Parenting and Obesity
Julie C. Lumeng, MD
University of Michigan
Center for Human Growth and Development
Department of Pediatrics
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman)
No Data
<10%
10%–14%
1990
No Data
<10%
10%–14%
1995
No Data
<10%
10%–14%
15%–19%
1997
No Data
<10%
10%–14%
15%–19%
20%–24%
1999
No Data
<10%
10%–14%
15%–19%
20%–24%
2002
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
2005
No Data
<10%
10–14%
15–19%
20–24%
25–29%
≥30%
Increase in Child Overweight
Prevalence, %
Increase in Obesity Prevalence
16
14
12
10
8
6
4
2
0
15
11
5
1960's
1988-94
Year
1999-2000
Increase in Rates of Overweight in
Children by Race Over 10 Years
Increase in Child Obesity by Race
Prevalence, %
25
African
American
20
Hispanic
15
White
10
5
1986
1998
Year
Strauss RS, Pollock HA, Epidemic increase in childhood overweight, 1986 –
1998. JAMA 286(22). 2845-2848, 2001.
Increase in Child Overweight by
Race and Socioeconomic Status
Increase in Child Obesity by Race and
Socioeconomic Status
Prevalence, %
30
Low income
African American
and Hispanic boys
25
20
15
Upper income
white girls
10
5
0
1986
1998
Year
Strauss RS, Pollock HA, Epidemic increase in childhood overweight, 1986 –
1998. JAMA 286(22). 2845-2848, 2001.
US Obesity Prevalence
by Race and Age, 2003-2006
30
23.8
% obese
25
21.3
20
15
14.9
16.7
15.0
10.7
10
5
0
White
Black
Mexican
American
2-5 years
White
Black
6-11 years
Ogden et al, High Body Mass Index for Age Among US Children and
Adolescents, 2003-2006 . JAMA. 2008;299(20):2401-2405.
Mexican
American
Overweight Prevalence in
Preschoolers and Poverty
30
25
20
15
10
5
0
White
Boys
White
Girls
Black
Boys
NHANES (national data)
Black
Girls
Hispanic
Hispanic
Boys
Girls
Head Start (children in poverty)
M Feese et al. Prevalence of Obesity in Children in Alabama and Texas
Participating in Social Programs. JAMA 289. 1780 – 1781; 2003.
Etiology of Overweight
Calories taken in exceed
calories expended
• Institute of Medicine, Committee on
Childhood Obesity: Preventing
Childhood Obesity: Health in the
Balance
– A National Priority
– Industry, advertising, media
– Local Communities
– Schools
– Home
“Expert Committee
Recommendations for Parents”
•
•
•
•
Limit consumption of sugar-sweetened
beverages
Encourage diets with recommended
quantities of fruits and vegetables
Limit television and other screen time by
allowing no more than 2 hours per day
Remove television and computer
screens from children's primary sleeping
areas
MM Davis, Pediatrics 2007
“Expert Committee”
Recommendations for Parents
•
•
•
•
•
•
•
Eat breakfast daily
Limiting eating at restaurants
Have family meals
Limit portion sizes
Have an authoritative parenting style
Avoid a restrictive parenting style
Model healthy behaviors
MM Davis, Pediatrics 2007
Watching Television
10
8.8
Percent overweight
9
8
7
6
5.6
5.8
1.75 - 3
3 - 4.9
5
4
3
2.0
2
1
0
<1.75
> 4.9
hrs/day
Hours per day of television
JC Lumeng, et al. Television Exposure and Overweight Risk in
Preschoolers Arch Pediatr Adolesc Med. 2006;160:417-422.
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.
Safety of the Neighborhood
18
16.8
Percent Overweight
16
14
11.5
12
10
8
6
4.1
4
2
0
Safest
Average Safety
Least Safe
Perception of Neighborhood Safety
Relationship not altered by child’s sex, race, maternal marital status, maternal education,
maternal depression, the child’s participation in structured after-school activities, parental
perception of neighborhood social cohesiveness, quality of the home environment
JC Lumeng et al., Neighborhood Safety and Overweight Status in Children.
Arch Pediatr Adolesc Med. 2006;160:25-31.
Who Feels Unsafe in Their
Neighborhood?
• Parents of African American children (as
opposed to parents of white children),
regardless of socioeconomic status
• Mothers who are depressed, have low
education, and are single
Feeding and Parenting
Parenting Behavior Impacts How
Much Children Eat from Infancy
• 8- to 14-week-old infants who are provided
social interaction while feeding eat 40%
more than those who are not provided
social interaction
• Infants who are held while fed closely
relate the time elapsed since the last
feeding to the amount they eat; when
infants are not held, this relationship
dissipates
Lumeng, Patil, & Blass, Developmental Psychobiology, 2007.
