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Child Care, Parenting, and Childhood Obesity Julie C. Lumeng, MD University of Michigan Center for Human Growth and Development Department of Pediatrics.

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Presentation on theme: "Child Care, Parenting, and Childhood Obesity Julie C. Lumeng, MD University of Michigan Center for Human Growth and Development Department of Pediatrics."— Presentation transcript:

1 Child Care, Parenting, and Childhood Obesity Julie C. Lumeng, MD University of Michigan Center for Human Growth and Development Department of Pediatrics

2 Obesity Trends* Among U.S. Adults BRFSS, 1985 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)

3 1990 No Data <10% 10%–14%

4 1995 No Data <10% 10%–14% 15%–19%

5 1997 No Data <10% 10%–14% 15%–19% 20%–24%

6 1999 No Data <10% 10%–14% 15%–19% 20%–24%

7 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

8 2005 No Data <10% 10–14% 15–19% 20–24% 25–29% ≥30%

9 Increase in Child Overweight

10 Increase in Rates of Overweight in Children by Race Over 10 Years Strauss RS, Pollock HA, Epidemic increase in childhood overweight, 1986 – 1998. JAMA 286(22). 2845-2848, 2001.

11 Increase in Child Overweight by Race and Socioeconomic Status Strauss RS, Pollock HA, Epidemic increase in childhood overweight, 1986 – 1998. JAMA 286(22). 2845-2848, 2001.

12 Overweight Prevalence in Preschoolers and Poverty M Feese et al. Prevalence of Obesity in Children in Alabama and Texas Participating in Social Programs. JAMA 289. 1780 – 1781; 2003.

13 Childhood Obesity is not Commonly Outgrown Odds of being obese at age 12 years if overweight at age: 2 years: 3.0 3 years: 3.3 4.5 years: 7.9 7 years: 32.8 9 years: 57.5 PR Nader, Pediatrics 2006

14 Childhood Obesity is More Responsive to Treatment than Adult Obesity 10-year follow-up of 113 obese parent-child pairs in medical center weight loss program Percent individuals maintaining more than 20% weight loss over time: –Children: 20% (nearly one third of children non-obese 10 years later) –Parents: < 1% LH Epstein, Obesity Research 1995, JAMA 1990

15 Etiology of Childhood Obesity Too rapid a change in the population to be genetics alone Calories taken in exceed calories expended Simple! –↓ calories taken in –↑ calories expended

16 Recommendations for Obesity Prevention MM Davis, Pediatrics 2007 Limit consumption of sugar-sweetened beverages (consistent evidence)

17 Recommendations for Obesity Prevention MM Davis, Pediatrics 2007 Encourage diets with recommended quantities of fruits and vegetables (mixed evidence)

18 Recommendations for Obesity Prevention MM Davis, Pediatrics 2007 Limit television and other screen time by allowing no more than 2 hours per day, as advised by the American Academy of Pediatrics (consistent evidence) Remove television and computer screens from children's primary sleeping areas (consistent evidence)

19 Watching Television JC Lumeng, et al. Television Exposure and Overweight Risk in Preschoolers Arch Pediatr Adolesc Med. 2006;160:417-422.

20 Which Children Watch More TV? Low maternal education Minority race/ethnicity More televisions in the home More eating meals while watching television TV in the bedroom Maternal depression Maternal obesity Child behavior problems Low quality home environment Saelens 2002. J Dev & Behav Pediatrics; Burdette 2003. Arch Pediatr Adolesc Med; Certain 2002. Pediatrics; Dennison 2002. Pediatrics; Lumeng 2006. Arch Pediatr Adolesc Med.

21 Recommendations for Obesity Prevention MM Davis, Pediatrics 2007 Eat breakfast daily (consistent evidence)

22 Recommendations for Obesity Prevention MM Davis, Pediatrics 2007 Limiting eating at restaurants, particularly fast food restaurants (consistent evidence)

23 Recommendations for Obesity Prevention MM Davis, Pediatrics 2007 Encourage family meals in which parents and children eat together (consistent evidence)

24 Recommendations for Obesity Prevention MM Davis, Pediatrics 2007 Limit portion sizes (consistent evidence)

25 140 calories 3-inch diameter Calorie Difference: 210 calories 350 calories 6-inch diameter BAGEL 20 Years Ago Today

26 Calorie Difference: 257 calories 590 calories CHEESEBURGER 20 Years Ago Today 333 calories

27 Calorie Difference: 165 Calories 250 Calories 20 ounces 85 Calories 6.5 ounces SODA 20 Years AgoToday

28 Recommendations for Prevention MM Davis, Pediatrics 2007 Actively engage families with parental obesity or maternal diabetes, because these children are at increased risk for developing obesity even if they currently have normal BMI Encourage parents to model healthy diets and portion sizes, physical activity, and limited television time Promote physical activity at school and in child care settings

29 Child Care and Obesity Risk Does attending child care, in and of itself, as opposed to being home with one’s mother, predict an increased risk of childhood obesity?

