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Toddler Obesity Prevention: Healthy Lifestyle Behaviors from the Beginning
Maureen Black, Ph.D.ProfessorDepartment of Pediatricsmblack@peds.umaryalnd.edu9-30-11
Objectives
To describe changes in rates of obesity among young children
To describe the Nutrition Transition and contribution to obesity
To describe responsive feeding To describe strategies to promote healthy growth and
physical activity among toddlers
Over The Past 30 Years The Number of Obese
Children (BMI > 95th %ile) Increased, Now Steady
5 6 5
13
1817
12.4
17 17.6
0
5
10
15
20
2-5 years 6-12 years 13-19 years
Per
cent
1976-1980 2004-2006 2006-2008
Double Triple TripleOgden 2006, 2008, 2010
NUTRITIONAL STATUS: CHILDREN UNDER 5 YRS OVERWEIGHT/OBESE IN USA
Overweight: BMI > 85th %ile & < 95th %ile Obese BMI > 95th %ile
National Center for Health Statistics, CDC
Nutrition Transition Improvements in development – urbanization,
economic growth Diet
More refined food, less fiber More animal source food Calorie sweeteners Eating away from home, snacks
Energy More leisure time Less physical labor Popkin, 2006, 2009
Nutrition Transition Change in growth patterns
Less underweight Fewer micronutrient deficiencies More overweight, obesity
Change in disease patterns More chronic diseases
Popkin, 2006, 2009
Energy Balance: Children
Energy In
Energy Out
Feeding
Playing
Inactivity
Need positive energy balance to support growth!
Sleep
Pediatric Obesity Prevention
Obesity prevention often targets school-age children Most interventions have no effect or very small effect Not sustainable
By age 2-5, > 25 % children overweight or obese Time to focus on prevention is
INFANCY and TODDLERHOOD!!
Ogden, JAMA, 2010; Summerbell, Cochrane, 2005
Risk Factors for Pediatric Obesity
Demographics Parental overweight Obesogenic parental eating, activity patterns High gestational weight gain Rapid infant growth Low income and education levels Minority race/ethnicity
Birch & Ventura, 2009
Risk Factors for Pediatric Obesity Physical activity
High television watching/screen time
Low physical activity
Short sleep duration
Eating Formula feeding Early intro solid foods Low intake fruit & veggies High intake energy dense foods Habitual “food away from
home” Large portions Frequent snacking Parent restriction, indulgence
Birch & Ventura, 2009
Weight-for-lengthUnderweight, Overweight, or Within Normal???
0.4%ile 91%ile 4%ile
Weight-for-length
56%ile
Underweight, Overweight, or Within Normal???
Toddler Silhouette Scale
Hager, McGill, Black (2010). Obesity
Perception and SatisfactionShow silhouettes Which picture looks like your child?
Compare with actual body size to determine perception
Show silhouettes again How would you like your child to look?
Difference is a measure of satisfaction
Parent Perceptions & Satisfaction With Toddler Body Size
72
44
12
45
78 81
0102030405060708090
100
< 15%ile 15-85%ile >85%ile
Per
cent
Accurate Satisfied
Hager, 2011. . . . . . . . . . .Toddler’s Body Size . . . . . . . . . .
• Preference for large body size • More likely to recognize underweight than overweight•Concern regarding small body size
Developmental Milestones Related to Eating
O-6 months normal suck/swallow feed on demand breast milk or formula only turn away from breast/bottle when full
~6 months Sit up good head control leans toward food with mouth open when hungry turns head when full starts to eat with fingers feed in high chair
Developmental Milestones Related to Eating
6-12 months puree reach for spoon to self feed use “2 spoon method” finger foods
12-24 months self feed transition from puree to complex
textures/flavors socialize to family meal toddlers often “picky” eaters
Challenges – Toddler Feeding Problems
Feeding Problems Common (Picky) 25-40%, Most resolve without major consequences
BUT Can undermine family relations Can signal GI problems (GERD, celiac, etc.) Can lead to nutritional deficiencies Can be a precursor to long lasting behavior problems
Feeding Infants and Toddlers Study (FITS)Percent of Parents Reporting Feeding Problems (n=3022)
19
2529
35
4650
0
10
20
30
40
50
60
4-6 mos 7-8 mos 8-11 mos 12-14 mos 15-18 mos 19-24 mos
Per
cent
Carruth, 2004
Challenges – Toddler Feeding Problems Genetic Influences
Internal regulatory cues re hunger and satiety Preference for salt & sugar
Autonomy Desire to self-feed Emerging feeding skills – messy time
Challenges – Toddler Feeding Problems
Neophobia I don’t like it: I never tried it! (Birch & Marlin, 1982) Ethological explanation – how do I know those
mushrooms will not kill me.
