8
Home

A child’s health and well-being are fostered by a home environment with engaged and skillful parenting that models, values, and encourages sensible eating habits and a physically active lifestyle. By promoting certain values and attitudes, by rewarding or reinforcing specific behaviors, and by serving as role models, parents can have a profound influence on their children. It is not surprising, therefore, that sedentary behaviors, obesity, and other chronic disease risk factors tend to cluster within families. Although some of these risk factors may have a genetic component, most have strong behavioral aspects. The family is thus an appropriate and important target for interventions designed to prevent obesity in children through increasing physical activity levels and promoting healthful eating behaviors.

In the United States in the 21st century, there are a great many pressures on parents and children that can adversely affect daily family life. For example, with the frequent need for both parents to work long hours, it has become more difficult for many parents to play with or monitor their children and to prepare home-cooked meals for them. Of two-parent households, 62.4 percent have both parents in the labor force; in one-parent homes, 77.1 percent of the mothers and 88.7 percent of fathers are working (Fields, 2003). Because the school day is shorter than the work day, many children come home to an empty house, where they may be unsupervised for several hours (Smith, 2002). In a national survey, parents report being well aware of the need to spend more time with their children but believe they do not have such time available (Hewlett and West, 1998). Parents



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Preventing Childhood Obesity: Health in the Balance 8 Home A child’s health and well-being are fostered by a home environment with engaged and skillful parenting that models, values, and encourages sensible eating habits and a physically active lifestyle. By promoting certain values and attitudes, by rewarding or reinforcing specific behaviors, and by serving as role models, parents can have a profound influence on their children. It is not surprising, therefore, that sedentary behaviors, obesity, and other chronic disease risk factors tend to cluster within families. Although some of these risk factors may have a genetic component, most have strong behavioral aspects. The family is thus an appropriate and important target for interventions designed to prevent obesity in children through increasing physical activity levels and promoting healthful eating behaviors. In the United States in the 21st century, there are a great many pressures on parents and children that can adversely affect daily family life. For example, with the frequent need for both parents to work long hours, it has become more difficult for many parents to play with or monitor their children and to prepare home-cooked meals for them. Of two-parent households, 62.4 percent have both parents in the labor force; in one-parent homes, 77.1 percent of the mothers and 88.7 percent of fathers are working (Fields, 2003). Because the school day is shorter than the work day, many children come home to an empty house, where they may be unsupervised for several hours (Smith, 2002). In a national survey, parents report being well aware of the need to spend more time with their children but believe they do not have such time available (Hewlett and West, 1998). Parents

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Preventing Childhood Obesity: Health in the Balance from diverse socioeconomic categories actually cite a “parental time famine”—insufficient time to spend with their children. Economic and time constraints, as well as the stresses and challenges of daily living, may make healthful eating and increased physical activity a difficult reality on a day-to-day basis for many families (Devine et al., 2003). The committee has adopted an ecological framework that considers children and youth as being influenced primarily by the family, particularly in the younger years, though other micro-environments—including the neighborhood, workplace, and school—also have important impacts on parenting and on individual and family functioning (see Chapter 3). In this ecological framework, parenting is influenced by the larger (macro) economic, political, social, and physical environments, as well as by socioeconomic status, parental goals, personal resources, and child characteristics (Parke and Buriel, 1998). Cultural norms are also an important factor. For example, parents may feel pressured to contribute cookies or soft drinks to the classroom or child-care setting if the other children are bringing in similar foods and beverages. On the other hand, if new values about what constitutes appropriate food choices for children become normative, this can produce positive changes in individual families and in their children’s daytime environments. The ecological perspective leads to strategies that target parents directly, as well as to other strategies designed to influence contextual factors that might otherwise serve to undermine healthful family values and practices. Therefore, a number of the committee’s recommendations focus on promoting changes in nonhome settings (e.g., schools, communities, the built environment, the media) in order to support parents in their efforts to serve as positive models for children’s eating and physical activity and to allow them to provide children with appropriate environments for preventing obesity. This is particularly important for families from high-risk populations who live in conditions that are not supportive of healthful lifestyles. From a practical standpoint, parents play a fundamental role as household policy makers. They make daily decisions on recreational opportunities, food availability at home, and children’s allowances; they determine the setting for foods eaten in the home; and they implement countless other rules and policies that influence the extent to which various members of the family engage in healthful eating and physical activity. The committee acknowledges the broad and diverse nature of families in the United States. According to a recent U.S. Census Bureau report, in 2002 there were more than 72 million children (under 18 years of age) in the United States (Fields, 2003). Approximately 69 percent of them lived with two parents, 23 percent lived with only their mother, approximately 5 percent lived with their father, and 4 percent lived with other family members, usually grandparents, or in other situations (Fields, 2003). This report

