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4 Healthy Eating GOALS: • romote the consumption of a variety of nutritious foods, P and encourage and support breastfeeding during infancy. • reate a healthy eating environment that is responsive to C children’s hunger and fullness cues. • Ensure access to affordable healthy foods for all children. • Help adults increase children’s healthy eating. T he majority of young children in the United States are not consuming nutri- tious diets (Fox et al., 2010; Fungwe et al., 2009; Siega-Riz et al., 2010). U.S. children of all ages are consuming diets that are too high in added sugar and fat and too low in fruits and vegetables, whole grains, and low-fat and nonfat dairy products (Reedy and Krebs-Smith, 2010; Williams, 2010). Taking action to ensure that children aged 0–5 have access to a variety of nutritious foods can contribute to healthy growth and a reduction in obesity risk. A child develops food preferences by responding to what he or she is fed and observing adults; the availability of food in the immediate environment also plays a role. Because food offered to young children is determined by caregivers, they should make every effort to introduce children to healthy foods and lifestyle 85

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habits from the beginning of infancy onward (Skinner et al., 2004). Children who have early experiences with eating healthy foods are more likely to prefer and consume those foods and to have dietary patterns that promote healthy growth and weight (Anzman et al., 2010; Mennella et al., 2008), patterns that may then persist in later childhood (Skinner et al., 2004). Given that more than half of chil- dren under the age of 5 receive care in out-of-home settings (HHS, 2011a), par- ents as well as other caregivers need information and guidance on how to foster the development of healthy eating patterns among young children. This chapter includes recommendations designed to improve nutrition through infancy to the consumption of solid foods. GOAL: PROMOTE THE CONSUMPTION OF A VARIETY OF NUTRITIOUS FOODS, AND ENCOURAGE AND SUPPORT BREASTFEEDING DURING INFANCY Recommendation 4-1: Adults who work with infants and their families should promote and support exclusive breastfeeding for 6 months and con- tinuation of breastfeeding in conjunction with complementary foods for 1 year or more. Potential actions include • hospitals and other health care delivery settings improving access to and availability of lactation care and support by implementing the steps outlined in the Baby-Friendly Hospital Initiative and following American Academy of Pediatrics policy recommendations; • hospitals enforcing the World Health Organization’s International Code of Marketing of Breast Milk Substitute (This step includes ensuring that hos- pitals’ informational materials show no pictures or text that idealizes the use of breast milk substitutes; that health professionals give no samples of formula to mothers [this can be complied with through the Baby-Friendly Hospital Initiative]; and that the Federal Communications Commission, the Department of Health and Human Services, hospital administrators [through the Baby-Friendly Hospital Initiative], health professionals, and grocery and other stores are required to follow Article 5, “The General Public and Mothers,” which states that there should be no advertising or promotion to the general public of products within the scope of the code [i.e., infant formula]); Early Childhood Obesity Prevention Policies 86

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• the Special Supplemental Nutrition Program for Women, Infants, and Children, the Child and Adult Care Food Program, Early Head Start, other child care settings, and home visitation programs requiring program staff to support breastfeeding; and • employers reducing the barriers to breastfeeding through the establishment of worksite policies that support lactation when mothers return to work. Rationale A number of systematic reviews on the relationship between breastfeeding and childhood obesity conclude that, while the nature of the study designs makes it difficult to infer causality, there is an association between breastfeeding and a reduction in obesity risk in childhood (Adair, 2009; Arenz et al., 2004; Harder et al., 2005; Monasta et al., 2010; Owen et al., 2005). Thus, in the committee’s judgment, a recommendation on breastfeeding is warranted. The first Institute of Medicine (IOM) report on childhood obesity prevention takes a similar position (IOM, 2005). There is a window of opportunity after birth during which breastfeeding can be initiated. However, many hospitals and health care providers do not pro- vide information about and support for breastfeeding. The most recent data from the Centers for Disease Control and Prevention (CDC) indicate that 75 percent of women in the United States initiate breastfeeding at birth, and 43 percent are breast- feeding at 6 months after birth; however, only 13 percent of mothers are breastfeed- ing exclusively at 6 months (CDC, 2010), and only 22.4 percent are breastfeeding at 12 months (HHS, 2011b). The American Academy of Pediatrics (AAP) and many other health organizations recommend exclusive breastfeeding for approximately the first 6 months of life, with the addition of complementary foods at around 6 months and continued breastfeeding through the first year of life and beyond (AAP, 2005; ADA, 2005; WHO, 2001). Although breastfeeding rates have improved over time, disparities exist by race and ethnicity and by socioeconomic status. Only 58 percent of black infants are ever breastfed, compared with 76 percent of white and 80.6 percent of Latino infants. Fully 88 percent of the infants of college graduates are ever breastfed, compared with only 66 percent of infants of high school graduates. These differ- ences continue for breastfeeding at 6 and 12 months. The Surgeon General’s Call to Action to Support Breastfeeding points out a number of barriers to breastfeed- ing in the United States, including lack of knowledge, social norms, poor family and social support, embarrassment, lactation problems, employment, child care, 87 Healthy Eating