30 Child Care and Obesity Risk: Mixed Results Attending some child care (< 15 hours per week) appears to be protective against obesity, if it has any effect at all, and this effect appears to be regardless of whether the child lives in poverty or the quality of the home environment. Attending non-parental care seems to be protective for Latino children Non-parental unstructured care seems to increase risk Attending child care seems to have no relationship with obesity JC Lumeng et al. International Journal of Obesity, 2005 E Maher et al, Pediatrics, 2008

31 Wednesday, May 16, 2007 – CNN Are women responsible for obesity among children? Women have been blamed for many of the world's problems since Eve in the Garden of Eden... the theory is that when American women started to enter the workforce en masse in the 1970s and '80s, kids started getting fatter...

32 Media on Parenting and Obesity “I've long suspected that rapidly growing rates of childhood obesity in the United States may be tied, at least in part, to the fact that American children in general seem more out of control and ill-behaved than ever. And that's because their parents seem more ineffective and less likely to tell their children "no" than ever. You've seen it. The screaming, crying, foot-stomping little kids yelling at their parents and making demands in the mall, the grocery store, and virtually every restaurant one enters. It is not particularly surprising kids try that stuff -- what's stunning is watching the impotent, terrified parents looking like deer caught in headlights as it's happening.” – one journalist

33 Parenting Style

34 K Rhee, JC Lumeng, et al. Parenting Styles and Overweight Status in First Grade. Pediatrics (117). 2047-2054. 2006. % obese *Adjusted for income-to-needs ratio and race Permissive Authoritative Neglectful Authoritarian

35 Media Response “Strict Parenting Raises Risk of Childhood Obesity” “How Parents Mold Their Children’s Weight” (NYT) “Do Very Strict Parents Raise Fat Kids” (CBS) “Insensitive Parents, Chubby Children” “Study: Mean, Maniacal Mom Made you Fat” “It’s All Our Fault Anyhow”

36 Why? Supporting response to satiety? Supporting physical activity? Affect regulation? Stress?

37 Maternal Feeding Behaviors Parenting and Obesity

38 Barriers to Treating Childhood Obesity Reported by Pediatricians “Most of the Time” or “Often” true Lack of: –Patient motivation 86% –Parent involvement 81% MT Story, Pediatrics 2002

39 Motivators to Pursue Child Weight Management Cited by Parents KE Rhee, Pediatrics 2005 Stages of Change: –Precontemplation: No interest in changing behaviors in the next 6 mo –Contemplation: Thinking about making a change but not soon –Preparation: Intending to make a change in the next month –Action: Making changes –Maintenance: Maintaining changes for at least 6 mo

40 Motivators to Pursue Child Weight Management Cited by Parents KE Rhee, Pediatrics 2005 Odds that parent of an overweight child would be in the ‘preparation’ or ‘action’ stage of change (versus precontemplation) by each characteristic: – Child age > 8 years (v 2-7): 3.7 –“Being overweight is a health problem”: 2.7 –“Child’s weight is a health problem”: 16.0 – Parent perceives child as overweight: 2.1 –Parent perceives self as overweight: 3.9 –Doctor made a comment: 10.8

41 Talking to Parents about Feeding and Weight

42 In every nursery there are ghosts. They are the visitors from the unremembered past of the parents. While no one has invited them, they take up residence and conduct the rehearsal of the family drama. In healthily developing relationships, the parents can move the ghosts aside to be present for the child. Selma Fraiberg, 1980

43 Topics to Raise with Parents and How to Raise Them

44 What the child brings to the table

45 A behavioral style or “phenotype” –relatively stable in individual children –believed to be genetic Children with low EAH –once they are satiated, are relatively unresponsive to prompts to eat from the environment Children with high EAH –eat in response to social cues in the environment –eat when they are not hungry –more likely to be obese Bring out different parental responses and require different types of parenting Eating in the Absence of Hunger (EAH)

46 "How can you be hungry? You just ate!" Starting the conversation: "Some parents tell me they have to remind their kids to eat, and others tell me their children are always looking for food, even when they've just eaten a good meal. What is your child like? Is it hard to figure out whether your child is really hungry? How do you tell? What do you do if the child says he's hungry, but you're pretty sure he can't be? Why do you think your child says she's hungry when she probably isn't? Are there times of day when this seems to happen? When she’s tired? When she’s bored? Can you think of anything you could do to make the child less likely to think she's hungry?"