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Preventing Childhood Obesity: Health in the Balance uses the term “parents” in its broadest sense to incorporate all those who are primary caregivers to children in the home. Although treatment of childhood obesity is beyond the scope of this report, treatment studies have demonstrated that intensive involvement of parents in interventions to change obese children’s dietary and physical activity behaviors has contributed to success in weight loss and long-term weight maintenance (Coates et al., 1982; Kirschenbaum et al., 1984; Epstein et al., 1990, 1994; Golan et al., 1998; Golan and Crow, 2004). It is plausible that family-based strategies that prevent weight re-gain in these studies are likely to be informative in the prevention of obesity. The fundamental influence of parents on the eating behavior of their children has also been demonstrated in the prevention of eating disorders (Graber and Brooks-Gunn, 1996). Finally, a 10-year longitudinal study conducted in Denmark has identified parental neglect as a powerful predictor of the subsequent development of obesity (as compared to putative biological predictors such as obesity in one or both parents) (Lissau and Sorensen, 1994). While the home is an influential setting, it is also the least accessible for health promotion efforts. Mechanisms for parent education are varied and many provide only brief opportunities for health-care professionals, teachers, or others to interact with parents and share information and resources. As discussed throughout the report, there are resources in the school and the broader community that can support and inform parents and caregivers, children, and youth (see Chapters 6 and 7). In the remainder of this chapter, the committee explores some of the ways in which parents and families can encourage healthful eating behaviors and increased physical activity. This report is not the place for an exhaustive discussion of diet and physical activity, nor is it meant to be the definitive source for parental advice; rather, the committee sought to present some actionable steps that can be taken by parents, families, children, and youth. It is important to note that many families are already quite physically active and put time and effort into providing healthful meals. It is important that parents and children extend these efforts and priorities to their schools, neighborhoods, and communities (Chapters 6 and 7) and become involved in ensuring that opportunities are made available and expanded for all families. PROMOTING HEALTHFUL EATING BEHAVIORS For decades, scientists have suggested that there are critical periods in the brain development of animals and humans that may profoundly affect food intake and body weight (in particular, body fat) beginning in utero—when many of the systems that regulate food intake and body weight initially develop. The factors that influence the quantity and quality of the

