Mending the gap: Measurement needs to address policy implementation through a health equity lens

Policies represent a key opportunity to improve the health outcomes of populations, and if implemented well, can reduce disparities affecting marginalized populations. Many policies are only evaluated on whether they elicit their intended health outcome. However, a lack of understanding regarding if and how they are implemented may hinder the intended impact overall and on addressing health disparities. Implementation science offers an array of frameworks and methodological approaches for assessing policy delivery, yet few examples exist that meaningfully include health equity as a core focus. This commentary describes the importance of equity-informed implementation measurement by providing case examples and implications for assessment. In addition, we highlight examples of emerging work in policy implementation grounded in health equity with suggested steps for moving the field forward. The ultimate goal is to move toward open-access measurement approaches that can be adapted to study implementation of a variety of policies at different stages of implementation, driven by input from marginalized populations and implementation practitioners, to move the needle on addressing health disparities.

Parents of preschoolers use multiple strategies to feed their children: Findings from an observational video pilot study

The current study leveraged observational data collection methods to fill gaps in our understanding of parent approach to feeding as well as child responses to various parental approaches. Specifically, the study aimed to: 1) characterize the broad range of food parenting practices used by parents of preschoolers during shared mealtimes at home, including differences by child gender, and 2) describe child responses to specific parent feeding practices. Forty parent-child dyads participated by recording two in-home shared meals. Meals were coded using a behavioral coding scheme that coded the occurrence of 11 distinct food parenting practices (e.g. indirect and direct commands, praise, bribes) and eight child responses (e.g., eat, refuse, cry/whine) to food parenting practices. Results revealed that parents engaged in a broad range of food parenting practices at meals. On average, parents in our sample used 10.51 (SD 7.83; Range 0-30) total food parenting practices per mealtime with a mean use of 3.38 (SD 1.67; Range 0-8) unique food parenting practices per mealtime. Use of indirect and direct commands to eat were most common; direct and indirect commands were used by 97.5% (n = 39) and 87.5% (n = 35) of parents at meals, respectively. No statistically significant differences were observed by child gender. No one specific feeding practice consistently yielded compliance or refusal to eat from the child, instead child responses were often mixed (e.g., compliance followed by refusal and/or refusal followed by compliance). However, use of praise to prompt eating was the practice that most often resulted in child compliance; 80.8% of children complied following parent's use of praise as a prompt to eat. Findings deepen our understanding of the types and frequency of food parenting practices used by parents of preschoolers during meals eaten at home and illuminate child responses to specific food parenting practices.

Age-related differences in eating location, food source location, and timing of snack intake among U.S. children 1-19 years

BACKGROUND

Snacking is nearly universal and contributes significant energy to U.S. children's diets. Little is known, however, about where and when snacking intake occurs and if such patterns change with age. This research evaluated age-related differences in eating location, food source location, and timing of snacking among U.S. children aged 1-19 years (y).

METHODS

A cross-sectional analysis of snacking among 14,666 children in the 2007-2018 U.S. National Health and Nutrition Examination Survey was conducted using a single 24-hour dietary recall. Snacking was participant-defined and included all eating occasions outside of meals. Linear regression and analysis of covariance were used to examine the effects of age (toddler 1-2 y, preschooler 3-5 y, school-age 6-11 y, adolescent 12-19 y) on the percentage of daily snack energy consumed by eating location (at home vs. away from home), food source location (grocery store, convenience store, school/childcare, restaurant, from someone else (i.e. "socially"), and other), and time of day (morning, 6am-12pm; early afternoon, 12pm-3pm; late afternoon/afterschool 3pm-6pm; evening 6pm-9pm, late-night 9pm-12am, and overnight 12am-6am).

RESULTS

On average, U.S. children consumed most of their daily snacking energy at home (71%), from foods and beverages obtained from grocery stores (75%), and in the late afternoon/afterschool (31%). Toddlers and preschoolers consumed a greater percentage of their daily snack energy during the morning hours compared to school-age children and adolescents (both p < 0.001); school-age children consumed the most in the evening (27%, p < 0.001), and adolescents consumed the most in the late-night period (22%, p < 0.001). Age-related increases were seen in the percentage of daily snacking energy eaten outside the home (p < 0.001), and obtained socially (p < 0.001), from restaurants (p < 0.001), and convenience stores (p < 0.001).

CONCLUSION

Findings reveal age-related differences in eating location, food source location, and timing of snack intake among U.S. children aged 1-19 y. Younger children consume a greater percentage of snacking calories in the morning and at home relative to older children. School-age children and adolescents show greater snacking in the evening and at night and from foods obtained and eaten outside the home. Efforts to promote healthy snacking behaviors among children should consider developmental differences in snacking patterns.