Behavior Problems Predicting
Childhood Obesity
• National Longitudinal Survey of Youth
• N = 629 non-obese children, ages 8 – 11 years
– 53% male
– 53% white
– 9% with behavior problems
• Tested relationship between baseline “significant
behavior problems” and becoming obese 2
years later
• Tested potential confounders:
– child’s sex
– Race
– mother’s marital status
– mother’s education
– family poverty status
– mother’s obesity
– mother’s depressive symptoms
– Home Observation for Measurement of the
Environment-Short Form (HOME-SF) cognitive
stimulation score
– mother’s smoking status
– use of behavior-modifying medication
– hours of television per day
– history of academic grade retention
Odds ratios for childhood obesity 2 years later
Covariate
Behavior problems (yes v no)
OR (95% CI)
5.23 (1.37 – 19.93)
Race
Black v. white
Hispanic v. white
Quality of home environment
1.82 (0.79 – 4.24)
5.47 (2.18 – 13.7)
Low v. high
Medium v. high
Baseline BMI z-score
2.43 (0.31 – 18.7)
4.10 (0.52 – 32.4)
5.86 (2.43 – 14.12)
JC Lumeng et al. Association Between Clinically Meaningful Behavior
Problems and Overweight in Children. Pediatrics (112). 1138-1145.
2003.
Which children are at higher risk for
behavioral problems?
•
•
•
•
•
Poverty
Single mother
Grade retention
Low maternal education
Maternal depression
JC Lumeng et al. Association Between Clinically Meaningful Behavior Problems
and Overweight in Children. Pediatrics (112). 1138-1145. 2003.
Media Response
• “Isn’t it all just bad parenting?”
• “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 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
Affect Regulation, Food,
Mood, and Parenting
• Children with behavior problems, difficult
temperaments more likely to be
overweight
• Children who have tantrums over food
more likely to become overweight
• Food regulates affect (cortisol, stress axis)
• Use of food to regulate mood in parents
and children
• “Food is love”
The Parent-Child Interaction
What Everyone Needs from
Relationships
• To feel known and
understood
• To feel “chosen”
• To experience a
balance of giving
and getting
What Everyone Needs from
Relationships
• To feel safe to be yourself
and to explore options for
change
• To be able to predict the
reactions of the other
• To experience conflict
cooperatively
Parenting Style
Parenting Style and
Childhood Obesity
• NICHD Study of Early Child Care and Youth
Development
• N = 872 children in 1st grade
– 49% male
– 83% white
– 11% obese
• Maternal sensitivity (scored from videotaped
standardized interaction, “supportive presence”,
“respect for autonomy”, “hostility”)
• Maternal expectations for self-control
Maternal Expectations
for Self-Control
How often do you expect your child to
(1) Sit or play quietly (or refrain from interrupting) while adults are
having a conversation?
(2) Be agreeable about an unexpected change in plans?
(3) Accept a new babysitter or caregiver without complaint?
(4) Be patient when trying to do something difficult?
(5) Go to bed without a hassle?
(6) Refrain from interrupting when you are on the telephone?
(7) Show self-control when disappointed?
(8) Stay in bed once put to bed?
(9) Be on "best behavior" when you are in public?
(10) Wait his or her turn without fussing?
(11) Control anger outbursts?
Potential Confounders
•
•
•
•
•
Race
Maternal education
Income-to-Needs Ratio
Family Composition (single mother v. not)
Child behavior problems (Achenbach Child
Behavior Checklist)
Odds ratios for child being obese in first grade
Covariate
Self-control (high v. low)
Sensitivity (high versus low)
Gender (male versus female)
Race (white versus other)
Maternal education
Income/needs ratio
Living with spouse or partner
Child behavior problems
OR (95% CI)
1.27(0.82–1.96)
0.47 (0.28–0.81)
1.23 (0.81–1.92)
1.54 (0.82–2.94)
0.98 (0.88–1.09)
0.92 (0.83–1.02)
0.97 (0.49–1.96)
1.01 (0.99–1.04)
Authoritarian
20
Neglectful
15
17.1
% obese
Permissive
10
5
9.9
9.8
Authoritative
3.9
0
Low Expectations for
Self-Control
Low
Sensitivity
High Expectations for
Self-Control
High
Sensitivity
*Adjusted for income-to-needs ratio and race
K Rhee, JC Lumeng, et al. Parenting Styles and Overweight Status
in First Grade. Pediatrics (117). 2047-2054. 2006.
