Fast food intake and excess weight gain over a 1-year period among preschool-age children

A Latent Class Analysis of Family Eating Behaviors and Home Environment Habits on Preschool-Aged Children's Body Mass Index

Background: The etiology of obesity is multifaceted, with multiple risk factors occurring during early childhood (e.g., fast food frequency, eating dinner as a family, TV in the bedroom). Many past studies have largely considered obesity risk factors in isolation, when in reality, the risk factors likely cluster together. A latent class analysis can be used to identify patterns in child eating behaviors, parent feeding behaviors, and household habits among preschool-aged children and their families to identify distinct, heterogenous classes and to determine if classes are associated with overweight and obesity. Methods: We used data from a community-based study of 624 three- to five-year-old children and a parent in New Hampshire, from March 2014 to October 2015. Parent-reported data were used to determine frequency of eating behaviors and household habits. Height and weight were objectively measured. Results: Four classes were identified; Class 1: "Healthy/Mildly accommodating," Class 2: "Healthy/Accommodating," Class 3: "Moderately healthy/Moderately accommodating," and Class 4: "Least healthy/Least accommodating." Compared with Class 1, children in Class 4 had increased odds of being overweight or obese [adjusted odds ratio (aOR): 1.64, 95% confidence interval (CI): 1.13-2.15], whereas Classes 2 and 3 were not associated with BMI (Class 2: aOR: 1.24, 95% CI: 0.62-1.86; Class 3: aOR: 1.31, 95% CI: 0.81-1.81). Conclusion: Study findings highlight that child-parent interactions around meals differentially relate to children's weight status given the context of children's eating habits. Most important, our study findings confirm the importance of adapting multiple healthy habits within the home social and physical environment to offset obesity risk in young children.

Development and testing of two tools to assess point-of-sale food and beverage marketing to children in restaurants

OBJECTIVE

To describe the development and testing of two assessment tools designed to assess exterior (including drive-thru) and interior food and beverage marketing in restaurants with a focus on marketing to children and teens.

DESIGN

A scoping review on restaurant marketing to children was undertaken, followed by expert and government consultations to produce a draft assessment tool. The draft tool was mounted online and further refined into two separate tools: the Canadian Marketing Assessment Tool for Restaurants (CMAT-R) and the CMAT-Photo Coding Tool (CMAT-PCT). The tools were tested to assess inter-rater reliability using Cohen's Kappa and per cent agreement for dichotomous variables, and intra-class correlation coefficients (ICCs) for continuous or rank-order variables.

SETTING

Waterloo, Ontario, Canada.

PARTICIPANTS

Restaurants of all types were assessed using the CMAT-R (n 57), and thirty randomly selected photos were coded using the CMAT-PCT.

RESULTS

The CMAT-R collected data on general promotions and restaurant features, drive-thru features, the children's menu and the dollar/value menu. The CMAT-PCT collected data on advertisement features, features considered appealing to children and teens, and characters. The inter-rater reliability of the CMAT-R tool was strong (mean per cent agreement was 92·4 %, mean Cohen's κ = 0·82 for all dichotomous variables and mean ICC = 0·961 for continuous/count variables). The mean per cent agreement for the CMAT-PCT across items was 97·3 %, and mean Cohen's κ across items was 0·91, indicating very strong inter-rater reliability.

CONCLUSIONS

The tools assess restaurant food and beverage marketing. Both showed high inter-rater reliability and can be adapted to better suit other contexts.

Factors Correlated With Ultra-Processed Food (UPF) Intake in Preschool-Aged Children and Association With Weight

OBJECTIVE

Understand the correlates of ultra-processed food (UPF) intake and examine the association of UPF on body mass index in children aged 3-5 years.