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Preventing Childhood Obesity: Health in the Balance maternal diet at the time of conception and throughout pregnancy—some of which may be within the control of the mother, while others result from social and economic environments—are thus important to consider. A recent study of 8,494 low-income children found that maternal obesity in the first trimester of pregnancy more than doubled the risk of the child being obese at 2 to 4 years of age (Whitaker, 2004). Furthermore, there are concerns that the offspring of mothers with gestational diabetes mellitus may be at higher risk for obesity, but the results are inconsistent (Silverman et al., 1998; Whitaker et al., 1998; Gillman et al., 2003). Needless to say, women of child-bearing years should pursue a healthful lifestyle that emphasizes sound dietary and physical activity habits, and because of the importance of a healthy maternal body weight at conception and adequate weight gain during pregnancy, these goals should be embraced and nurtured by the entire family. Infancy Researchers are examining early determinants of obesity, including factors during infancy; however, much remains to be learned. Issues being explored include the combined effects of low birthweight followed by rapid weight gain during early infancy (Stettler et al., 2002, 2003). The associations between various feeding methods during infancy and childhood obesity have been the most thoroughly explored. Epidemiological data suggest that breastfeeding, even as it is generally practiced in the United States—that is, as a nonexclusive source of nutrition, usually of short duration—confers a small but significant degree of protection from childhood obesity, although it is not certain why this is so or the extent to which other factors may confound this finding. A recent review of 11 epidemiologic studies with adequate sample size1 found that eight of the studies showed breastfed children to be at a lower risk of overweight after controlling for potential confounders (Dewey, 2003). Studies published since that review have generally confirmed that finding but not in all subpopulations. For example, Bergmann and colleagues (2003) examined the weight status of a cohort of children at 6 years of age and found that those who were bottle fed as infants had a higher prevalence of obesity than those who were breastfed. Other risk factors for adiposity at 6 years of age 1 Criteria for studies in this review were (1) sample size of greater than 100 children per feeding group (in most cases breastfeeding versus formula feeding); (2) age at follow-up of over 3 years; and (3) measured outcomes includes percentage of children who were overweight (Dewey, 2003).

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Preventing Childhood Obesity: Health in the Balance included overweight of the mother, maternal smoking during pregnancy, and low social status. In research on the weight status of 12,587 children in the United States at 4 years of age, Grummer-Strawn and Mei (2004) found that greater duration of breastfeeding showed a protective effect on the risk of overweight among non-Hispanic whites, but not among non-Hispanic blacks or Hispanics. The reasons for differences among ethnic groups are not clear; the study did not examine supplementation by formula or foods or varying dietary or physical activity patterns. A study by Bogen and colleagues (2004) also found no association between breastfeeding and obesity among 20,518 low-income black children (the study sample did not include Hispanics). Breastfeeding is thought to promote the infant’s ability to regulate energy intake, allowing him or her to eat in response to internal hunger and satiety cues—that is, to assume greater control in determining meal size (Fisher et al., 2000). In contrast, a caregiver who is formula feeding an infant may use visual information about how much remains in the bottle to “encourage” the infant to finish the bottle, potentially fostering overfeeding. Even if the caregiver makes no such effort, the uniform composition of formula, both during a single feeding and over the duration of infancy, may not provide the infant with the same metabolic/hormonal cues that are supplied with breast milk. Because the composition of breast milk changes during each feed and from one feeding to the next over the course of lactation, the full effects of this variation are not experienced when breastfeeding is nonexclusive or of short duration (Lederman et al., 2004). Factors in breast milk may elicit metabolic programming effects that contribute to the protective association between breastfeeding and childhood obesity. There is the possibility that other parental lifestyle factors and behaviors, not yet identified, may undermine or overwhelm that protection (Dewey, 2003). Lifestyle and cultural factors may also explain the discrepant findings among different ethnic groups. It is worth emphasizing that a protective effect of breastfeeding was found in the majority of studies reviewed although not in all. But in none of the 11 studies reviewed by Dewey (2003) or those published since that review has breastfeeding been associated with increased risk for childhood obesity; breastfeeding was found to be either protective or neutral. None of the studies have found formula feeding to be protective against childhood obesity. Research indicates that many flavors from the mother’s diet are transmitted to her breast milk (Mennella and Beauchamp, 1991; Mennella, 1995). By the time complementary foods are introduced, therefore, the breastfed infant has already had experience with a variety of flavors from the adult diet, which may promote acceptance of foods during weaning (Sullivan and Birch, 1994; Mennella et al., 2001; Lederman et al., 2004). Experience with numerous flavors in breast milk (as opposed to the lack of