47 The “Good Eater” Child with innately voracious or ravenous eating style (i.e. Cookie Monster) more likely to become overweight –Infants with a fast and strong suck are more likely to become overweight by 2 to 3 years old. –Children who eat fast and chew each bite less are more likely to be overweight by 18 months. Mothers' response may differ, depending on her own goals –Mother concerned about overweight may adopt restrictive feeding style –Mother whose vision of a healthy child is a heavy child may reinforce this type of eating with more frequent and enthusiastic feedings

48 "Look how well she eats!" Starting the conversation: "Some children are very careful, selective, and slow in their eating. Others are enthusiastic eaters who dive right in, eat a lot, eat it quickly, and really enjoy it. What's your child's eating style? Most people really like to see children who love to eat. Do you feel that way about it? Do you think it's a good thing, or does it seem like a problem? Have you ever changed the way you feed her because of her eating style? What do you think is the best way for a mother to respond to different eating styles?"

49 Temperament The HOW of behavior Children born with unique combination of temperamental characteristics Defines behavioral style Seems to be largely innate or genetic Stable over time, but can change

50 Temperament Traits Activity Level Rhythmicity/Regularity/Predictability Distractibility Approach or Withdrawal to New Stimuli Adaptability Attention Span or Persistence Intensity of Reaction Sensitivity or Threshold of Responsiveness Quality of Mood

51 Temperament and Obesity Traits linked with higher risk of obesity –Distractible –Active –Inattentive –Unpredictable –Having a ‘difficult’ temperament –Having tantrums over food at age 3 years or older These children may need more external control from parents –Mothers may need to exert more control over eating

52 "The child who lacks inhibitions" Starting the conversation: "Children have different ways of reacting to new situations. Some hang back and want to come to understand the situation, while others like to jump right in. Some parents tell me their child is very focused, selective, and careful about eating, while other parents say their children are uninhibited, enthusiastic, busy eaters. How would you describe your child? Does your child's way of approaching eating have an effect on their nutrition, do you think? Is that ever a problem for you? What works well in dealing with it?"

53 "If I don't let him have the food he wants, he throws a fit" Starting the conversation: "Sometimes parents tell me that if they don't provide food when the child asks for it, the child has a tantrum. The parents often tell me that it's really difficult to tell if the child is actually hungry, or is having a tantrum for some other reason. Do you ever think your child demands food when she (or he) really isn't hungry? Why do you think she (or he) does that? Have you found any good ways of dealing with this behavior?"

54 What mom brings to the table

55 Feeding styles –Pushing, pressuring, or prompting Thinner children are prompted more Heavier children are prompted more No association –Controlling Associated with mother being more concerned about child being too heavy, and child being heavier Especially true in girls More control seems to only increase the excessive weight gain –“Hands off" style Heavier children allowed more choice Thinner children allowed more choice No relationship Hot area of research

56 Differences in Reported Feeding Practices by Income Low-income minority mothers (compared to upper-income white mothers) self-reported: Greater concern about their infant’s hunger Using food less often to calm their infants More scheduled feedings Greater difficulty feeding their preschoolers Pushing their preschool children to eat more More divergent feeding practices Less mealtime structure at toddler/preschool age Baughcum 2001. J Developmental & Behavioral Pediatrics

57 Differences in Feeding Practices by Race Hispanic parents have been described as self-reporting a more indulgent or permissive feeding style. African American parents self-report a more authoritarian (directive) feeding style. Hispanic parents self-report more controlling practices in their feeding than do African American parents.

58 Feeding Styles Differ Across Demographic Groups Certain feeding styles cluster within the same demographic groups in which maternal and child obesity are more common. Some advocate altering these feedings styles on the premise that they cause obesity, but we don’t really know that to be true

59 "I don't allow eating between meals" Starting the conversation: "Some parents find they need to have a lot of rules and restrictions about eating, or else their children would not eat a healthy diet. Other families don't feel they need many food rules. What's your family like? What kind of rules and restrictions do you have? Which ones work best? Which don't work so well? Why do you think that is? Do you think some children need more rules about eating than others? Why is that?"