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”
Why?
•
•
•
•
Supporting response to satiety?
Supporting physical activity?
Affect regulation?
Stress?
Sleep and Childhood Obesity:
Does “Poor” Parenting
Explain the Link?
• NICHD Study of Early Child Care and
Youth Development
• N = 785 children in 6th grade
– 50% male
– 81% white
– 18% obese
• Sleep duration by maternal response to
Children’s Sleep Habits Questionnaire
Potential Confounders
•
•
•
•
Gender
Race
Maternal education
Child Behavior Checklist, internalizing and
externalizing subscale scores
• Parenting measures
– CHAOS Scale
– Mid-Childhood Home Observation for
Measurement of the Environment (quality of
the home environment)
– Greenberger's Raising Children Checklist, lax
control subscale
Odds ratios for child being obese in 6th grade
Covariate
OR (95% CI)
Sleep duration in 3rd grade,h
0.60 (0.36–0.99)
Change in sleep duration
0.68 (0.44–1.06)
between 3rd and 6th grades, h
Gender (male versus female)
0.82 (0.40–1.71)
Race (white versus other)
1.42 (0.54–3.73)
Maternal education
0.84 (0.72–0.99)
BMI z score at 3rd grade
127.4 (48.0–337.8)
JC Lumeng, et al. Shorter Sleep Duration Is Associated With
Increased Risk for Being Overweight at Ages 9 to 12 Years.
Pediatrics (120). 1020-1029. 2007.
Is it All Just “Bad Parenting”?
Covariate
OR (95% CI)
CHAOS Score
0.98 (0.92 – 1.04)
Quality of Home Environment
1.01 (0.97 – 1.05)
Lax Control Subscale
0.99 (0.93 – 1.05)
Beliefs about Childhood Obesity
Among Low-Income Mothers
•
•
•
•
•
•
N = 91
Ages 3-5 years
Children: 21% obese, 26% overweight
Mothers: 49% obese, 41% overweight
41% of mothers < high school education
26% of families food insecure
“Why are children obese?”
•
I definitely blame overweight children on the parents. One hundred percent.
I think it’s because they’re not educated, because they don’t know any
better, because they’re feeding them things that are making [them]
overweight and not giving them a healthy diet. Um, too much fast food. Um,
a lot of parents just don’t care. I mean, honestly, there’s a lot of parents that
just don’t care. Some parents feed their kids fat and let them be lazy in
front of the TV all day, every day. I think children are overweight because of
parents neglecting to do their jobs the way that they should, and [not] caring
about their weight and their health.
•
There is people that, like the women that work here a lot, sometimes can’t
take care of their children and when they take care of them, they are not
used to making them something to eat, then they take them to those
restaurants and I think that that makes you gain weight a lot.
•
So, I see a lot of kids that have, a lot of mothers that have heavy-set kids
and they just…just because they’re hungry…they just ate two
cheeseburgers…you know, just because they hungry you don’t have to feed
them. And they’d say never turn down a child to eat. Yeah, I think you do.
You just don’t feed your kid every time they’re hungry.
•
The mothers give them Twinkies, candy and ice cream and -- everyday, this
is an everyday thing -- cookies and, you know, to me that’s what causes a
child to be overweight.
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
“How were you fed as a child?”
•
When I was a kid we didn’t have dinners. “Here’s a hot dog. Here’s a
sandwich. Eat it.” You know? Not with me and my daughter. I make dinner.
I don’t throw a hot dog at her and say, “Here you go. Eat that. You’re good.”
No. I don’t do that. wish things would have been different for me, but it
wasn’t.
•
My parents were actually very strict so dinner was somewhat stressful. We
were expected to use our manners and, like, we weren’t allowed to drink
while we ate. You couldn’t sit and slug down your glass of milk. You had to
either sip it or it was taken away from you. Um, we had to clean our plates
and it didn’t matter portion size, whatever, you had to eat everything that
was on your plate.
•
I spend a lot of time with my kids and we eat together and my dad never did
that, so, um, we do eat together and I do cook a little bit. But I always make
sure my kids have breakfast, lunch, and dinner. My dad never did that. He
just --- fend for yourself, really. I make sure that they eat and I make sure
that we eat together.
•
My dad raised me by himself. Um, and he had a gambling problem. There
was a bar just down the road. So, from like, ten and up, um -- I don’t
remember much from ten and down -- I fed myself.