Food advertising to children Average child in US views 13 food ads on TV/day
Calorie-dense, low nutrient snacks Advertisers protected by First Amendment Types of marketing
Informational Contains vitamins…
Emotional Ummm - yummy
Boring…
The Winner!!
Weak Link Between Information and Behavior
Dora the Explorer
Scooby Doo
Shrek
Licensed Cartoon Characters
Preschoolers Food Choice by Cartoon Characters
12.5 15
27.5
87.5 85
72.5
0
20
40
60
80
100
Graham crackers Gummy fruit snacks Carrots
Per
cent
No character Character
Roberto, Pediatrics, 2010
• Children more likely to choose food with cartoon characters.
• Role of advertising …..
Preschoolers Food Choice: Plain vs McDonalds (ages 3-5 years)
37
1813
21 2315
23
1018
23
4859
77
6154
0
20
40
60
80
100
Hamburger Childennugget
French Fries Milk/applejuice
Carrots
Per
cent
Plain Same McDonalds
Robinson, Archives of Pediatrics, & Adolescent Medicine, 2007
•Children more likely to choose food with McDonald’s labels
• Food industry….
Preschoolers Food Choice: Plain vs. McDonalds (ages 3–5 years)
0.1
0.2
0.4 0.40.45
0.50.55
0.6
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
TVs in household Eat McDonalds food
Pre
fere
nce
Scor
e
1 / <1 per month 2 / 1-3 per month 3 / 1 per week 4 / 2-3 per week
Robinson, Archives of Pediatrics, & Adolescent Medicine, 2007
• TVs in household and Eating McDonald’s food increased preference for McDonald’s food.
Does M&M consumption vary by color???
YES!!! Wansink, Mindless Eating, 2010
• Adults are more likely to eat multicolored M&Ms than 1 color M&Ms even if the taste is the same.
Summary Children’s food preferences are influenced by
internal cues and contextual factors What others are eating Familiarity of food Attractiveness of food (cartoon characters) Expectations/responsivity of parents Mealtime routines Mealtime setting - distractions
RESPONSIVE PARENTING
Interactive behaviors between caregivers and children
• Sensitive to child’s cues
• Prompt
• Appropriate
Parental Responsivity - applied to feeding
Sensitive to child’s cues Respond to child’s cues:
Prompt Appropriate
Development/age Culture Situation
Black & Aboud, J Nutr, 2010
Parental Responsivity is not: Giving children whatever they want.
Letting children be in charge of what they want, whenever they want it.
Child opens
mouth & accepts
Mother offers another
bite
Child looks away,
mouth shut
Mother offers a bite
of food
…………………...Time…………
RESPONSIVE FEEDING BEHAVIORS
PROMOTES HEALTHY EATING & GROWTH PATTERNS
Ummm, maybe she is telling me she wants to feed herself.
Child opens
mouth & accepts
Mother offers another
bite
Child looks away,
mouth shut
Child picks up food
& eats
Mother waits, smiles,
finger food
Mother offers a bite
of food
…………………...Time…………
PROMOTES HEALTHY EATING & GROWTH PATTERNS
RESPONSIVE FEEDING BEHAVIORS
WHAT IS NON-RESPONSIVE FEEDING? Excessive parental control
Forceful – Eat! Eat! Underweight children remain
underweight
Restrictive – No dessert for you! Overweight children remain
overweight
Fisher & Birch, AJCN, 1999
Child opens
mouth & accepts
Mother offers another
bite
Child looks away,
mouth shut
Mother offers a bite
of food
…………………...Time…………
NON-RESPONSIVE FEEDING BEHAVIORS
HINDERS HEALTHY EATING & GROWTH PATTERNS
Oh no, I am late. She has to finish eating.
