Head Start children's lifestyle behaviors, parental perceptions of weight, and body mass index

Family lifestyle is related to low-income preschoolers' emotional well-being during COVID-19 pandemic

PROBLEM

COVID-19 has profoundly impacted children's behavioral and psychosocial development, especially young children from low-income families. This study examined how caregivers' and preschoolers' lifestyle behaviors (sleep, screen time, physical activity, eating behavior) were related to preschoolers' emotional well-being (sadness, fear, anger, and positive affect).

METHODS

Using a cross-sectional design, we recruited low-income caregivers from Head Start organizations and the Qualtrics panel. Participants provided consent and completed an online survey.

FINDINGS

A total of 408 caregivers (mean age = 31) participated: 17% Hispanic, 21% Black, 49% separated/single, 44% unemployed, and 39% with ≤high school education. After adjusting for demographics and preschoolers' lifestyle behaviors, caregivers' sleep disturbance was positively correlated with preschoolers' anger, fear, and sadness, while negatively related to positive affect. Similarly, caregivers' sleep time was positively correlated with preschoolers' sadness and negatively related to positive affect. Preschoolers' sleep time was negatively related to fear and positively related to positive affect. Likewise, preschoolers' physical activity was negatively correlated with fear, sadness, and positively correlated with positive affect. Additionally, preschoolers' fruit/vegetable intake was negatively associated with anger, fear, sadness, and positively associated with positive affect.

CONCLUSIONS

The identified behavior-emotion connection provides a foundation for developing family-based lifestyle interventions in promoting mental health among preschoolers.

Global Prevalence of Meeting Screen Time Guidelines Among Children 5 Years and Younger: A Systematic Review and Meta-analysis

IMPORTANCE

Pediatric guidelines suggest that infants younger than 2 years avoid screen time altogether, while children aged 2 to 5 years receive no more than 1 hour per day. Although these guidelines have been adopted around the world, substantial variability exists in adherence to the guidelines, and precise estimates are needed to inform public health and policy initiatives.

OBJECTIVE

To derive the pooled prevalence via meta-analytic methods of children younger than 2 years and children aged 2 to 5 years who are meeting guidelines about screen time.

DATA SOURCES

Searches were conducted in MEDLINE, PsycINFO, and Embase up to March 2020.

STUDY SELECTION

Studies were included if participants were 5 years and younger and the prevalence of meeting (or exceeding) screen time guidelines was reported.

DATA EXTRACTION AND SYNTHESIS

Data extraction followed Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent reviewers extracted all relevant data. Random-effects meta-analyses were used to derive the mean prevalence rates.

MAIN OUTCOMES AND MEASURES

Prevalence of meeting screen time guidelines.

RESULTS

From 63 studies, 95 nonoverlapping samples with a total of 89 163 participants were included. For children younger than 2 years, the pooled prevalence of meeting the screen time guideline (0 h/d) was 24.7% (95% CI, 19.0%-31.5%). Moderator analyses revealed that prevalence of meeting screen time guidelines varied as a function of year of data collection (increased over time), measurement method (higher when questionnaires compared with interview), and type of device use (higher when a combination of screen use activities compared with television/movies only). For children aged 2 to 5 years, the mean prevalence of meeting the screen time guideline (1 h/d) was 35.6% (95% CI, 30.6%-40.9%). Moderator analyses revealed that the prevalence of meeting screen time guidelines varied as a function of type of device use (higher when screen time was television/movies only compared with a combination of screen use activities).

CONCLUSIONS AND RELEVANCE

The findings of this meta-analysis indicate that only a minority of children 5 years and younger are meeting screen time guidelines. This highlights the need to provide support and resources to families to best fit evidence-based recommendations into their lives.

Underestimation of overweight weight status in children and adolescents aged 0-19 years: A systematic review and meta-analysis

BACKGROUND

Perceptions of children's weight status may be important in obesity prevention and treatment.

AIMS

This review identifies the prevalence of the underestimation of overweight status in children by parents/main carers, children, and healthcare professionals (HCP). The review critically synthesized both quantitative and qualitative evidence to explore the factors associated with this underestimation. The diverse methods used to assess this phenomenon are reported.