Parenting and Obesity
Maternal Feeding Behaviors
Conceptualizations of
Maternal Feeding Behaviors
(1) along a continuum of more or less
controlling (which may encompass both
pushing and restricting intake)
(2) 2 separate domains of prompting versus
restricting
(3) 4 parenting styles: authoritative,
authoritarian, permissive, and indulgent
What is the “Right” Way to Feed?
•
Prompting to eat associated with:
– Thinner child
– Heavier child
– No relationship
• Controlling and restrictive feeding practices associated with:
– Heavier child and increased caloric intake in unrestricted
settings
– Thinner child
– No association
• Allowing children more choice in what to eat
– Heavier child
– Thinner child
– No relationship
overweight and high restriction
normal weight and low restriction Δ
normal weight and high restriction ▲
overweight and low restriction O
overweight and high restriction ●
LL Birch et al, Am J Clin Nutr, 2003.
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
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.
Effect of Maternal Feeding Behaviors
May Differ By Maternal Weight Status
• In children of obese mothers, more
prompting to eat familiar foods was
inversely associated with higher child BMI.
• In children of non-obese mothers,
prompting to eat was not associated with
the child’s BMI.
JC Lumeng et al, J Pediatrics, 2006.
Predictors of Observed Maternal
Feeding Behaviors
• NICHD Study of Early Child Care and Youth
Development
• N = 734 mother-child dyads at age 3 years
• Videotaped while eating standardized snack
• Maternal behavior coded:
– intrusiveness (1 to 4, higher scores = more
intrusiveness)
– total prompts to eat (defined as verbal
encouragements, physical encouragements, and food
offers)
• Multiple regression predicting each
Multiple regression predicting each feeding behavior
Covariate
Sex (Female v. Male)
Race (white v.not)
Maternal Education
Maternal Depression
Maternal Weight Status
Child Overweight v. Not
Child obese v. Not
* p<.05
Intrusive
β (SE)
-.16 (.06)*
.17 (.08)*
-.03 (.01)*
.01 (.00)
.01 (.02)
.20 (.09)*
.17 (.12)
Prompts
β (SE)
-.52 (.40)
-1.15 (.54)*
-.31(.08)*
.06 (.03)*
.30 (.14)*
.25 (.61)
.42 (.85)
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)
• The jury is still out on which specific feeding
practices and behaviors should be
recommended
Food for Thought: Maternal
Beliefs about Feeding in
Low-Income Groups
Low Income
African American Mother
In response to: Do you worry about having enough food at the end of the month?
Sometimes, sometimes. Yea, sometimes. I run low on food and I don’t have the type of
food that I normally give them, you know? As long as I got some sandwiches they’re
happy, you know? Cause, see, when it’s not nothing and she’s like, ‘Momma I’m
hungry. I’m hungry,’ then it worries me. Like my mother always said, you always got
food when you got canned goods in your cabinet, you know? I had to take all the
canned good down, open them up, mix them all together and come up with
something a couple times. Everybody looked at it ‘What’s that, momma?’ ‘I don’t
know baby. It’s something. We need something to eat and we going to eat whatever it
is. You got to eat it.’ You know, and they try it and they like it. It’s then when I go to
other peoples’ houses and they’re down low—they have less than what I had to make
what I got. He got to have a hotdog. And then I always wonder, them hotdogs, they’re
not filling him up. He can eat three or four, but he has always ate three or four
hotdogs behind each other, but it’s just that I be wondering if that is enough.” And
then when I don’t have no hotdogs and can’t get no hotdogs and having a hard time
trying to figure out what [my son] is going to eat. You know, because I got to make
sure I got something that he will eat, cause if it’s not nothing he’s guaranteed to eat
then I start wondering ‘Dang, my baby’s losing weight. My baby’s not this, my baby’s
not that.’ You know.” All I can ask for is just something for him. Just give me some
hotdogs and some bologna—just give me that. As long as my baby can wake up to a
hotdog and go to bed to a hotdog, I’m happy. It may not be healthy for him, but . . .
you know.
Low Income Hispanic Mother
To feed them, you have to do it with love. Because if you do
it when you are in a bad mood or tired, they won’t even
eat. The most beautiful thing is that you always give
them [food] with love and with that desire -- that you
know that you are feeding them and that you know that
its your responsibility to feed your children. You should
do it with lots of care, lots of love and to always try to
think that they are being fed by you and that you have to
give them the best that you can -- with patience -because sometimes [they say] “I don’t want this”, [and I
say], “What do you want, mijo? If you didn’t like the food
today, what do you want?” You have to give them with
patience and with love because it is very hard
sometimes. One is trying to understand all of them [her
children].