Child Weight Status: The Role of Feeding Styles and Highly Motivated Eating in Children

Although parental feeding plays an important role in child eating and weight status, high food motivation among children may also be a factor shaping how feeding impacts child weight. This study explored whether individual differences in preschool children’s food motivation interacted with mothers’ feeding styles in predicting subsequent child weight status. Participants included 129 Hispanic Head Start mother/child dyads. Data were collected at ages 4–5 years (Time 1) and 7–9 (Time 3). Staff measured heights/weights and observed children in an eating in the absence of hunger task. Mothers reported on feeding styles/practices and children’s eating behaviors. A principal components analysis derived a measure of highly motivated eating in children. Multiple regressions predicted Time 3 child BMI z-scores. Time 3 BMI z-scores were positively predicted by authoritative and indulgent feeding styles and negatively predicted by monitoring. Since feeding style interacted with highly motivated eating, separate regressions were run for high and low food motivation in children. Unexpectedly, results showed that authoritative feeding positively predicted Time 3 child BMI z-scores only for children showing low levels of food motivation. Characterizing differential parental feeding and child eating phenotypes may assist in tailoring childhood obesity prevention programs for the target populations.

Maternal responsiveness and toddler body mass index z-score: Prospective analysis of maternal and child mealtime interactions

Responsive feeding, where parents are guided by children's hunger and satiation cues and provide appropriate structure and support for eating, is believed to promote healthier weight status. However, few studies have assessed prospective associations between observed parental feeding and toddler growth. We characterized toddler growth from 18 to 36 months and, in a subset of families, examined whether observed maternal responsiveness to toddler satiation cues and encouraging prompts to eat at 18 and 24 months were associated with toddler body mass index z-score (BMIz) from 18 to 36 months. Participants included 163 toddlers and their mothers with overweight/obesity who had participated in a lifestyle intervention during pregnancy. Anthropometrics were measured at 18, 24, and 36 months. In a subsample, mealtime interactions were recorded in families' homes at 18 (n = 77) and 24 (n = 75) months. On average, toddler BMIz remained stable from 18 to 36 months with 31.3% (n = 51) categorized with a healthy weight, 56.4% (n = 92) with at risk for overweight and 12.3% (n = 20) with overweight. Fewer maternal prompts to eat at 18 months was associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p = .002). Higher child weight status at 12 months was also associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p < .001). Neither 24-month maternal prompts nor 18 or 24 month responsiveness to satiation cues were associated with toddler BMIz. In this diverse sample, weight status was relatively stable from 18 to 36 months. Maternal prompts to eat measured earlier in toddlerhood and prior child weight status were associated with toddler BMIz.

A descriptive assessment of a broad range of food-related parenting practices in a diverse cohort of parents of preschoolers using the novel Real-Time Parent Feeding Practices Survey

Background

Much of the research to-date on food parenting has evaluated typical use of various parent feeding practices via questionnaire. The Real-Time Parent Feeding Practices Measurement survey was developed for use within an Ecological Momentary Assessment (EMA) protocol to capture momentary use of parent feeding practices in real-time.

Methods

This manuscript describes the development of the EMA-based Real-Time Parent Feeding Practices survey and highlights initial descriptive data on the real-time use of 22 individual parent feeding practices (e.g., pressure-to-eat, guided choices, etc.) as reported via EMA by parents of preschool-aged children (n = 116) over a 10-day data collection time period. A total of 3382 eating occasions were reported, with an average of 29.2 reported eating occasions per participant.

Results

Results revealed that most participants used a variety of food-related parenting practices day-to-day that span four higher-order domains: structure, autonomy support, coercive control and indulgence. Supportive feeding practices, defined as those from the structure and autonomy support domains, were reported most frequently, with one or more structure behavior (e.g., specific mealtime rules/routines) was used at 88.9% of reported eating occasions and one or more autonomy support behavior (e.g., involvement of the child in meal preparation) was used at 87.3% of eating occasions. While unsupportive feeding practices, defined as practices from within the coercive control (e.g., pressure-to-eat) and indulgent (e.g., anticipatory catering) feeding domains, were reported less frequently, one or more behaviors from each of these domains were still reported at over 25% of all eating occasions.

Conclusions

Results of the current study take a next step towards deepening our understanding of the use of a broad range of food-related parenting practices in real-time. Findings revealed that the vast majority of practices used by parents fall within the structure and autonomy support domains. However, most parents did not exclusively use supportive or unsupportive practices, rather they used a combination of food-related parenting practices across all domains. Future research should continue to explore a broad range of food-related parenting practices and seek to understand how parent approaches to feeding are associated with long-term child outcomes, including dietary intake, food preferences, and eating patterns.