METHODS

Pooled effect sizes were calculated using random-effects model. Published studies, up to 2020, were accessed using the following search engines: CINAHL, EMBASE, PUBMED, and Psych-Info and including the "Cited by" and "Related Articles" functions. Hand-searching was used to retrieve further articles. Publication language and location had no bearing on the nature of the included studies.

RESULTS

A total of 91 articles were included. In the quantitative studies, 55% (95% CI 49%-61%) of caregivers underestimated their child's level of overweight and obesity using a verbal scale and 47% (95% CI 36%-55%) using visual scales. Of the children studied, 34% (95% CI 25%-43%) underestimated their own level of overweight and obesity using both scales. In (n = 3) articles, HCPs reflected this misperception, but limited studies prevented meta-analysis. Underestimation was associated with the child's age, gender, BMI and parental weight status, ethnicity and education. In the qualitative studies, parents/main carers of children with overweight and obesity described their child's weight in terms other than overweight, for example, "big boned," "thick," and "solid."

CONCLUSION

The results confirm the prevalence of underestimation of child overweight status across international studies. Understanding the factors which lead to this inaccuracy may help to improve communication within the therapeutic triad and facilitate the recognition and management of children's overweight status.

Health belief model factors as predictors of parental misclassification of the weight of the preschool child

Background

Parental misperception and underestimation of their child’s weight are documented in studies. Demographic factors like age and gender have been linked to misclassification. However, modifiable factors that could potentially frame future intervention and prevention strategies have not been explored. This study aimed to assess factors that could predict parental misclassification of their preschool child’s weight.

Methods

This was a cross-sectional study with 198 parents and their 2- to 5-year-old children who attended standalone preschools or childcare centers with preschools. Parents completed a questionnaire that asked about demographic features, personal and family health, and the assessment of their child’s weight using the three most frequently utilized measures. Logistic regression was conducted to assess the association between parental factors and child weight classification status. Instruments included the Parental Self-Efficacy for Promoting Healthy Physical Activity and Dietary Behaviors in Children Scale (PSEPAD), the Obesity Risk Scale (ORK-10), and the Adolescent Obesity Risk Scale (AORK). Analyses included frequencies, chi-square tests, Kappa coefficients, and logistic regressions.

Results

Parents were least accurate (35.9%) identifying child weight when selecting a picture (κ = -.028, p = .42). The pictorial and Likert method (κ = -.032, p = .37) showed parental agreement with child weight was not significantly better than chance. Statistically, a significant agreement was found in the weight-reporting method (κ = .21). Two of the three HBM-related measures were significantly related to accurate classification. Logistic regression showed child sex, PSEPAD scores, and ORK-10 scores were statistically significant predictors in the Likert method. The model had no statistical significance for the pictorial or weight-reporting method.

Conclusion

Results indicate parents support intervening if aware of child weight problems. However, parents do not accurately recognize healthy versus unhealthy weights and report that health providers are not informing them of weight deviations. Further, important relationships between the HBM variables were identified. Results show barriers (self-efficacy) mediate the impact of perceived severity (knowledge) regarding the parental ability to assess child weight accurately. These relationships and incorporation of the HBM principles of barriers and severity into prevention/intervention strategies need further exploration.

Measurement of screen time among young children aged 0-6 years: A systematic review