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and health services and health professionals that fail to promote or support the practice (HHS, 2011b). The rapid attrition seen among mothers who breastfeed indicates that support, education, and public policy are inadequate to ensure that all women who want to breastfeed can do so. Support for breastfeeding initiation and maintenance needs to begin during prenatal care and continue at the hospital or other place of childbirth and into child care settings and workplaces. Institutional support within hospitals is critical to help mothers learn to breastfeed. Hospitals have the potential to influence, educate, and support virtually all new mothers, especially those who have been shown to be less likely to ever breastfeed or sustain breastfeeding up to 6 months or a year. The Baby-Friendly Hospital Initiative is a global program designed to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding (see Box 4-1). The initiative increases the duration of breast- feeding and the initiation of exclusive breastfeeding (Fairbank et al., 2000; Kramer et al., 2001). Mothers in the United States were 13 times more likely to stop breastfeeding before 6 weeks if they delivered in a hospital where none of the 10 steps of the Baby-Friendly Hospital Initiative were followed as compared with mothers who delivered at hospitals where at least 6 of the 10 steps were followed (DiGirolamo et al., 2008). Furthermore, following the steps decreased the disparities in initiation and duration rates of breastfeed- ing seen across different income, ethnic, and racial groups (Merewood et al., 2005). Although more than 18,000 hospitals worldwide are designated as Baby-Friendly, only 3 percent of maternity hospitals in the United States are so designated (Baby-Friendly USA, 2011; CDC, 2008). Although employment outside the home is one of the biggest reasons for discontinuing breastfeeding (Mandal et al., 2010) workplace lactation programs can increase the duration of breastfeeding (Abdulwadud and Snow, 2007). Not only do workplace lactation programs increase breastfeeding duration, but they also confer advantages on the employer, such as decreased absenteeism (Cohen and Mrtek, 1994; Mills, 2009; Wyatt, 2002). Twenty-four states have laws related to breastfeeding at the workplace, and the Patient Protection and Affordable Care Act of 2010 and the Reconciliation Act of 2010, which amends the Fair Labor Standards Act of 1938 (29 U.S. Code 207), require an employer to provide reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth (National Conference of State Legislatures, 2011). However, many women still Early Childhood Obesity Prevention Policies 88

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Box 4-1 Baby-Friendly Hospital Initiative The Baby-Friendly Hospital Initiative (BFHI) is a global program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to encourage and recognize hos- pitals and birthing centers that offer an optimal level of care for infant feeding. The BFHI assists hospi- tals in helping mothers initiate and continue breastfeeding, and gives special recognition to hospitals that have done so. The BFHI promotes breastfeeding through the Ten Steps to Successful Breastfeeding for Hospitals. The steps for the United States are: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within one hour of birth. 5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants. 6. Give newborn infants no food or drink other than breastmilk, unless medically indicated. 7. Practice “rooming in”—allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. SOURCE: http://www.babyfriendlyusa.org. struggle to breastfeed when they go back to work because of a lack of enforce- ment of the law (74 percent of employers do not offer lactation rooms or accom- modations for breastfeeding, and some employers see little value to breastfeeding in the workplace) (Grummer-Strawn and Shealy, 2009; Libbus and Bullock, 2002). In addition to workplace lactation programs, breastfeeding duration is affected by the degree of control a woman has over her job, including the flexibil- ity she is allowed; whether she works full time; and the length of maternity leave (Abdulwadud and Snow, 2007; Hawkins et al., 2007; Mandal et al., 2010). These factors are highly relevant for breastfeeding mothers, because the Family and Medical Leave Act covers only 56 percent of women with children younger than 18 months of age (Mandal et al., 2010). 89 Healthy Eating