DESIGN

Secondary analysis of a prospective cohort of 3-5-year-olds/parent, followed 1-year between March 2014 and October 2016. Usual UPF intake from 2 3-day food records completed 1 year apart, a standardized nutrient database customized with child-specific foods, and a NOVA food classification system was used. Child/parent characteristics and media use were measured via parent-reported surveys. Child weight/height objectively measured.

SETTING

New Hampshire community.

PARTICIPANTS

Six hundred and sixty-seven parent-child dyads were screened, and 624 were enrolled with 90% follow-up.

MAIN OUTCOME MEASURE(S)

Primary outcome: identify correlates of UPF intake.

SECONDARY OUTCOME

determine if UPF intake is associated with body mass index change.

ANALYSIS

Adjusted β linear regression, linear regression, P <0.05.

RESULTS

Ultra-processed food accounted for 67.6% of total caloric intake. In adjusted models, children's UPF intake was positively associated with increasing child age, greater hours watching television, and more frequent parent soda/fast-food intake. Ultra-processed food intake was negatively associated with higher parent education and reported race/ethnicity other than non-Hispanic White. There was no association between UPF intake and weight.

CONCLUSIONS AND IMPLICATIONS

There are several predictors of UPF intake in young children. Family-level interventions could be implemented to encourage the intake of minimally processed foods before and during preschool years.

Feeding, television, and sleep behaviors at one year of age in a diverse sample

Background

Healthy lifestyle behaviors that can prevent adverse health outcomes, including obesity, are formed in early childhood. This study describes feeding, television, and sleep behaviors among one-year-old infants and examines differences by sociodemographic factors.

Methods

Caregivers of one-year-olds presenting for well care at two clinics, control sites for the Greenlight Study, were queried about feeding, television time, and sleep. Adjusted associations between sociodemographic factors and behaviors were performed by modified Poisson (binary), multinomial logistic (multi-category), or linear (continuous) regression models.

Results

Of 235 one-year-olds enrolled, 81% had Medicaid, and 45% were Hispanic, 36% non-Hispanic Black, 19% non-Hispanic White. Common behaviors included 20% exclusive bottle use, 32% put to bed with bottle, mean daily juice intake of 4.1 ± 4.6 ounces, and active television time 45 ± 73 min. In adjusted analyses compared to Hispanic caregivers, non-Hispanic Black caregivers were less likely to report exclusive bottle use (odds ratio: 0.11, 95% confidence interval [CI] 0.03-0.39), reported 2.4 ounces more juice (95% CI 1.0-3.9), 124 min more passive television time (95% CI 60-188), and 37 min more active television time (95% CI 10-64). Increased caregiver education and higher income were associated with 0.4 (95% CI 0.13-0.66) and 0.3 (95% CI 0.06-0.55) more servings of fruits and vegetables per day, respectively.

Conclusion

In a diverse sample of one-year-olds, caregivers reported few protective behaviors that reduce the risk for adverse health outcomes including obesity. Differences in behavior by race/ethnicity, income, and education can inform future interventions and policies. Future interventions should strive to create culturally effective messaging to address common adverse health behaviors.

Neighborhood Availability and Use of Food, Physical Activity, and Social Services Facilities in Relation to Overweight and Obesity in Children and Adolescents

OBJECTIVE

To evaluate the association of a combined measure of availability and use of facilities from the food environment and overweight (including obesity) among schoolchildren, while taking into account the physical activity and social-assistance environments.

METHODS

Cross-sectional study with a probabilistic sample of schoolchildren aged 7 to 14 years living in a southern Brazilian city (n = 2026). Multilevel analyses were performed with overweight as outcome and the food environment as main exposure. Models were adjusted for the physical activity and social-assistance environments, as well as individual and other residential neighborhood characteristics.