The impact of screen-based devices on children's health and development cannot be properly understood without valid and reliable tools that measure screen time within the evolving digital landscape. This review aimed to summarize characteristics of measurement tools used to assess screen time in young children; evaluate reporting of psychometric properties; and examine time trends related to measurement and reporting of screen time. A systematic review of articles published in English across three databases from January 2009 to April 2020 was undertaken using PROSPERO protocol (registration: CRD42019132599) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles measured screen time as outcome, exposure, or confounder in children 0-6 years. The search identified 35,868 records, 1035 full-text articles were screened for eligibility, and 622 met inclusion criteria. Most measures (60%) consisted of one to three items and assessed duration of screen time on a usual day. Few measures assessed content (11%) or coviewing (7%). Only 40% of articles provided a citation for the measure, and only 69 (11%) reported psychometric properties-reliability n = 58, validity n = 19, reliability and validity n = 8. Between 2009 and 2019, the number of published articles increased from 28 to 71. From 2015, there was a notable increase in the proportion of articles published each year that assessed exposure to mobile devices in addition to television. The increasing number of published articles reflects increasing interest in screen time exposure among young children. Measures of screen time have generally evolved to reflect children's contemporary digital landscape; however, the psychometric properties of measurement tools are rarely reported. There is a need for improved measures and reporting to capture the complexity of children's screen time exposures.

Dietary Intake Among Head Start Preschooler-caregiver Dyads

PURPOSE

The purpose of this study was to examine the relationship between Head Start preschooler-caregiver dyad's dietary intake and factors influencing dietary intake.

DESIGN AND METHODS

A cross-sectional, correlational design was used. Height and weight were measured. Caregivers completed an online survey assessing demographics, dietary intake, feeding practices, and psychosocial factors.

RESULTS

Seventy dyads, recruited from two urban Head Start centers in the Midwestern U.S., participated. The mean age for preschoolers and caregivers was 3.90 (63% female) and 28.97 years (94% female), respectively. About 43% of preschoolers and 81% of caregivers were overweight/obese. Sixty-seven percent of caregivers, but only 9% of preschoolers, met the fruit/vegetable (F/V) recommendation. Preschoolers' F/V intake was not significantly correlated with their caregivers' F/V intake after adjusting for demographics and psychosocial factors (B = 0.05, p = .607). Caregiver race (B = -0.71, p = .05), nutrition knowledge (B = -0.35, p = .017), perceived caregiver weight (B = -0.85, p = .035), perceived child weight (B = 1.09, p = .029), and concerns of preschoolers' weight (B = 0.79, p = .004) were significantly correlated with preschoolers' F/V intake, after adjusting for demographics, caregiver F/V intake, and other psychosocial factors.

CONCLUSIONS

The study findings indicate the critical need to improve preschoolers' dietary intake and the important influence of caregivers on their preschoolers' dietary intake. Given the few limitations of the study (e.g., small sample size, food frequency questionnaire), interpretation and application of the study's findings warrant caution.

PRACTICE IMPLICATIONS

Pediatric practitioners and researchers need to design effective programs to improve low-income Head Start preschoolers' dietary intake, thereby helping to curb the current childhood obesity epidemic.

Perceived Parental Barriers to and Strategies for Supporting Physical Activity and Healthy Eating among Head Start Children

Despite the need for parents to support their children's healthy behaviors, knowledge of factors preventing parents from doing so is still rudimentary. This study primarily aimed to explore perceived parental barriers to and strategies for supporting physical activity and healthy eating among Head Start children. A semi-structured interview format was used with four focus groups conducted at two urban Head Start centers in the Midwestern U.S. A qualitative content analysis of audio-recorded sessions was facilitated using ATLAS.ti7. A convenience sample of 32 parents (Mage = 34.97 years) participated. Over half were female (78.1 %), African Americans (65.6 %), and single (65.6 %). About 61.3 % reported an annual family income <$20,000, and 43.8 % were unemployed. Three themes reflected the barriers: (1) intrapersonal (child): short attention span and limited eating preferences; (2) interpersonal (parent): lack of time and cooking skills and a tight family budget; and (3) environmental: inaccessible programs, lack of age-appropriate education, electronic media use, and unsafe environment. Parents across all groups expressed high interest in enrolling in a program with their children. Recommendations included: parents' support team; family outings at parks; taking a walk or enrolling in a class with children; and planting a garden. Many parents showed their preference for face-to-face meetings and a support group, but repulsion of counseling. To promote parental support in future interventions with Head Start children, their perceived intrapersonal, interpersonal, and environmental barriers should be considered as intervention targets. Involving parents through a support group and face-to-face meetings is recommended.