Child opens
mouth & accepts
Mother offers another
bite
Child looks away,
mouth shut
Child Cries & spits
out food
Mother holds child &force feeds
Mother offers a bite
of food
…………………...Time…………
HINDERS HEALTHY EATING & GROWTH PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
WHAT IS NON-RESPONSIVE FEEDING? Lack of parental control
Indulgence Eat whatever you want Risk of overweight / obesity
Uninvolved Eats meals alone Risk of underweight
Child opens
mouth & accepts
Mother offers another
bite
Child looks away,
mouth shut
Mother offers a bite
of food
…………………...Time…………
NON-RESPONSIVE FEEDING BEHAVIORS
HINDERS HEALTHY EATING & GROWTH PATTERNS
Oh no, she does not like dinner. She likes ice cream
Child opens
mouth & accepts
Mother offers another
bite
Child looks away,
mouth shut
Child eats ice cream
not dinner
Mother gives child ice cream
Mother offers a bite
of food
…………………...Time…………
HINDERS HEALTHY EATING & GROWTH PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
CONSEQUENCES OF EXCESSIVE CONTROL: FORCEFUL/RESTRITIVE Forceful
Overrides internal regulation, reduces desire for food that is being forced
Increases likelihood of subsequent food refusal
Restrictive Increases desire for food that is being
restricted Increases disinhibited eating “Eating in the
absence of hunger”
Reciprocity of Feeding Balance between caregiver and child
Child opens
mouth & accepts
Mother offers another
bite
Child looks away,
mouth shut
WHY PARENTS USE NON-RESPONSIVE FEEDING
Concern regarding child’s size: Too thin or too heavy
Concern regarding child’s eating behavior: Eats too much or does not eat enough
Concern regarding child’s temperament: Difficult, easily distracted, Child will get upset
Concern regarding child’s health Sick - won’t eat without parent insisting or giving
“favorite” foods
Concern regarding child’s competence: Too immature or incompetent to self-feed
Concern regarding food availability, waste, spillage, time
Attachment and Obesity
6650 children (ECLS) Attachment – 24 mos Weight status – 4 ½ yrs
Odds of obesity amonginsecurely attached children1.30 (1.05,1.62) adjustingfor maternal BMI, mother-child interaction, parenting,socio-demographics
Anderson & Whitaker, 2011
Familial Transmission of Eating Behaviors Toddlers and mothers often share food and eat the
same diets Overweight toddlers , likely to display
External eating (sweets) Food responsiveness (craving) Speed of eating
Mothers’ emotional eating (Eating in Absence of Hunger) Emotional eating among preschool boys
Papas et al., 2009; Jahnke & Warschburger, 2008
Toddler Self-Regulatory Skills
Graziano, Calkins, & Keans, 2010
Self regulation at age 2 measured in play context. Weight measured at age 5.
Self regulatory behaviorsat age 2 predict overweight/obesity atage 5.
Preschool Interventions Can preschool interventions prevent childhood
obesity? Recent review of 37 studies
8 strong design 15 moderate potential of bias 14 high potential of bias
Some evidence of obesity prevention, but not strong Evidence for social and educational benefits Potential area for further research re obesity prevention –
include the family! D’Onise, SSM, 2010
Hip Hop to Health - Preschoolers
Efficacy trial: 14 week intervention re diet and PA taught in preschools by special educators * Smaller increases in BMI 1 and 2 years post intervention
Effectiveness trial: taught by preschool teachers** More time in physical activity (accelerometer) Less screen time (parent report) No difference: diet, change in BMI z score
* Fitzgibbon et al., 2005 ** Fitzgibbon et al., 2011
Toddler Overweight Prevention Study (TOPS)
Toddler obesity may be linked to parenting practices (using food to manage behavior).
Social Cognitive Theory: Reduce toddler obesity risk behaviors Parenting intervention? Maternal lifestyle intervention?