RESULTS

Greater availability of restaurants around the home was associated with higher odds of overweight (odds ratio [OR] = 1.40; 95% CI = 1.06-1.85). Stronger associations were found for schoolchildren reporting to use restaurants (OR = 1.48; 95% CI = 1.15-1.90). This association remained significant after adjusting for the presence of other food retailers. Schoolchildren who had social-assistance facilities around their homes, but reported not to use them, showed consistently higher odds of being overweight (OR = 1.34; 95% CI = 1.01-1.78) as compared to schoolchildren who had these facilities near home and used them. The physical activity environment was not associated with the outcome.

CONCLUSIONS

Availability and use of the food and social-assistance environments were significantly associated with overweight (including obesity) among the schoolchildren. Future research should consider the use of environmental facilities in combination to their geographical availability. Our results highlight the need for policies that limit the access to obesogenic food outlets by children and adolescents.

Nudging low-medium income mothers towards healthy child options in an online restaurant scenario

Helping mothers make the healthiest choices for their children when eating out can contribute to preventing the prevalence of childhood overweight and obesity, particularly in economically disadvantaged classes. Herein, we tested whether two different nudges (a default option and a social norm prompt) could guide low- and middle-income mothers towards healthier children's menu choices in a fictive restaurant setting and investigated the drivers of healthy child menu selection. A cross-sectional online survey was performed among 809 Italian mothers with children aged between 3 and 12 years, and a between-subjects design (control, nudge 1, and nudge 2) was applied. The findings revealed that both nudges had no significant effect on the number of healthy menu selections compared with the healthy choices made in the control condition. Furthermore, considering the entire sample, the results show that certain characteristics of a mother (e.g., authoritative parenting style) and child (younger age) duo increase the likelihood of the former selecting a healthy children's menu. Similarly, a positive correlation between the likelihood of choosing a healthy children's menu and the mother's involvement in the child's nutrition (meal preparation and weekly diet) was observed.

Maternal diet quality and associations with body composition and diet quality of preschool children: A longitudinal study

BACKGROUND

Nutrition, associated with nutritional status, influences the growth of children. This study aimed to identify the association between maternal diet quality and the diet and body composition of their children.

METHODS

This is a prospective longitudinal study with mother-child pairs. To assess diet quality, nutritional status, and socioeconomic data, two interviews in the children's first and third months of life (2011-2016) and one interview when children were of preschool age (2017-2019) were performed. Diet quality was assessed based on daily food consumption and frequency, considering: 1) food groups, based on the Brazilian food pyramid; 2) level of processing, according to the NOVA classification (unprocessed and/or minimally processed foods, processed foods and ultra-processed foods). One-way ANOVA with Tukey post hoc and Kruskal-Wallis with Dunn's post hoc tests were used to evaluate the influence of factors on children's diet quality. Pearson and Spearman's correlations were used to evaluate the relationship between maternal and children's diet quality, maternal schooling level, and child age. Along with the nutritional assessment of children, multiple linear regression models assessed the impact of covariables on maternal and children's diet quality.

RESULTS

Eighty-three mother-child pairs participated in this study. The more frequent the maternal consumption of unprocessed and/or minimally processed foods, the higher the consumption of these foods by children (r = +0.30; p = 0.006) and the lower their subscapular skinfold (SSF) thickness (p = 0.011; β = -0.278). On the other hand, the higher the maternal consumption of ultra-processed foods, the higher the children's tricipital skinfold (TSF) thickness (p = 0.010; β = +0.274) and SSF (p = 0.043; β = +0.222).

CONCLUSION

Maternal diet quality was associated with the diet and body composition of children.