Mothers' conceptions about excess weight in infancy and the nutritional status of their children

OBJECTIVE

To analyze maternal conceptions about excess weight in infancy and the nutritional status of their preschool-aged children.

METHODS

A mixed, exploratory study was performed using semi-structured interviews. Two study groups were defined: a group of 16 mothers of children with excess weight and a group of 15 mothers of eutrophic children. The interviews were submitted to content analysis using CHIC software (Classification Hiérarchique Implicative et Cohésitive¯).

RESULTS

The mothers of children with excess weight tended to conceive thin children as malnourished, while those of normal weight children emphasized the influence of family and genetics as determinants of a child's nutritional status. Although there was a certain consensus among the mothers that an unhealthy diet contributes to the risk of a child developing excess weight, the concept of genetics as a determinant of a child's nutritional status was also present in the dialogue from the mothers of both groups. This result indicates a lack of clarity regarding the influence of eating behavior and family lifestyle on weight gain and the formation of a child's eating habits. Both groups indicated that the mother has a decisive role in the eating habits of her child; however, the mothers of children with excess weight did not seem to take ownership of this concept when addressing the care of their own children.

CONCLUSION

Differences in conceptions, including taking ownership of care, may contribute to the development of excess weight in preschool-aged children.

Hispanic parents' perceptions of their preschool children's weight status

PURPOSE

The purpose of this study was to examine the accuracy of Hispanic parents' perceptions of their preschool children's weight status.

DESIGN AND METHODS

A cross-sectional descriptive design with Hispanic parent-child dyads (n = 83) from a Head Start setting was used to compare parents' perceptions of their children's weight status with their 2- to 5-year-old children's body mass index (BMI) and weight categories. Methods included a word choice from five response options, and varying body size silhouettes presented in a linear fashion and a random circular pattern. Parents' perceptions were compared with the children's BMI, and in relationship to parents' demographic characteristics and BMI.

RESULTS

Approximately half of parents underestimated their child's weight status, and overweight/obese parents tended to underestimate their overweight/obese children's weight status.

PRACTICE IMPLICATIONS

Eliciting parent perception of their child's weight is one way providers can engage in obesity prevention dialogue.

Perceptions of low-income mothers about the causes and ways to prevent overweight in children

BACKGROUND

Childhood overweight and obesity remain major health conditions, affecting nearly one-third of children in the USA. Multiple factors have been identified that contribute to children becoming overweight; however, little is known regarding what low-income mothers perceive to be the causes of and the ways to prevent children from becoming overweight.

METHODS

Low-income mothers (n = 286) with children aged 4-8 years participated in semi-structured interviews, during which they were asked for their opinions about the causes of and ways to prevent children from becoming overweight. After themes were identified, interviews were coded for the presence or absence of each theme.

RESULTS

The majority of mothers were non-Hispanic White (69.2%) and overweight or obese (77.3%). Additionally, many of the children (41.9%) were overweight or obese. Six causes of children becoming overweight were identified by mothers: types or quantities of food eaten (90.9%); parenting behaviours (44.9%); lack of activity (42.3%); genetics, slow metabolism or medical issues (24.5%); stress or emotion (5.2%); and limited access to resources (3.5%). Five ways to prevent children from becoming overweight identified by mothers included the following: healthy eating (84.9%), more activity (54.8%), limiting screen time (19.9%), limiting sugar-sweetened beverages (12.2%) and drinking more water (6.6%). The majority of mothers (77.1%) reported that they carried out their suggestions to prevent their children from becoming overweight.

CONCLUSION

Within this cohort with a high prevalence of maternal and child overweight, most mothers identified many of the evidence-based strategies for childhood obesity prevention. Future intervention development may benefit from focusing on content areas that were less commonly identified by mothers as well as helping mothers translate knowledge to implementation.

Parental underestimates of child weight: a meta-analysis

BACKGROUND AND OBJECTIVE

Parental perceptions of their children's weight play an important role in obesity prevention and treatment. The objective of this study was to determine the proportion of parents worldwide who underestimate their children's weight and moderators of such misperceptions.