Mothers/toddlers recruited from WIC
Black, 2011
TOPS: Randomize into 3 Groups Parenting manage behavior, no food Maternal Lifestyle
mothers’ diet & activity
Safety Placebo
Results (Preliminary n = 178)CAREGIVERS
Maternal BMI Parenting & Maternal > Placebo
-0.45 (0.26) P=0.08
Maternal vegetable intake
Parenting > Placebo 0.62 (0.36) P=0.08
Maternal green vegetable intake
Parenting > Placebo 0.97 (0.41) P=0.02
TODDLERS
Toddler fruit intake Parenting & Maternal > Placebo
0.7 (0.36) P=0.04
Toddler physical activity
Parenting & Maternal > Placebo
107K (54K) P=0.049
Change in Maternal BMI
Changes in Toddler Servings of Fruit
Change in Toddler Physical Activity
Conclusion (Preliminary) Intervention based on social cognitive theory
focusing on parenting practices and maternal lifestyles reduced maternal and toddler obesity risk behaviors
Implementation of Toddler Feeding Recommendations Into Policy/Programs
The Start Health Feeding Guidelines for Infants and Toddler
American Dietetic Association
“Tip Sheet” for Families on Child Feeding USDA
Infant & Toddler Forum (UK) Provides Responsive Feeding messages
Promote breast feeding Begin prenatally Breast feeding peer counselors Infants regulate How to breast feed and work
Healthy foods with repeated exposure Children imitate – they want to eat what others are
eating Repeated exposure makes new foods familiar and
avoids neophobia and pickiness
Age-appropriate portion size Small portion size With a large portion, children are tempted to overeat Toddler portion size is ¼ of an adult portion size
1/4 to 1/2 slice of bread 1/4 cup of dry cereal 1 - 2 tablespoons of cooked vegetables No more than 16-24 oz. milk or 4 oz juice
Fruits & veggies Make fruits & veggies accessible
Serving size Cut up and available
Substitute for energy-dense snacks
Avoid indulgent feeding Indulgence is allowing children to be in charge of
what and when they eat Likely to choose sweet or salty snacks
Use behavioral strategies, not food, to manage behavior Do not emotionalize food by using it as a reward or
punishment – use behavioral strategies
Avoid restricting food Restricting means telling children they can not have
preferred food (e.g., desserts) Leads children to over-value restricted food Strategies to avoid “restriction”
Do not have dessert food in the house Do not have others eating dessert Offer small portion of dessert, regardless of food eaten
during meal
Avoid pressuring child to eat Parent provides – child decides Pressuring creates tension – children do not eat well
in tense situations Alternative
Be sure child is hungry Provide attractive bite size portions of healthy food Eat with child and keep mealtime pleasant If child does not eat, end the meal, and serve another meal
1 ½ - 2 hours later.
Where to intervene:
Individual
Eat This, Not That
Family
Buy This Not That
School
Serve This Not That
Ecological Model
Community Norms
Thank You.
70
Hunger (Food Insecurity) in the USA
• Unable to obtain adequate food for all family members due to lack of money
Over 1 in 5 children live in food insecure households
Households with children < age 6, over 20% food insecure
Baltimore, Boston, Little Rock, Los Angeles, Minneapolis, Philadelphia, & Washington DC
Children’s HealthWatchChildren’s HealthWatch
Children's HealthWatch monitors the impact of economic conditions and public policies on the health and well-being of very young children
A consortium of pediatric health care providers in major cities across the USA
Baltimore, Boston, Little Rock, Los Angeles, Minneapolis, Philadelphia, & Washington DC www.childrenshealthwatch.org
Child and Caregiver Outcomes by Food Security Status, n = 30,098
0
10
20
30
40
50
Ch
ild
Hea
lth
Ho
spit
aliz
atio
ns
At
risk
un
der
wei
gh
t
Ove
rwei
gh
t
Dev
elo
pm
enta
lri
sk
Car
egiv
erH
ealt
h
Dep
ress
ive
sym
pto
ms
Food Secure (77%) Food Insecure (23%)
* ****
* P < .001
Adjusted for site, race/ethnicity, US born, marital status, education, child gender, employment, breastfed, LBW, and maternal age
Screening Questions
1. We worried whether our food would run out before we got money to buy more
2. The food we bought just didn’t last and we didn’t have money to get more
_____Often True_____Sometimes True_____Never True
Families are considered “at risk for food insecurity” if they answer “sometimes true” or “often true” to either or both statements
Hager, Quigg, Black (2010), Pediatrics.
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