Unhealthy Food and Beverage Consumption in Children and Risk of Overweight and Obesity: A Systematic Review and Meta-Analysis

This WHO-commissioned review contributed to the update of complementary feeding recommendations, synthesizing evidence on effects of unhealthy food and beverage consumption in children on overweight and obesity. We searched PubMed (Medline), Cochrane CENTRAL, and Embase for articles, irrespective of language or geography. Inclusion criteria were: 1) randomized controlled trials (RCTs), non-RCTs, cohort studies, and pre/post studies with control; 2) participants aged ≤10.9 y at exposure; 3) studies reporting greater consumption of unhealthy foods/beverages compared with no or low consumption; 4) studies assessing anthropometric and/or body composition; and 5) publication date ≥1971. Unhealthy foods and beverages were defined using nutrient- and food-based approaches. Risk of bias was assessed using the ROBINS-I (risk of bias in nonrandomized studies of interventions version I) and RoB2 [Cochrane RoB (version 2)] tools for nonrandomized and randomized studies, respectively. Narrative synthesis was complemented by meta-analyses where appropriate. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation. Of 26,542 identified citations, 60 studies from 71 articles were included. Most studies were observational (59/60), and no included studies were from low-income countries. The evidence base was low quality, as assessed by ROBINS-I and RoB2 tools. Evidence synthesis was limited by the different interventions and comparators across studies. Evidence indicated that consumption of sugar-sweetened beverages (SSBs) and unhealthy foods in childhood may increase BMI/BMI z-score, percentage body fat, or odds of overweight/obesity (low certainty of evidence). Artificially sweetened beverages and 100% fruit juice consumption make little/no difference to BMI, percentage body fat, or overweight/obesity outcomes (low certainty of evidence). Meta-analyses of a subset of studies indicated a positive association between SSB intake and percentage body fat, but no association with change in BMI and BMI z-score. High-quality epidemiological studies that are designed to assess the effects of unhealthy food consumption during childhood on risk of overweight/obesity are needed to contribute to a more robust evidence base upon which to design policy recommendations. This protocol was registered at https://www.crd.york.ac.uk/PROSPERO as CRD42020218109.

State and Local Healthy Kids' Meal Laws in the United States: A Review and Content Analysis

BACKGROUND

To address unhealthy restaurant food intake among children, localities and states are passing healthy restaurant kids' meal laws. However, there is limited knowledge of what these policies require and how they compare with expert and industry nutrition standards.

OBJECTIVES

The aim of this study was to develop a research instrument to evaluate healthy kids' meal laws and assess their alignment with expert and industry nutrition standards.

DESIGN

The study team conducted a content analysis of healthy kids' meal laws passed between January 2010 and August 2020 in the United States. Using a structured codebook, two researchers abstracted policy elements and implementation language from laws, regulations, fiscal notes, and policy notes. Nutritional criteria for kids' beverages and meals were compared with existing expert and industry nutrition standards for meals and beverages.

MAIN OUTCOME MEASURES

Measures included law characteristics, implementation characteristics, enforcement characteristics, definitions of key terms, and nutritional requirements for meals and default beverage options and alignment with expert and industry nutrition standards.

STATISTICAL ANALYSES PERFORMED

Interrater reliability of the coding tool was estimated using the Cohen kappa statistic, and researchers calculated descriptive statistics of policy elements.

RESULTS

Twenty laws were identified. Eighteen were healthy default beverage policies, two were toy restriction policies, and one was a nutrition standards policy. The nutrition standards, default beverage offerings, and implementation characteristics varied by location. No law met the expert nutrition standards for kids' meals or beverages.

CONCLUSIONS

The variations in policy specifications may influence how restaurants implement the policies, and, consequently, the policies' influences on children's consumption. Future policies could use expert nutrition standards to inform the standards set for kids' meals and specify supports for implementation.

The ontology of fast food facts: conceptualization of nutritional fast food data for consumers and semantic web applications

Background

Fast food with its abundance and availability to consumers may have health consequences due to the high calorie intake which is a major contributor to life threatening diseases. Providing nutritional information has some impact on consumer decisions to self regulate and promote healthier diets, and thus, government regulations have mandated the publishing of nutritional content to assist consumers, including for fast food. However, fast food nutritional information is fragmented, and we realize a benefit to collate nutritional data to synthesize knowledge for individuals.