METHODS

Original studies published to January 2013 were chosen through literature searches in PUBMED, PSYCHINFO, and CINAHL databases. References of retrieved articles were also searched for relevant studies. Studies were published in English and assessed parental perceptions of children's weight and then compared perceptions to recognized standards for defining overweight based on anthropometric measures. Data were extracted on study-level constructs, child- and parent-characteristics, procedural characteristics, and parental underestimates separately for normal-weight and overweight/obese samples. Pooled effect sizes were calculated using random-effects models and adjusted for publication bias. Moderators were explored using mixed-effect models.

RESULTS

A total of 69 articles (representing 78 samples; n = 15,791) were included in the overweight/obese meta-analysis. Adjusted effect sizes revealed that 50.7% (95% confidence interval 31.1%-70.2%) of parents underestimate their overweight/obese children's weight. Significant moderators of this effect included child's age and BMI. A total of 52 articles (representing 59 samples; n = 64,895) were included in the normal-weight meta-analysis. Pooled effect sizes indicated that 14.3% (95% confidence interval 11.7%-17.4%) of parents underestimate their children's normal-weight status. Significant moderators of this effect included child gender, parent weight, and the method (visual versus nonvisual) in which perception was assessed.

CONCLUSIONS

Half of parents underestimated their children's overweight/obese status and a significant minority underestimated children's normal weight. Pediatricians are well positioned to make efforts to remedy parental underestimates and promote adoption of healthy habits.

A parent-focused pilot intervention to increase parent health literacy and healthy lifestyle choices for young children and families

Health literacy affects caregivers' ability to engage in preventive health care behaviors for themselves and their children. Studies suggest that health literacy among low-income families needs improvement, and this possibly contributes to disparities in preventive health care rates. Additionally, parents and caregivers may not be able to provide or seek preventive health care for their children because of lack of knowledge and skills to do so effectively. This study designed and piloted an intervention that delivered to parents of young children (1) health literacy information in an experiential manner and (2) practical skills to engage their families in healthy lifestyle choices. Specifically, the intervention focused on diet/nutrition, physical activity, sleep hygiene, parenting, and mental wellness. Postintervention improvements were noted for factual knowledge for diet/nutrition, physical activity, and sleep, beliefs about diet/nutrition, and the relationship between mental health and stress. Additionally, postintervention improvements were noted for general knowledge and beliefs about sleep, knowledge about the relationship between sleep and health, knowledge about common childhood sleep problems, and parents' bedtime interactions with children. The efficacy of the intervention should be evaluated on a larger, more diverse sample in the future with considerations for multiple health behavior change in the evaluation.

Perceptions of preventive health care and healthy lifestyle choices for low income families: a qualitative study

This paper examines Head Start parents' perceptions of preventive health and healthy lifestyle choices and Head Start administrators' perceptions of the needs of parents they serve. To address the preventive health of the population, it is necessary that we explore perceptions, risks, and protective factors of preventive health. Focus groups were conducted with parents and administrators to elicit this information and to obtain suggestions for improving preventive health and healthy lifestyle choices among this group. Overall, nutrition and physical activity emerged as themes in parents' definition of preventive health and healthy lifestyle choices. They further identified social support and education as major protective factors for engaging in preventive health and healthy lifestyle choices. Results of this study can be used to inform research and practice to develop interventions to increase preventive health and healthy lifestyle choices among low income families.

Difference between parental perception and actual weight status of children: a systematic review

An increasing number of children worldwide are overweight, and the first step in treating obesity is to identify overweight. However, do parents recognise overweight in their child and which factors influence parental perception? The aim of the present review is to systematically study differences between parental perception and the actual weight status of children. Medline, EMbase, CINAHL and PsychINFO were searched. After screening 2497 abstracts and 106 full texts, two reviewers independently scored the methodological quality of 51 articles (covering 35 103 children), which fulfilled the inclusion criteria. The primary outcome parameters were sensitivity and specificity of parental perception for actual weight status of their child. The methodological quality of the studies ranged from poor to excellent. Pooled results showed that according to objective criteria 11 530 children were overweight; of these, 7191 (62.4%) were incorrectly perceived as having normal weight by their parents. The misperception of overweight children is higher in parents with children aged 2-6 years compared with parents of older children. Sensitivity (correct perception of overweight) of the studies ranged from 0.04 to 0.89, while specificity (correct perception of normal weight) ranged from 0.86 to 1.00. There were no significant differences in sensitivity or specificity for different cut-off points for overweight, or between newer and older studies. Therefore we can conclude that parents are likely to misperceive the weight status of their overweight child, especially in children aged 2-6 years. Because appropriate treatment starts with the correct perception of overweight, health care professionals should be aware of the frequent parental misperception of the overweight status of their children.

