Methods (supplementary description)

Design: The multi-disciplinary group who developed scripts for interviews and focus groups included a dietitian, pediatrician, psychologist, public health worker and a qualitative research methodologist, among others. We designed open-ended questions to stimulate discussion and more specific probes to clarify responses (Table 1). Children’s questions addressed similar issues as adult prompts, but aimed at a developmentally appropriate level as determined by the pediatrician and psychologist. We modified scripts after input from additional researchers and community representatives. Focus groups and interviews were conducted by two of the authors, a pediatrician and a public health researcher. Focus groups lasted approximately one hour; interviews were conducted at community leaders’ places of work and also lasted approximately one hour.

Participants: In recruiting families with overweight children, we used reported weight rather than BMI as height measurements were unknown to many parents.

Supplement to Table 2: Additional Sample Quotations from Focus Groups and Interviews

Domain 1: Barriers to Healthy Nutrition and Exercise Behaviors

Theme 1: Awareness is higher for other, acute health conditions such as asthma.

The seriousness of [overweight] is not recognized. The seriousness of diet, of even exercise, the potential to be life threatening—that message is not conveyed. It is not conveyed to the obese children that we’re seeing… I think the seriousness of the disease—the message is not communicated in schools, at home, or in the media. (Community leader)
Asthma, asthma – that’s number one, asthma! Asthma would be the one they have the most concern about. (Community leader)

Theme 2: Time pressures present a barrier to physical activity and to healthy eating.

You gotta do your homework, you gotta do chores. You don’t have the time. You have to go to school and do homework. You have other stuff you gotta do. You gotta have the time. (Child)

Theme 3: Financial pressures make healthy nutrition and weight a lower priority.

Wouldn’t it be wonderful if they put fresh fruit on sale as much as they put the junk on sale? ... Cause you know those Little Debbie’s are always 99 cents. They say 99—then they go down. 79. (Parents)

Theme 4: Safety issues present a barrier to physical activity.

A lot of families talk about feeling not safe in their environment. I know that is not really a health-related thing, but it kind of effects the obesity, because people are inside and don’t want to go outside, can’t go outside after dark, can’t go and play. (Community leader)

Theme 5: Kids express preferences for sedentary activities and for foods high in fat.

Most kids, when they’re—by the time they are ready to walk until they are, I’d say 5 or maybe 8 years old—they beg to run and play, they are constantly asking, “Can I go outside?” You’re constantly telling kids: sit down, keep still. By the time they are 9 and over, if they are constantly told, year after year, sit in the house, go read a book, be quiet, after a while they stop asking. And so they don’t go outside anymore and after a while it just becomes a behavior that they don’t play—they aren’t kids anymore—or what I call kids. (Community leader)
I used to play softball. I played with a little soccer ball. I used to hit it out of the park. (Child)
She eats everything; she’s not a picky eater. But she loves her ice cream! (Parent)
Oh, they love pop. Any kind of pop. No special choice, just be pop. (Parent)

Domain 2: Parental Challenges and Concerns Regarding Overweight Children

Theme 6: Parents want information about healthy nutrition and healthy weight for kids.

You know, again it's a lot of things out there that is confusing. I mean one while they say this is great, and the next while it's causing something. You know, your hair going to fall out or whatever. So you don't know what's really safe and what's not. (Parent)
What is healthy? Things vacillate from one minute – one minute, you know, aspirin is good for you; aspirin is not. Red wine is good for you. No, it’s white wine… I know something is not that cut and dry. (Parent)
I don’t even know what is in a green vegetable that you should eat it, and there must be something you can substitute for it that would have the same thing. (Parent)

Theme 7: Kids get sweets/junk foods from sources other than home, including school and other family members.

We have a little candy store at school where I eat chips. ... Sometimes [I eat chips] every day but not all, all, all the time. (Child)

Theme 8: Parents have difficulty setting limits on screen time (tv/computer) and food intake.

My thing is, when do you say, “This is enough?” You know, “You can’t have anymore [food].” (Parent)

Theme 9: Parents worry about the psychosocial effects of overweight on their kids.

And then I'm worried, because she doesn’t look – she’s solid; she doesn’t look chunky, but she’s got a tummy. And I don’t want to make her feel self-conscious. I don’t know what to do. Look at me—oh, gosh, I’ve struggled with it all my life. (Parent)

Domain 3: Definitions of Overweight and Societal Norms

Theme 10: Bigger kids and adults are just built differently (charts don’t always apply).

They do have their charts…but it’s like different frames for everybody. I don’t go by the charts. (Parent)

Theme 11: Children were more apt than parents to use size and appearance to determine if someone is overweight. (Children were looking at a figure rating scale while discussing this topic)

She’s petite a little bit. Like kind of skinny, kind of thick. ... They ain’t overweight, they’re just right. (Child)
She not too skinny, she’s just right in the middle. (Child)