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Preventing Childhood Obesity: Health in the Balance variety experienced by the formula-fed infant) may also have more general effects, promoting the infant’s acceptance of a wide range of new foods as he or she matures; further research is needed in this area (Mennella and Beauchamp, 1998; Lederman et al., 2004). Much remains to be learned about the extent of the association between breastfeeding and childhood obesity. Nonetheless, breastfeeding is likely to be at least weakly protective against obesity, and despite the fact that the protective effects may be overwhelmed by events and environmental factors that occur later in childhood, there are numerous ancillary benefits of breastfeeding (AAP, 2004). Breastfeeding is recommended for all infants. Exclusive breastfeeding is recommended for the first 4 to 6 months of life and breastfeeding, along with the age-appropriate introduction of complementary foods, is encouraged for the first year of life. This is in accordance with the American Academy of Pediatrics (2004) statement recommending breastfeeding and stating that in developed countries “complementary foods may be introduced between 4 and 6 months” and the World Health Organization (2003) recommendation that encourages exclusive breastfeeding for the first 6 months of life, to the extent that this is practical for the mother and family. Another issue that is discussed regarding infant feeding is serving size—ensuring that infants receive the appropriate amounts of milk or foods. Research has shown that early in life, infants are responsive to the energy density of food and are capable of controlling the volume taken during a feeding. Thus, even by about 6 weeks of age, infants can adjust the volume of formula consumed based on the energy density of the formula, so that total energy intake remains relatively constant (Fomon et al., 1975). Nonetheless, there is the possibility that infants can be coaxed to eat beyond satiety and that has been postulated by several researchers as a potential contributor to childhood obesity (Bergmann et al., 2003; Dewey, 2003; Lederman et al., 2004). Concern has been expressed that precocious introduction of sweetened beverages and high-fat/sweet-tasting foods may be important contributors to childhood obesity by possibly developing early preferences for such foods and beverages (Fox et al., 2004; Lederman et al., 2004). Documentation that such concerns are well founded are the findings from the Feeding Infants and Toddlers Study (FITS) that soft drinks and French fries are being fed to infants as young as 7 months of age (Fox et al., 2004). Toddlers and Young Children Children tend to avoid new foods. But during the transition from the exclusive milk diet of infancy to consuming a varied, modified adult diet, virtually all foods are new to the child. Fortunately, it has been found that

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Preventing Childhood Obesity: Health in the Balance if children have opportunities to try new foods without being coerced to eat them, many of these foods, even if initially rejected, will become part of their diet (Birch and Marlin, 1982; Loewen and Pliner, 1999). Such early experience with new options will be especially important in learning to accept fruits, vegetables, and other nutrient-rich foods later on in life (Birch, 1999; Skinner et al., 2002). Food flavor preferences are powerful determinants of intake for children. Because infants are predisposed to prefer sweet and salty tastes, they tend to readily accept foods that are sweet or salty (Cowart, 1981; Beauchamp and Cowart, 1985; Mennella and Beauchamp, 1998). In contrast, preferences for foods that lack such tastes are learned, requiring repeated positive experiences. Initial rejection of new foods is expected and normal. As many as five to ten exposures may be needed before certain new foods are accepted, and repeated experience is most critical during the first few years of life. Recent findings reveal that parent-led exposure can increase children’s acceptance of vegetables (Wardle et al., 2003; Lederman et al., 2004), and that childcare and preschool settings are also effective locations for promoting children’s acceptance of new foods (Nicklas et al., 2001). Research also shows that increasing the school-based availability and accessibility of fruits and vegetables in particular can promote children’s intake, at school as well as at home (Baranowski et al., 2000; Weber Cullen et al., 2000). Of course, children can be equally responsive to less healthful options when made available. Because their preferences for high-fat, energy-dense foods are, in part, learned, providing children with frequent exposure to such foods may reinforce their liking for them (Johnson SL et al., 1991). In the 2002 FITS, which examined the dietary intake of 3,022 infants and toddlers, parents reported that 23 percent of infants and 33 percent of toddlers had not consumed any fruit during the preceding 24 hours; similarly 18 percent and 33 percent of infants and toddlers, respectively, had not consumed any vegetables (Fox et al., 2004). This study also reported changes in intake from 4 to 8 months of age when deep yellow vegetables (e.g., carrots, sweet potatoes, squash) were the vegetables consumed most often, to the patterns at 15 to 18 months, when French fries or other fried potatoes were the predominant vegetables (Fox et al., 2004). Parents should promote healthful food choices among toddlers and young children by making a variety of nutritious, low-energy-dense foods, such as fruits and vegetables, available to them. Encouraging toddlers and young children to try a variety of foods, including fruits and vegetables, often involves offering new foods multiple times. Beyond quality is the issue of quantity. Limited empirical evidence suggests that children, especially those in the toddler years, have a physiological sense of satiety that guides them to eat only until they are full.