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Providers in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), child care settings, Early Head Start, and home visi- tation programs also have many opportunities to support breastfeeding, especially among low-income women (Shealy et al., 2005). The WIC program, for example, serves almost half of the babies born in the United States (IOM, 2006). One-to- one health education and peer counseling in the prenatal and postnatal periods have been found to be highly effective in increasing the initiation and duration of breastfeeding (Fairbank et al., 2000; Gross et al., 2009). Home visitation has been used successfully to provide instruction, guidance, and support to mothers who are learning to breastfeed and continuing to do so throughout the baby’s first year. Moreover, as the current work environment often is not conducive to supporting women who breastfeed, the support of health care providers can be integral in overcoming the isolation and other obstacles mothers often face while balancing work and breastfeeding an infant. Child care centers that provide lactation rooms or other space for breast- feeding mothers and optimally support working mothers, including their staff, who want to breastfeed their infant could be labeled as Breastfeeding-Friendly (Box 4-2). This label could be similar to the Baby-Friendly Hospital designation, indicating child care centers that follow basic guidelines to support breastfeeding schedules. Breastfeeding-Friendly space would allow women to continue breast- feeding even after returning to work, a key factor in increasing breastfeeding rates. Multiple stakeholders should explore incentives and actions such as these for encouraging and supporting breastfeeding at the worksite, as suggested by the Surgeon General (HHS, 2011b) and by the IOM in Local Government Actions to Prevent Childhood Obesity (IOM and NRC, 2009). Bottle Feeding Breastfeeding is the best way to support the growth and development of a young infant. However, the committee realizes that some women will formula feed their infant and not breastfeed, and that many women who breastfeed may use a bottle to feed their infant breast milk or formula on some occasions, often because of one or more of the barriers to breastfeeding described above. These women also need the advice and support of their health care providers, especially because there is a greater risk that a bottle-fed infant can be overfed or encouraged to “finish the bottle,” in turn increasing the risk for obesity. The literature suggests the fol- lowing guidelines on bottle feeding: Early Childhood Obesity Prevention Policies 90

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Box 4-2 Ten Steps to Breastfeeding-Friendly Child Care Centers 1. Designate an individual or group who is responsible for development and implementation of the ten steps. 2. Establish a supportive breastfeeding policy and require all staff be aware of and follow the policy. 3. Establish a supportive worksite policy for staff members who are breastfeeding. 4. Train all staff so that they are able to carry out breastfeeding promotion and support activities. 5. Create a culturally appropriate breastfeeding-friendly environment. 6. Inform expectant and new families and visitors about your center’s breastfeeding-friendly policies. 7. Stimulate participatory learning experiences with the children, related to breastfeeding. 8. Provide a comfortable place for mothers to breastfeed or pump their milk in privacy, if desired. 9. Educate families and staff that a mother may breastfeed her child wherever they have a legal right to be. Establish and maintain connections with local breastfeeding coalition or community breastfeeding resources. 10. Maintain an updated resource file of community breastfeeding services and resources kept in an accessible area for families SOURCE: Wisconsin Department of Health Services, http://www.dhs.wisconsin.gov/health/physical activity/pdf_files/BreastfeedingFriendlyChildCareCenters.pdf. • Only breast milk or infant formula should go in the bottle (USDA, 2009). Juice, soda, and sweetened or carbonated beverages should not be put in the bottle. Cow’s milk should not be introduced until at least 1 year of age (AAP, 2008). • Based on the average intake of 2–4 ounces of breast milk or formula by an infant from birth to 4 months of age (Hagan et al., 2008), a 4-ounce bottle should be used to feed an infant. If the infant shows signs of hunger after finishing a 4-ounce bottle, it may be time to transition to a larger bottle size. • The bottle should be held by an adult caregiver. It should not be propped, which prevents the infant from being able to stop feeding. An adult should feed the infant to watch for cues of satiety (Shelov, 2009). • Feeding should not be initiated automatically any time the infant cries. Infant hunger cues should be appreciated (see Table 4-1). A bottle should not be used as a quieting device. Alternative soothing strategies, such as 91 Healthy Eating

