath. Using the resource \u0026lsquo;Talking to your child about weight\u0026rsquo;: A training session for professionals.\u003c/li\u003e\n\u003cli\u003eBritish Dietetics Association. Childhood Obesity Toolkit. Available from: https://www.bda.uk.com/specialist-groups-and-branches/paediatric-specialist-group/childhood-obesity-toolkit.html.\u003c/li\u003e\n\u003cli\u003eBritish Dietetics Association. Leading Conversations. Available from: https://www.bda.uk.com/specialist-groups-and-branches/paediatric-specialist-group/childhood-obesity-toolkit/leading-conversations.html.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019;11(4):589-97.\u003c/li\u003e\n\u003cli\u003eRoyal Society for Public Health. The public health workforce: struggling to recruit and retain... but still delivering. Available from: https://www.rsph.org.uk/about-us/news/the-public-health-workforce-voicing-their-concerns-on-recruitment-and-retention.html; 2022.\u003c/li\u003e\n\u003cli\u003eGOV.UK. National Child Measurement Programme: conversation framework. A conversation framework for talking to parents about the National Child Measurement Programme (NCMP). Available from: https://www.gov.uk/government/publications/national-child-measurement-programme-conversation-framework; 2019 (updated 2023).\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO Strategic Communications Framework for effective communications. Available from: https://www.who.int/docs/default-source/documents/communicating-for-health/communication-framework.pdf; 2017.\u003c/li\u003e\n\u003cli\u003eTwoomey. Exploring the acceptability and modes of use of new evidence-informed guidance for parents on talking to children about weight. MSc dissertation: University of Bath; 2024.\u003c/li\u003e\n\u003cli\u003eWHO. WHO European Childhood Obesity Surveillance Initiative (COSI). Available from: https://www.who.int/europe/initiatives/who-european-childhood-obesity-surveillance-initiative-(cosi).\u003c/li\u003e\n\u003cli\u003eThompson HR, Madsen KA. The Report Card on BMI Report Cards. Current Obesity Reports. 2017;6(2):163-7.\u003c/li\u003e\n\u003cli\u003eGovernment of Canada. Canadian Community Health Survey. Available from: https://www.canada.ca/en/health-canada/services/food-nutrition/food-nutrition-surveillance/health-nutrition-surveys/canadian-community-health-survey-cchs.html.\u003c/li\u003e\n\u003cli\u003eAustralian Institute of Health and Welfare. Australia\u0026apos;s children. Available from: https://www.aihw.gov.au/reports/children-youth/australias-children/contents/health/overweight-obesity; 2022.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"obesity, overweight, children, parents, NCMP, UK, qualitative, guidance, public health, weight management, healthier lifestyle","lastPublishedDoi":"10.21203/rs.3.rs-6254356/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6254356/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eOne in five children starting primary school in England are living with overweight or obesity, rising to one in three by the end of primary school. In England, the prevalence of overweight/obesity of children is monitored through the annual National Child Measurement Programme (NCMP). Research suggests parents often lack confidence in discussing weight with their children. In 2021, evidence-based guidance was produced for parents of young children to facilitate these conversations, but it is unclear how this guidance is being promoted to parents or used by public health practitioners (PHPs). This study evaluated the implementation of parental guidance on talking to children about weight.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We conducted a mixed-methods study, including a national online survey and in-depth qualitative interviews with public health practitioners working on children’s healthier lifestyles programmes in the UK. Invitations to participate were distributed via the Office of Health Improvement and Disparities (OHID) and regional and national networks. Online interviews were audio-recorded, transcribed, and analysed thematically. Survey data were descriptively reported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eTwenty-one participants completed the survey; twenty-four were interviewed. Practice varied between organisations with the guidance being used in NCMP letters to parents, in follow-up phone calls with parents, and in training NCMP staff and other health or education professionals. Participants valued the evidence-based guidance and its compassionate tone, feeling it gave them, and parents, confidence in addressing a sensitive topic. Some felt it was too lengthy for parents with learning disabilities or low literacy levels. Others identified a need for similar guidance for older children. Though helpful, participants acknowledged the guidance was only one small part of a necessary systems-wide approach to promoting healthy weight.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eThe guidance is a useful tool but needs systematic promotion to increase use and effectiveness. Further work is warranted to develop adapted versions for other populations.\u003c/p\u003e","manuscriptTitle":"Talking to children about weight–how is guidance for parents being used by professionals?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-21 07:52:48","doi":"10.21203/rs.3.rs-6254356/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a25532f-929f-4b39-98ad-810dd07e3b2e","owner":[],"postedDate":"March 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-25T10:09:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-21 07:52:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6254356","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6254356","identity":"rs-6254356","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}