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Preventing Childhood Obesity: Health in the Balance McConahy and colleagues (2002) found that the food portion sizes consumed by children 1 to 2 years of age have been consistent over the past 20 years. However, as children develop, they become increasingly responsive to environmental cues such as portion size; by the age of 5 years, larger portions can lead to increased food intake (Rolls et al., 2000). This issue is discussed further below. Older Children and Youth As children develop, they play an expanding role in determining the foods that are available to them. They make their own choices at school and in other out-of-home settings, and they increasingly influence family food purchases. Furthermore, as they begin to be influenced by their peers and the broader culture, they may make certain food choices based on popular appeal. It is also important to note, however, that parents are important role models and their dietary intake influences that of their children (see section below on role models). Food and Beverage Selection and Availability Parents can promote wise food selections and a wholesome overall diet by making nutritious options available to children. Research has shown that children’s consumption of fruit, 100 percent fruit juice, and vegetables are positively influenced by the availability and accessibility of these foods in the home (Nicklas et al., 2001; Cullen et al., 2003). Similarly, parents can limit the types and quantity of energy-dense high-calorie foods (e.g., cookies, chips) that are available in the home, particularly those that have low nutrient content. Improved consumer nutrition information in restaurants and on food labels (see Chapter 5) will provide parents and young people with enhanced information on which to base their dietary decisions. Parents are responsive to children’s attempts to influence food purchases (Galst and White, 1976). Interviews with 500 children and youth aged 8 to 17 years found that 78 percent of respondents noted that they influence family food purchases (Roper ASW, 2003). For their part, 84 percent of the parents stated that their children do indeed influence such purchases. The Dietary Guidelines for Americans and the Food Guide Pyramid provide information on the types of foods that make up a balanced and nutritious diet (USDA and DHHS, 2000; USDA, 2004). Although it is not the purpose of this report to duplicate that information, the committee wishes to emphasize the responsibilities of children (particularly older children), youth, and parents in choosing and providing a balanced diet. Parents should promote healthful food choices by school-age children and