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holding or swaddling the infant, should be tried first (AAP, 2008; Hagan et al., 2008; Shelov, 2009). • Infants should not be forced to finish the bottle (Hagan et al., 2008; Li et al., 2010). • Infants should be “off the bottle” and drinking from a cup around 1 year of age, but no older than 18 months of age (Shelov, 2009). Complementary Feeding Complementary solid foods should be introduced at around 6 months of age (AAP, 2005). However, a substantial percentage of mothers introduce solid foods before their infant is 4 months of age (Fein et al., 2008), particularly if they per- ceive the infant to be “fussy” (Wasser et al., 2011). Mothers may also add cereal to the bottle in the belief that doing so will help the infant sleep longer (Kavanagh TABLE 4-1 Infant Feeding Cues Age Hunger Cues Fullness Cues Birth through 5 months • Wakes and tosses • Seals lips together • Sucks on fist • Turns head away • Cries or fusses • Decreases or stops sucking • Opens mouth while feeding • Spits out the nipple or falls to indicate wanting more asleep when full 4 months through 6 months • Cries or fusses • Decreases rate of sucking or • Smiles, gazes at caregiver, stops sucking when full or coos during feeding to • Spits out nipple indicate wanting more • Turns head away • Moves head toward spoon or • May be distracted or pay more tries to swipe food toward attention to surroundings mouth 5 months through 9 months • Reaches for spoon or food • Starts eating more slowly • Points to food • Pushes food away 8 months through 11 months • Reaches for food • Starts eating more slowly • Points to food • Clenches mouth shut or pushes • Gets excited when food is food away presented 10 months through 12 months • Expresses desire for specific • Shakes head to say “no more” food with words or sounds SOURCE: USDA, 2009. Early Childhood Obesity Prevention Policies 92

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et al., 2010). Yet complementary foods introduced too early do not benefit the infant and may even be harmful because of the possibility of the infant’s choking (since the infant may not have the neuromuscular mechanisms needed for swal- lowing), developing food allergies, or consuming less than the appropriate amount of breast milk or infant formula (Fiocchi et al., 2006; Grummer-Strawn et al., 2008; Walker et al., 1996). Additionally, an infant’s gut is not sufficiently mature for solid food prior to 4 months of age (USDA, 2001). Research on the effects of early introduction of complementary foods and obesity risk is inconsistent, with some studies reporting a possible association (Huh et al., 2011) and others report- ing no clear association (Moorcroft et al., 2011). The foods and beverages offered to infants during the transition to solid foods are important in setting the foundation for eating patterns later in life; those that become familiar early in life will tend to be preferred to those that are unfamiliar. A preponderance of energy-dense foods, high in sugar, fat, and salt, provides an eating environment that can foster preferences for these foods, result- ing in diets that are inconsistent with the Dietary Guidelines for Americans (DGA) (Birch, 1999). Children are predisposed to like sweet and salty foods but must learn to like those that are not (Cowart et al., 2004; IOM, 2010). Healthy foods such as vegetables will be accepted if they become familiar and if children see oth- ers eating and enjoying them (Addessi et al., 2005; Harper and Sanders, 1975). As children are being introduced to the adult diet, all foods are new. They will tend to reject new foods initially, but with frequent opportunities to try these foods, will accept many of them. At home and in child care settings, therefore, young children should be introduced to healthy foods and given frequent opportunities to try them. It is important to note that, according to recent evidence, children attending child care programs that participate in the Child and Adult Care Food Program (CACFP) consume diets of better nutritional quality than children not attending such programs (Bruening et al., 1999; Crepinsek and Burstein, 2004; Whaley et al., 2008). Recommendation 4-2: To ensure that child care facilities provide a variety of healthy foods and age-appropriate portion sizes in an environment that encourages children and staff to consume a healthy diet, child care regula- tory agencies should require that all meals, snacks, and beverages served by early childhood programs be consistent with the Child and Adult Care Food Program meal patterns and that safe drinking water be available and acces- sible to the children. 93 Healthy Eating