Methods

We developed the ontology of fast food facts as an opportunity to standardize knowledge of fast food and link nutritional data that could be analyzed and aggregated for the information needs of consumers and experts. The ontology is based on metadata from 21 fast food establishment nutritional resources and authored in OWL2 using Protégé.

Results

Three evaluators reviewed the logical structure of the ontology through natural language translation of the axioms. While there is majority agreement (76.1% pairwise agreement) of the veracity of the ontology, we identified 103 out of the 430 statements that were erroneous. We revised the ontology and publicably published the initial release of the ontology. The ontology has 413 classes, 21 object properties, 13 data properties, and 494 logical axioms.

Conclusion

With the initial release of the ontology of fast food facts we discuss some future visions with the continued evolution of this knowledge base, and the challenges we plan to address, like the management and publication of voluminous amount of semantically linked fast food nutritional data.

Promotion of Meal Premiums in Child-Directed TV Advertising for Children's Fast-food Meals

BACKGROUND

Fast-food intake is a modifiable obesity risk factor in early childhood, and child-directed fast-food marketing is common. Per self-regulatory guidelines regarding deception, premiums (ie, incentives or toy giveaways) in child-directed advertisements must be secondary to the advertised product.

METHODS

Content analyses were performed of all child-directed fast-food television (TV) advertisements aired on four national US children's TV networks, February 1, 2019, through January 31, 2020, to assess the emphasis of premiums relative to food. We quantified the percent of the audio transcript (word count) and visual airtime (seconds) that included premiums or food and the on-screen size of premiums relative to food in randomly selected frames from each advertisement.

RESULTS

There were 28 unique child-directed advertisements for children's fast-food meals in the study year; 27 advertisements were from one restaurant and accounted for nearly all (99.8%) of the total airtime for the 28 advertisements. Premiums were present in 27 of the 28 unique advertisements. On average, premiums (versus food) accounted for 53.0% (vs 16.0%) of words in the audio transcript and 59.2% (vs 54.3%) of the visual airtime per advertisement. In the random subset of frames that includes both premiums and food imagery, imagery of premiums accounted for 9.7% (95% CI: 6.4%-13.0%) of the on-screen area, whereas imagery of food accounted for 5.7% (95% CI: 4.4%-7.0%), an average ratio of 1.9:1 within each frame when excluding one large outlier.

CONCLUSIONS

Child-directed fast-food TV advertisements emphasize premiums over food in violation of self-regulatory guidelines, counter to childhood obesity prevention efforts.

Exploring the extent of digital food and beverage related content associated with a family-friendly event: a case study

Background

Exposure to unhealthy food and beverage content is a contributing factor to the obesity epidemic. Youth are susceptible to unhealthy digital food marketing including content shared by their peers, which can be as influential as commercial marketing. Current Canadian regulations do not consider the threat digital food marketing poses to health. No research to date has examined the prevalence of food related posts on social media surrounding family-friendly events. The aim of this study was to explore the frequency of food related content (including food marketing) and the marketing techniques employed in social media posts related to a family-friendly event in Canada.

Methods

In this case study, a content analysis of social media posts related to a family-friendly event on Facebook, Twitter, and Instagram was conducted between January to February 2019. Each post containing food related content was identified and categorized by source and food category using a coding manual. Marketing techniques found in each food related post were also assessed.

Results

A total of 732 food and beverage related posts were assessed. These posts were most commonly promoted through Instagram (n = 561, 76.6%) with significantly more individual users (61.5%; p < 0.05) generating food and beverage related content (n = 198, 27%) than other post sources. The top most featured food category was fast food (n = 328, 44.8%) followed by dine-in restaurants (n = 126, 17.2%). The most frequently observed marketing techniques included predominantly featuring a child in the post (n = 124, 16.9%; p < 0.0001), followed by products intended for children (n = 118, 16.1%; p < 0.05), and the presence of family (n = 57, 7.8%; p < 0.0001).