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Preventing Childhood Obesity: Health in the Balance youth by making a variety of nutritious, low-energy-dense foods, such as fruits and vegetables, available in the home. Because nutrient quality should be a major consideration in selecting the family’s foods and beverages, parents should limit their purchases of items characterized by high caloric content and low nutrient density. The mealtime setting has been shown to affect diet quality in children and youth. Several studies have shown that increased frequency of family dinners is positively associated with older children’s and adolescents’ consumption of fruits and vegetables, grains, and calcium-rich foods, and negatively associated with their consumption of fried food and soft drinks (Gillman et al., 2000; Neumark-Sztainer et al., 2003a). The influence of watching television during mealtime is another area for further research. Coon and colleagues (2001) found that watching television during mealtime was associated with consumption of fewer fruits and vegetables and increased consumption of soft drinks, salty snacks, pizza, and red meat. One of the issues that has been raised regarding childhood obesity is the potential role of sweetened beverages, such as soft drinks and “flavored drinks” (not 100 percent juices). These beverages do not provide nutrients that are needed by growing children, but do increase the caloric intake. Nevertheless, soft drink consumption more than tripled among adolescent boys between 1977-1978 and 1994, rising from 7 to 22 ounces per day (Guthrie and Morton, 2000; French et al., 2003). By the time they are 14 years of age, 32 percent of adolescent girls and 52 percent of boys are consuming three or more eight-ounce servings of soft drinks daily (Gleason and Suitor, 2001). FITS reported that infants as young as 7 months of age are consuming soft drinks as well (Fox et al., 2004). There are concerns about the effect of increased soft drink consumption on reducing micronutrient intakes and increasing energy intake (IOM, 2002) and on displacing the intake of more nutrient-rich options such as milk (ADA, 2004). Milk consumption by adolescents declined 36 percent from 1965 to 1996 (Cavadini et al., 2000). An analysis of data from the 1994-1996, 1998 Continuing Survey of Food Intakes by Individuals (CSFII) found that children and adolescents (>12 years of age) drank more soft drinks than milk, 100 percent juices, or fruit drinks (Rampersaud et al., 2003). The link between beverage consumption and body mass index (BMI) is not definitive. In an analysis of CSFII data, Forshee and Storey (2003) reported that BMI calculated from self-reported height and weight had little or no cross-sectional association with beverage consumption. In contrast, in a prospective study of middle schoolers in which height and weight were measured directly, Ludwig and colleagues (2001) reported significant positive associations between sweetened beverage consumption and increases in BMI and obesity incidence. In a recent randomized controlled trial of a 1-year classroom-based intervention focused on carbonated beverages, dental

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Preventing Childhood Obesity: Health in the Balance health, and dietary intake, James and colleagues (2004) reported a significant decrease in the prevalence of overweight and obesity in the group of children receiving the intervention compared to controls. However, methodological limitations prevent conclusions regarding whether reducing soft drink consumption led to the observed changes in obesity prevalence (French et al., 2004). Further, experimental studies of the effects of reducing sweetened beverage intakes are needed to examine the potential efficacy of this approach for reducing weight gain, as well as the hypothesized causal link between sweetened beverage consumption and obesity. Much remains to be learned about whether a unique association exists between intake of sweetened beverages and changes in BMI. Because of concerns about excessive consumption of sweetened options and the displacement of more nutrient-rich or lower calorie alternatives, children should be encouraged to avoid high-calorie, nutrient-poor beverages. Portion Control and Eating in the Absence of Hunger In addition to ensuring the quality of children’s diets, it is important for parents to consider the quantity of food being consumed. Researchers examining the recent increases in portion sizes have found that Americans consumed larger portion sizes of nearly one-third of 107 widely consumed foods when comparing 1989-1991 with 1994-1996 data (Nestle, 2003; Smiciklas-Wright et al., 2003). Although long-term studies investigating the effects of portion size on weight gain are lacking, short-term studies confirm that larger portions do increase intake, especially among adults and children aged 5 years and older. In research involving a range of foods that included sandwiches, macaroni and cheese, popcorn, and cookies, the larger the portion size offered, the larger the amount consumed (reviewed by Rolls, 2003; Diliberti et al., 2004). While evidence shows that infants and toddlers can self-regulate their energy intake (discussed earlier), a series of studies found that by the age of 5 many children eat what they are served; physiological satiety cues, if they are present, are overridden by environmental cues (such as larger portion sizes) that stimulate them to eat more, even if they are not hungry (Rolls et al., 2000). In this research, 3- to 5-year-olds were fed a standard lunch on two different days in their usual preschool setting. Lunches differed only in the portion size of the entrée. Older preschoolers responded in much the same way that adults do; when given a larger portion, they ate more. But younger children were relatively unresponsive to portion size, providing more indirect support that they are still eating primarily in response to internal signals of hunger and satiety (Rolls et al., 2000; see Rolls, 2003 for a review of the adult literature). In subsequent research, Orlet-Fisher and colleagues (2003) explored