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Rationale Children who consume a diet rich in nutrient-dense whole grains, fruits, veg- etables, and low-fat or nonfat milk and other dairy products and low in energy- dense, nutrient-poor foods are less likely to be overweight or obese (Bradlee et al., 2010; Frank, 2008). As noted in Chapter 1, overweight and obese children are more likely to become obese adolescents and adults (Taveras et al., 2009; Whitaker et al., 1997) and more likely to suffer from the chronic diseases associ- ated with excess weight. Some of these diseases that are associated with obesity and that may be present during childhood include type 2 diabetes, hypertension, hyperlipidemia, dyslipidemia, hepatic steatosis, obstructive sleep apnea, gallblad- der disease, and musculoskeletal and psychosocial disorders (Daniels et al., 2009; Freedman et al., 2007). Overweight and obese adults are more likely to develop cardiovascular diseases, type 2 diabetes, stroke, certain types of cancer, and osteo- arthritis (Pi-Sunyer, 2009). The DGA provide guidance on what constitutes a healthy diet for children 2 years of age and older (USDA and HHS, 2010). In the absence of governmental science-based national dietary recommendations for children younger than 2 years of age, AAP guidelines are used for this age group. For the purposes of this report and to be consistent with the DGA, nutritious foods and healthy foods are defined as lean and low-fat protein foods; whole-grain products; fruits and vegetables prepared with little or no added sugar, salt, or fat; and low-fat or nonfat milk and other dairy products. At the request of the U.S. Department of Agriculture (USDA), the IOM has made recommendations for updating meal patterns served through the CACFP in child care settings (see Box 4-3). The final regulations may vary once the USDA rulemaking process is complete. Children in the United States are not meeting these nutritional guidelines. Their diets are low in whole fruits, dark green and orange vegetables and legumes, and whole grains, key sources of nutrients. Although children aged 2–5 meet the DGA recommendations for total fruit and milk, their diets are high in saturated fat, sodium, added sugar, and calories (Fungwe et al., 2009; Guenther et al., 2008). Indeed, many young children consume discretionary calories from added sugars or fat every day (Fox et al., 2010). These are considered energy-dense, nutrient-poor foods, which provide many calories in a small volume with few essential nutrients. In layman’s terms, these are “junk foods” and “fatty foods.” Preventing obesity early in life is easier than treating it. Thus, it is critical that health care providers, researchers, and policy makers explore ways to limit access to energy-dense, nutrient-poor foods for even young children. Whole grains, fruits, Early Childhood Obesity Prevention Policies 94

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Box 4-3 Recommended Daily Meal Patterns for CACFP Breakfast, Lunch/ Supper, and Snacks: Number of Servings and Range of Serving Sizesa Food Group Number of Servings Range of Serving Size Breakfast Fruits or nonstarchy vegetables 1 to 1/2 cup 1/ 4 Grains/breads 1 2 to 2 /2 ounce equivalent 1/ 1 Lean meats/meat alternatives 1 1/ to 1 ounce equivalent 2 (3 times weekly) Milk 1 to 3/4 cup 1/ 2 Lunch/Supper Fruits 1 to 1/2 cup 1/ 4 Vegetables 2 4 to 1 cup 1/ Grains/breads 1 1/ to 2 ounce equivalent 2 Lean meats/meat alternatives 1 1/ to 2 ounce equivalent 2 Milk 1 1/ to 1 cup 2 Snacks (Choose two food groups per snack) Fruits 2 per week to 1 cup 1/ 2 Vegetables 2 per week to 1 cup 1/ 8 Grains/breads 2 per week 1/ to 2 ounce equivalent 2 Lean meats/meat alternatives 2 per week 1/ to 1 ounce equivalent 2 Milk 2 per week 1/ cup 2 aServing sizes vary by age group. SOURCE: Adapted from IOM, 2011a. 95 Healthy Eating

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