title: The role of grandparents in childhood obesity in China - evidence from a mixed methods study.
abstract: BACKGROUND
  The current literature on the influences of family environment on childhood obesity is predominantly based on western populations and has focused on the role of parents. This study examined the influence of grandparents on the development of obesity among Chinese primary school aged children.
  
  
  METHODS
  A mixed methods study was conducted in four socioeconomically distinct primary school communities in two cities of southern China. The qualitative study (17 focus groups and four personal interviews) involved parents, grandparents, school staff, and food retailers in the vicinity of the schools (n = 99) and explored perceived causes of childhood obesity. The cross-sectional study examined the association between children's objectively measured weight status and reported health behaviours, and the presence and role of grandparents in the household. It included children from three randomly selected third grade (8 to 10 years) classes from each school (n = 497).
  
  
  RESULTS
  Grandparents were commonly perceived to contribute to childhood obesity through inappropriate perception (e.g. fat children are healthy and well cared for), knowledge (e.g. obesity related diseases can only happen in adults; the higher the dietary energy/fat content, the more nutritious the food), and behaviour (e.g. overfeeding and indulging through excusing the children from household chores). Conflicting child care beliefs and practices between grandparents and parents, and between grandparents and school teachers, were felt to undermine efforts to promote healthy behaviours in children. In the cross-sectional study, children who were mainly cared for by their grandparents were more likely to be overweight/obese (adjusted OR = 2.03; 95 % CI = 1.19 to 3.47); and to consume more sugar-added drinks and unhealthy snacks (B = 2.13, 95 % CI = 0.87 to 3.40), than children who were mainly cared for by their parents or other adult. Children who lived with two or more grandparents in the household were more likely to be overweight/obese than children who did not live with any grandparent (adjusted OR = 1.72; 95 % CI = 1.00 to 2.94).
  
  
  CONCLUSIONS
  Involvement of grandparents in childcare is an important factor contributing to childhood obesity in China. Future preventive interventions should include strategies that target grandparents.
authors.affiliation: College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. lzhashdown@gmail.com.
authors.forename: Bai
authors.initials: B
authors.lastname: Li
authors.affiliation: College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. p.adab@bham.ac.uk.
authors.forename: Peymané
authors.initials: P
authors.lastname: Adab
authors.affiliation: College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. k.k.cheng@bham.ac.uk.
authors.forename: Kar Keung
authors.initials: KK
authors.lastname: Cheng
mesh_terms: D000328:Adult; D001290:Attitude; D001835:Body Weight; D002648:Child; D002681:China; D003430:Cross-Sectional Studies; D004032:Diet; D005178:Faculty; D005191:Family Characteristics; D005247:Feeding Behavior; D005260:Female; D017144:Focus Groups; D000066502:Grandparents; D015438:Health Behavior; D006801:Humans; D008297:Male; D016487:Parenting; D010290:Parents; D063766:Pediatric Obesity / Q000209:etiology*; D010465:Perception; D036301:Qualitative Research; D012111:Residence Characteristics