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Preventing Childhood Obesity: Health in the Balance the effects of children’s chronic exposure to large portions. Results indicated that when served larger portions, children ate substantially more food—but giving them the opportunity to serve themselves mitigated these effects because they tended to self-select smaller portions. In one study, they consumed 25 percent less of the lunch entrée when they served themselves, as compared to other occasions when a larger portion was served to them (Orlet-Fisher et al., 2003). The portion sizes that the children self-selected and consumed were more similar to standard, recommended serving sizes than to the large portions they had been offered, suggesting that giving children control over portion size may prevent overeating or eating in the absence of hunger. The goal for parents is to promote the normal and effective development of internal satiety cues so that children learn to rely on their own sense of fullness. However, research suggests that restricting palatable foods can lead to increased preference for these foods and that pressuring children to “clean the plate” can encourage overeating. Such practices can prompt children to attend to external cues, such as the availability of food or the amount remaining on the plate, and divert them from internal cues of hunger and satiety (Birch et al., 1987; Fisher and Birch, 1999; Orlet-Fisher et al., 2003). Golan and Crow (2004) point out the impact of parenting styles on children’s eating behaviors: “authoritative parenting (in which parents are both firm and supportive and assume a leadership role in the environmental change with appropriate granting of child’s autonomy) rather than authoritarian style (which controls child-feeding practices) was found to be the effective parental child-feeding modality” (p. 358). Child characteristics influence the choice of these feeding practices; overweight children tend to elicit higher levels of parental restriction, and thinner children are more likely to be pressured to eat. Pressure and restriction tend to be used with different foods (pressure with perceived “healthful foods” that parents want to encourage; restriction with some snack foods that parents want to limit), but a parent who uses one tactic is likely to use the other as well (Fisher et al., 2002). However, one of the limitations of this research to date is that it has been conducted with middle-class white families and sometimes only with one gender, severely limiting the ability to generalize. Research has also shown that using foods as rewards or in other positive contexts can result in greater preference for and intake of those foods (Birch et al., 1980; Birch, 1981). Furthermore, this practice dissociates eating from hunger. Parents should avoid using food as a reward. More research is also needed to understand developmental progression—the neural and physiological underpinnings of hunger and satiety—and the regulation of food intake and energy balance. It is also important to learn more about how the timing of snacks and meals influence eating and weight status.

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Preventing Childhood Obesity: Health in the Balance that schools conduct periodic assessments of students’ weight status and provide the resulting information to parents—and to the children themselves, as age-appropriate. RECOMMENDATION Home environments that support healthful eating and physical activity are important in helping children maintain energy balance at a healthy weight. Preventing childhood obesity starts with a healthful diet and lifestyle at conception and throughout pregnancy and is promoted by exclusive breastfeeding during infancy. As discussed throughout this chapter, parents can ensure that healthful foods are available in the home and that healthful eating behaviors (e.g., family meals, limited snacking, and portion control) are promoted. Older children and youth must be aware of their own eating habits and activity patterns and engage in health-promoting behaviors. By being supportive of their children’s athletic and other interests in physical activity and by encouraging children to play outside, parents can enhance opportunities for moderate to vigorous physical activity and promote physical fitness. Furthermore, parents can set a good example for their children by modeling healthful eating behaviors and being physically active. Parents can also be effective advocates by becoming involved in efforts in their neighborhoods, schools, and community to improve neighborhood safety and to expand the access and availability of opportunities such as recreational facilities, playgrounds, sidewalks, bike paths, and farmers’ markets (Chapters 6 and 7). Recommendation 10: Home Parents should promote healthful eating behaviors and regular physical activity for their children. To implement this recommendation parents can: Choose exclusive breastfeeding as the method for feeding infants for the first four to six months of life Provide healthful food and beverage choices for children by carefully considering nutrient quality and energy density Assist and educate children in making healthful decisions regarding types of foods and beverages to consume, how often, and in what portion size Encourage and support regular physical activity Limit children’s television viewing and other recreational screen time to less than two hours per day

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