60 The other kids on the block Mothers judge weight status in comparison with the child's peers Entire distribution of BMI has shifted up Child at the 50 th percentile according to charts now on the thinner side of the class Particularly shifted in high-obesity prevalence groups

61 "My mother says he's thinner than most other boys in the neighborhood." Starting the conversation: "Sometimes when parents look back at their own childhood, they remember only one or two kids who were really overweight. When you look at your child's classroom or neighborhood today, do you see more overweight kids than when you were growing up? Sometimes it's hard to tell what a normal weight is any more, since so many grownups and children are overweight. Do you think it's hard to tell if a child is overweight?"

62 Adiposity Rebound Between the ages of 4 and 6, children reach the nadir, or low point, of body fat (naturally) –A 5-year-old looks skinnier than a 3-year-old or an 11- year-old –When a 5-year-old is compared with children his own age, he may actually be overweight. Parents sometimes respond to this “skinny stage” by prompting the child to eat well beyond when they are full Earlier adiposity rebound predicts higher risk of future obesity

63 Adiposity Rebound Body fatness decreases during early childhood and rebounds as children grow older In normally growing children, occurs between ages 4 and 7 years

64 Losing the baby fat Starting the conversation: "When you look at photographs of yourself growing up, when do you think you were skinniest? How old were you when you started to put on a little more weight? Does your child take after you, do you think? Most children are at their skinniest between the ages of 4 and 7, and after that they start putting more weight on. Some parents worry that their child is always going to grow up to be too thin. Do you ever worry about this?"

65 Ideal Body Image of the Child Mother may want her child to be heavier No strong data to support the notion that low-income or minority mothers prefer a heavier body type for children Mothers do not accurately perceive their child’s weight status

66 "I don't care what the growth chart shows. I know he's too skinny!" Talking about growth charts and the child’s percentile on the curve is often not useful Studies show that parents –don't understand growth charts –think the charts have no relevance for their children

67 "His grandmother says..." Parents are more likely to turn to family members for advice about feeding Grandparents, particularly those who have immigrated from countries where food is sometimes scarce, often have views about how children should be fed and how much they should weigh.

68 "His grandmother says..." Starting the conversation: "Most parents find family members' advice about feeding really helpful. What advice have you been given that you agree with? What do you disagree with, or question? Sometimes doctors give advice that's different from what grandparents say: What does your mother think about the advice experts give today? Why do you think she feels that way? Why does your mother think your child should weigh more and be bigger? How did your mother feed you when you were a child? Would you do it the same way, or differently? Do you think the way your mother fed you has influenced the way you eat today?"

69 Overweight parents More likely to attune feeding behavior to child's weight status More likely to address a child's overweight Starting the conversation: "Is being overweight a common problem in your family? How do your family members feel about their weight? Was being overweight something that concerned you as a child? How did you deal with it? What tactics do you find helpful in managing your own weight? What do you find hardest? Do you think the challenges are the same for your child, or different?"

70 Are there effective ways to shape children’s eating behaviors so that they will eat more vegetables and like sugar less?

71 Almost two thirds of parents report one or more problems with their toddler's eating. –Not always hungry at mealtime (~1/2) –Do not seem to enjoy meals (~ 1/3) –Have strong food preferences (~ 1/3) –Often refuses to eat (~ ¼) –Requests specific foods and then refuses them (~ 1/5) –Tries to end a meal after a few bites (~ ½) What Is Picky Eating? N Reau et al. Journal of Developmental and Behavioral Pediatrics; 1996.

72 20% to 30% of parents report that their preschool-aged child is a picky eater. Picky preschoolers (compared to non-picky) –Eats a limited variety of foods (79% vs. 16%) –Want the food prepared in specific ways (62% vs. 18%) –Do not accept new foods readily (90% vs. 39%) –Have strong dislikes (97% vs. 63%). What Is Picky Eating? C Jacobi et al. Journal of the American Academy of Child and Adolescent Psychiatry; 2003.

73 Prevalence of Picky Eating n = 3022 (Feeding Infants And Toddlers Study (FITS)) Children aged 4-24 months, 77% white, diverse SES “Is your child a... “ –“Picky eater” –“Somewhat picky eater” –“Not a picky eater” BJ Carruth et al; Journal of the American Dietetic Association, 2004.