Conclusions

The present study highlights the proliferation of unhealthy food and beverage content by individuals at a family-friendly event as well as the presence of food marketing. Due to the unfettered advertising found in digital spaces, and that they are largely unregulated, it is important for future policies looking to combat childhood obesity to consider incorporating social media into their regulations to safeguard family-friendly events. General awareness on the implications of peer to peer sharing of unhealthy food and beverage posts should also be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10716-w.

Taste Ratings of Healthier Main and Side Dishes among 4-to-8-Year-Old Children in a Quick-Service Restaurant Chain

Restaurants are regular eating environments for many families. Children's consumption of restaurant foods has been linked with poorer diet quality, prompting emerging research examining strategies to encourage healthier eating among children in restaurants. Although taste is a primary determinant of restaurant meal choices, there is a lack of research considering children's perspectives on the taste of different healthier kids' meal options. The current study sought to examine, via objective taste testing, children's liking of and preference for healthier kids' meal options at a quick-service restaurant (QSR) and to describe bundled kids' meals with evidence of both taste acceptability and consistency with nutrition guidelines. Thirty-seven 4-to-8-year-old children completed taste tests of ten healthier main and side dish options. Liking and preference were assessed using standard methods after children tasted each food. Children also reported their ideal kids' meal. Results show the majority of children liked and preferred three main (turkey sandwich, chicken strips, peanut butter/banana sandwich) and side dishes (yogurt, applesauce, broccoli), with rank order differing slightly by age group. Accepted foods were combined into 11 bundles meeting nutritional criteria. Results highlight healthier kids' meals with evidence of appeal among children in a QSR. Findings can inform future research and may increase the success of healthy eating interventions in these settings.

Energy imbalance: obesity, associated comorbidities, prevention, management and public health implications

The prevalence of obesity has been continually increasing, as have its associated comorbidities and health care costs. Effective management of obesity and early intervention measures are necessary to overcome this global issue. The responsibility for preventing and managing this global epidemic does not lie solely on an individual, but also on the entire health care system. Policy makers-nationally and globally-must play their roles to solve the issue. In this review article, we examine methods of controlling and managing obesity through interventions, such as a low caloric diet, physical exercise, pharmacological guidance, and bariatric surgical procedures. While health care professionals should educate patients about all available treatment options for severe obesity, bariatric surgical procedures have increased in popularity and are considered very beneficial with outcomes fruitful in managing severe obesity.

The Homeostatic Theory of Obesity: An Empirical Verification of the Circle of Discontent with an Assessment of Its Relationship to Restrained and Uncontrolled Eating among Children and Adolescents

The purpose of the present study was to provide an empirical verification of the Circle of Discontent with an assessment of its relationship to restrained and uncontrolled eating among children and adolescents. This study examined whether our results confirm a new hypothesized model. The total sample comprised 282 children and adolescents (148 girls and 134 boys; 141 participants with normal body weight and 141 with obesity). The mean age was 12.23 years (SD = 2.80), and the average BMI (body mass index) was 23.29 kg/m² (SD = 6.27). The following were used: Positive and Negative Affect Scale for Children, Children’s Body Image Scale, Figure Rating Scale, Three-Factor Eating Questionnaire and Eating Disorders in Youth. The obtained values of the model fit indices proved the goodness of fit. Our findings show that obesity accompanies body dissatisfaction and uncontrolled and restrictive eating. Moreover, the higher the level of restrictive eating, the lower the level of uncontrolled eating. The relationships between body dissatisfaction, negative affect and restrictive eating, as well as that between uncontrolled eating and high-energy consumption, are significant and positive. Other relationships are non-significant. The above-mentioned relationships established in the Circle of Discontent, as well as relationships of restrained and uncontrolled eating with variables described in the circle, were confirmed. Based on our results, preventive strategies and psychological interventions can be created and may include changes in body image, eating behaviors and emotional functioning.