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.