74 Picky Eating by Age

75 The Course of Picky Eating Both a developmental stage and a personality trait C Jacobi et al. Journal of the American Academy of Child and Adolescent Psychiatry; 2003. P Pliner P et al. Appetite 1997.

76 Why are Children Picky? Children become increasingly picky at about the age they begin walking Hypothesized that humans evolved to be picky when they first become mobile so that when we lived in more natural environments, the young would not wander into the bush and eat poisonous vegetation The foods we are most picky about eating are vegetables EA Cashdan, Human Nature, 1994.

77 Why are children picky eaters? Inherited Taste Preferences

78 Genetic Variation in Pickiness Ability to taste PROP (6-n-propylthiouracil) (the bitter compound in vegetables like broccoli and Brussels sprouts) Fewer veggies Keller et al. Appetite; 2002; Obesity; 2004.

79 Living in Different Sensory Worlds Children taste flavors differently than adults. “Taster” child born to a non-taster parent is perceived by parent as difficult or picky eaters. JA Mennella, Pediatrics, 2005.

80 Biologic Preference for Sweet Children have an inborn preference for sweetness Preference for high degree of sweetness decreases into late adolescence This pattern is true in children around the world J Steiner, J. Annals of the New York Academy of Sciences; 1974. J Desor. Physiology and Behavior, 1987. J Desor,, et al. Science, 1975.

81 Critical Role of Early Experience Exposure to flavors in the womb and in breast milk predict greater preference when infants were later given the food Exposure to protein hydrolysate formulas (very sour) in infancy predicts preference for sour in early childhood Exposure to sugar water in infancy predicts greater sweet preference in early childhood JA Mennella et al; Early Human Development, 2002. JA Mennella et al; Pediatrics; 2004. JA Mennella, et al; Developmental Psychobiology, 1999. G Beauchamp et al; Appetite, 1982.

82 Why are children picky eaters? Innate Social Influences

83 Humans Learn to Prefer Foods That They Observe Peers Eating A preference for a vegetable is increased when eating in the presence of other children eating the target vegetable Peers and admired figures are more powerful than adults in inducing this preference LL Birch; Child Development, 1980. K Duncker; Journal of Abnormal & Social Psychology, 1938.

84 Recommendations to improve food acceptance

85 Research Finding: Children are less likely to eat unfamiliar foods in atmospheres that are over- stimulating or stressful Implication: Another reason to promote calm, quiet mealtimes P Pliner et al; Physiology & Behavior, 2002.

86 Research Finding: Children are more likely to follow the lead of a peer model (another child) to eat a new food than an adult (parent or teacher) model Implication : Focus energy on highlighting how much other children are enjoying the food as opposed to how much the teacher or adult enjoys the food HM Hendy; Appetite, 2002..

87 Research Finding: Both verbal praise for eating a food as well as tangible rewards decrease liking for the food over time. Implication: Do not reward children for eating target foods. LL Birch; Child Development, 1984.

88 Research Finding: Using a food as a reward for completing another task increases liking for the food. Implication: Do not use desserts as rewards (but may consider using a healthy alternative). LL Birch, et al. Child Development, 1980.

89 Research Finding: Eating a food along with positive adult attention increases liking for the food. Implication: More support for pleasant family mealtimes. LL Birch, et al. Child Development, 1980.

90 Research Finding: Foods typically must be tasted 10 times before they are accepted and preference begins to increase. Implication: Present target foods repeatedly (10 different meals). LL Birch, et al. Appetite, 1982.

91 How Many Times Do You Offer a Food Before Deciding the Child Dislikes It? BJ Carruth et al; Journal of the American Dietetic Association, 2004.

92 Research Finding: Requiring that children “try one bite” is associated with an increased willingness to try other new foods over time Implication: If it does not cause undue distress for anyone involved, the “try one bite rule” is reasonable R Loewen et al. Appetite, 1999.

93 Research Finding: Combining a non-preferred food with a preferred food may be helpful, to an extent. Implication: Provide opportunities to combine foods (e.g. dipping). P Pliner et al; Appetite, 2000.

94 Conclusions Obesity is tough to prevent and treat, and will require interventions on multiple different levels (community, school, home) Parents play an important role, but the dyadic interaction needs to be considered (i.e. innate child behavioral predispositions likely bring something to the situation) Though there are some specific feeding practices which seem to be linked to childhood obesity or food preferences, a lot more research is still needed

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