Toddler Obesity Prevention: Healthy
Lifestyle Behaviors from the Beginning
Maureen Black, Ph.D.
Professor
Department of Pediatrics
mblack@peds.umaryalnd.edu
9-30-11
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
1976-1980
2004-2006
20
18
Percent
15
2006-2008
17 17.6
17
13 12.4
10
5
6
5
5
0
2-5 years
Ogden 2006, 2008, 2010
Double
6-12 years
Triple
13-19 years
Triple
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
Sleep
Energy Out
Playing
Energy In
Inactivity
Feeding
Need positive energy balance to support growth!
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








Birch & Ventura, 2009
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
Weight-for-length
Underweight, Overweight, or Within Normal???
Weight-for-length
Underweight, Overweight, or Within Normal???
0.4%ile
91%ile
56%ile
4%ile
Toddler Silhouette Scale
Hager, McGill, Black (2010). Obesity
Perception and Satisfaction
Show 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
• Preference for large
Toddler Body Size
body size
Percent
Accurate
100
90
80
70
60
50
40
30
20
10
0
• More likely to recognize
Satisfied underweight than
overweight
•Concern regarding small
body size
81
78
72
45
44
12
< 15%ile
15-85%ile
>85%ile
. . . . . . . . . . .Toddler’s Body Size . . . . . . . . . .
Hager, 2011
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)
60
50
50
46
Percent
40
35
29
30
20
25
19
10
0
4-6 mos
7-8 mos
8-11 mos
12-14 mos 15-18 mos 19-24 mos
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
Boring…

Informational


Contains vitamins…
Emotional

The Winner!!
Ummm - yummy
Weak Link Between Information and Behavior
Licensed Cartoon Characters
Scooby Doo
Dora the Explorer
Shrek
Preschoolers Food Choice by Cartoon
Characters
• Children more likely to
No character
100
choose food with cartoon
Charactercharacters.
• Role of advertising …..
87.5
85
Percent
80
72.5
60
40
20
27.5
12.5
15
0
Graham crackers
Gummy fruit snacks
Carrots
Roberto, Pediatrics, 2010
Preschoolers Food Choice: Plain vs
•Children more likely to choose food
McDonalds (ages 3-5 years) with McDonald’s labels
Plain
Same
• Food industry….
McDonalds
100
77
Percent
80
60
40
20
61
59
54
48
37
18
15
23
13 10
21 18
23 23
0
Hamburger
Childen
nugget
French Fries Milk/apple
juice
Carrots
Robinson, Archives of Pediatrics, & Adolescent Medicine, 2007
Preschoolers Food Choice: Plain vs.
• TVs in household and Eating
McDonalds (ages 3–5 years)
McDonald’s food increased preference for
McDonald’s food.
1 / <1 per month
2 / 1-3 per month
3 / 1 per week
4 / 2-3 per week
0.8
Preference Score
0.7
0.6
0.55
0.6
0.5
0.4
0.5
0.45
0.4
0.4
0.3
0.2
0.2
0.1
0.1
0
TVs in household
Eat McDonalds food
Robinson, Archives of Pediatrics, & Adolescent Medicine, 2007
Does M&M consumption vary by color???
•
Adults are more likely to eat
multicolored M&Ms than 1 color
M&Ms even if the taste is the
same.
YES!!!
Wansink, Mindless Eating, 2010
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.
PROMOTES HEALTHY EATING &
GROWTH PATTERNS
RESPONSIVE FEEDING BEHAVIORS
Ummm,
maybe she is
telling me
she wants to
feed herself.
Mother
offers a bite
of food
Child
opens
mouth &
accepts
…………
Mother
offers another
bite
Child
looks away,
mouth
shut
………
………...Time…
PROMOTES HEALTHY EATING &
GROWTH PATTERNS
RESPONSIVE FEEDING BEHAVIORS
Mother
offers a bite
of food
Child
opens
mouth &
accepts
…………
Mother
offers another
bite
Mother
waits, smiles,
finger food
Child
looks away,
mouth
shut
Child
picks up food
& eats
………
………...Time…
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
HINDERS HEALTHY EATING &
GROWTH PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
Mother
offers a bite
of food
Child
opens
mouth &
accepts
…………
Oh no, I am
late. She has
to finish
eating.
Mother
offers another
bite
Child
looks away,
mouth
shut
………
………...Time…
HINDERS HEALTHY EATING &
GROWTH PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
Mother
offers a bite
of food
Child
opens
mouth &
accepts
…………
Mother
offers another
bite
Mother
holds child &
force feeds
Child
looks away,
mouth
shut
Child
Cries & spits
out food
………
………...Time…
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
HINDERS HEALTHY EATING &
GROWTH PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
Mother
offers a bite
of food
Child
opens
mouth &
accepts
…………
Mother
offers another
bite
Child
looks away,
mouth
shut
Oh no, she
does not like
dinner. She
likes ice
cream
………
………...Time…
HINDERS HEALTHY EATING &
GROWTH PATTERNS
NON-RESPONSIVE FEEDING BEHAVIORS
Mother
offers a bite
of food
Child
opens
mouth &
accepts
…………
Mother
offers another
bite
Mother
gives child
ice cream
Child
looks away,
mouth
shut
Child
eats ice cream
not dinner
………
………...Time…
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
Mother
offers another
bite
Child
opens
mouth &
accepts
Child
looks away,
mouth
shut
WHY PARENTS USE NONRESPONSIVE FEEDING

Concern regarding child’s size:


Concern regarding child’s eating behavior:


Sick - won’t eat without parent insisting or giving “favorite” foods
Concern regarding child’s competence:


Difficult, easily distracted, Child will get upset
Concern regarding child’s health


Eats too much or does not eat enough
Concern regarding child’s temperament:


Too thin or too heavy
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 among
insecurely attached children
1.30 (1.05,1.62) adjusting
for maternal BMI, motherchild 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
Self regulation at age 2
measured in play context.
Weight measured at age 5.
Self regulatory behaviors
at age 2 predict
overweight/obesity at
age 5.
Graziano, Calkins, & Keans, 2010
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 &
-0.45 (0.26)
Maternal > Placebo
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
Toddler fruit intake
Parenting &
0.7 (0.36)
Maternal > Placebo
P=0.04
Toddler physical
activity
Parenting &
107K (54K)
Maternal > Placebo
P=0.049
TODDLERS
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:
School
Family
Community
Norms
Individual
Eat This, Not That
Buy This Not That
Serve This Not That
Ecological Model
Thank You.
Hunger (Food Insecurity) in the USA
• Unable to obtain adequate food for all family
members due to lack of money
70
Households
with children
< age1 6,
Over
in 5
over
20%live
children
food
insecure
in food
insecure
households
Children’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,
Los Angeles,
Minneapolis,
Baltimore, Boston,
LittleLittle
Rock, Rock,
Los Angeles,
Minneapolis,
Philadelphia, &Philadelphia,
Washington DC
& Washington DC www.childrenshealthwatch.org
Child and Caregiver Outcomes by Food
Security Status, n = 30,098
* P < .001
*
*
*
Caregiver
Health
Depressive
symptoms
Overweight
At risk
underweight
*
Hospitalizations
*
Child Health
50
40
30
20
10
0
Food Insecure (23%)
Developmental
risk
Food Secure (77%)
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.