Validity and feasibility of a digital diet estimation method for use with preschool children: a pilot study

OBJECTIVE

The goal of the study was to assess the validity and feasibility of a digital diet estimation method for use with preschool children in Head Start.

METHODS

Preschool children and their caregivers participated in validation (n = 22) and feasibility (n=24) pilot studies. Validity was determined in the metabolic research unit using actual gram weight measurements as the reference method. Feasibility of using the digital diet estimation method was determined in Head Start and in the home by assessing 3 separate lunch and dinner meals.

RESULTS

The average correlation between estimated weights and actual weights was 0.96 (P < .001), and the average mean difference was 10.6 g. The digital diet estimates were 5% lower than the actual weights.

CONCLUSIONS AND IMPLICATIONS

The digital diet estimation method may be a valid and feasible method for assessing food intake of preschool children.

Childhood obesity among Puerto Rican children: discrepancies between child's and parent's perception of weight status

Public concern about childhood obesity and associated health problems calls for the identification of modifiable factors that could halt this epidemic. Parental perceptions of their children’s weight status could be associated to how parents influence children’s eating patterns. We aimed to identify the perceptions Puerto Rican parents have of their children’s weight and children’s own perceptions of weight status as compared to real weight. A cross sectional survey was performed in a representative sample of 1st–6th grade students. Only half of the children correctly identified their weight, and only 62.4% of the parents correctly classified their children’s weight. Most obese/overweight children did not perceive themselves as such. Almost half of obese/overweight children were identified by the parents as normal weight while over half of the underweight children were perceived by their parents at normal weight. More girls than boys perceived themselves as obese/overweight and more parents of girls than of boys perceived them as such. Higher-educated parents were better at recognizing overweight/obesity among their children compared to less-educated parents. This study suggests an influence of parents’ SES characteristics on their perceptions of children’s weight status as well as on children’s own perceptions of their weight status.

Obesity in preschoolers: behavioral correlates and directions for treatment

Nearly 14% of American preschoolers (ages 2-5) are obese (BMI ≥ 95th percentile for age and gender), yet this group has received little attention in the obesity intervention literature. This review examines what is known about behavioral correlates of obesity in preschoolers and the developmental context for lifestyle modification in this age group. Information was used to critically evaluate existing weight management prevention and intervention programs for preschoolers and formulate suggestions for future intervention research development. A systematic search of the medical and psychological/behavioral literatures was conducted with no date restrictions, using PubMed, PsycInfo, and MEDLINE electronic databases and bibliographies of relevant manuscripts. Evidence suggests several modifiable behaviors, such as sugar sweetened beverage intake, television use, and inadequate sleep, may differentiate obese and healthy weight preschoolers. Developmental barriers, such as food neophobia, food preferences, and tantrums challenge caregiver efforts to modify preschoolers' diet and activity and parental feeding approaches, and family routines appear related to the negative eating and activity patterns observed in obese preschoolers. Prevention programs yield modest success in slowing weight gain, but their effect on already obese preschoolers is unclear. Multi-component, family-based, behavioral interventions show initial promise in positive weight management for already obese preschoolers. Given that obesity intervention research for preschoolers is in its infancy, and the multitude of modifiable behavioral correlates for obesity in this age group, we discuss the use of an innovative and efficient research paradigm (Multiphase Optimization Strategy; MOST) to develop an optimized intervention that includes only treatment components that are found to empirically reduce obesity in preschoolers.