Associations Between Independent Assessments of Child Appetite Self-Regulation: A Narrative Review

A variety of eating behaviors among children have been associated with obesity risk and are thought to broadly reflect child appetite self-regulation (ASR). While ASR is thought to occur on cognitive, emotional, motivational, biological, and behavioral levels, the inter-relatedness of ASR constructs as assessed by different methods/measures is not well-characterized. This narrative review describes the correspondence between different methods/measures of child ASR constructs as assessed by self-report questionnaires and/or observational tasks and their relationship to child standardized body mass index (BMIz). Research involving at least two different methods/measures is presented including observational tasks such as the Eating in the Absence of Hunger task, compensation trials, and eating rate, as well as various child eating behavior self-report questionnaires. Keyword searches in the PubMed and PsycINFO databases for articles published between 2000 and July 2021 identified 21,042 articles. Eighteen articles met the inclusion criteria and examined at least two of the targeted measures. Studies comparing questionnaire data with other questionnaire data showed the most evidence of significant associations (r values ranging from −0.45 to 0.49), whereas studies comparing questionnaires with observational tasks mostly showed weak (r values ranging from −0.17 to 0.19) or not significant associations, with only few studies finding moderate associations (r values ranging from −0.38 to 0.33). Studies comparing different observational tasks showed no significant associations. Overall, studies comparing self-report questionnaires showed the most correspondence, whereas those comparing observational tasks showed no correspondence. Studies across methods (questionnaires with tasks) showed less correspondence. Significant associations were found between ASR constructs and child BMIz across five studies using self-report questionnaires and two studies using observational tasks. Future research is needed to clearly define the various ASR constructs, their expected correspondence, and the strength of that correspondence, as well as the relations between ASR constructs and child weight among youth with and without overweight/obesity.

Breakfast in the Classroom Initiative Does Not Improve Attendance or Standardized Test Scores among Urban Students: A Cluster Randomized Trial

BACKGROUND

Breakfast in the Classroom (BIC), a common approach to implementing the federal School Breakfast Program, is advocated as a method to improve students' academic performance. However, the impacts of BIC on academic outcomes are unclear.

OBJECTIVE

To examine the effect of a BIC initiative which provided free, universal BIC on attendance and standardized test performance over 2.5 years, versus free universal breakfast served in the cafeteria before school, among students in an urban school district serving a low-income population.

DESIGN

Secondary analysis of data from a cluster randomized controlled trial conducted between 2013 and 2016; sixteen kindergarten through 8^th grade public schools in Philadelphia, Pennsylvania were enrolled and randomized to condition. Baseline data for 1,362 4^th through 6^th grade students were provided by the school district. Midpoint data were collected after 1.5 years and endpoint data after 2.5 years.

PARTICIPANTS/SETTING

Schools were eligible if ≥50% of students qualified for free/reduced-priced meals, did not offer BIC, and received programming as part of the USDA's Supplemental Nutrition Assistance Program. Parents consented for their children to participate.

INTERVENTION

Intervention schools provided BIC and breakfast-related nutrition promotion activities. Control schools provided breakfast in the cafeteria before the school day.

MAIN OUTCOME MEASURES

Student attendance and standardized exam scores.

STATISTICAL ANALYSES PERFORMED

Weighted generalized estimating equations were used to evaluate differences in outcomes between conditions at midpoint and endpoint.

RESULTS

The BIC initiative did not impact attendance (Beta (SE) = 0.004 (0.06), P = 0.94) or standardized reading exam scores (Beta (SE) = 0.02 (0.06), P = 0.79) after 2.5 years. Students in BIC initiative schools had lower standardized math exam scores than those in control schools although this difference was small (Beta (SE) = -0.20 (0.07), P = 0.005).

CONCLUSIONS

BIC did not improve academic outcomes among students attending low-income, urban schools.

Infant and Toddler Consumption of Sweetened and Unsweetened Lipid Nutrient Supplements After 2-Week Home Repeated Exposures

BACKGROUND

Small-quantity lipid-based nutrient supplements (SQ-LNS) are designed to address undernutrition during the complementary feeding period. SQ-LNS contains added sugars, but limited research has assessed whether infants' acceptance varies between versions with and without sugars.

OBJECTIVES

Our objective was to examine the effects of repeated exposure on children's acceptance of sweetened and unsweetened SQ-LNS. We aimed to understand caregivers' perceptions of children's liking of the 2 SQ-LNS versions and their influences on infant acceptance of SQ-LNS.

METHODS

Caregivers (86% non-Hispanic White) and children (7-24 mo), participated in a randomized, 2-week home-exposure study and baseline and post-home exposure assessments. Children were randomized to receive sweetened or unsweetened SQ-LNS versions, mixed with infant oatmeal. At in-person visits, caregivers fed both SQ-LNS versions to children and rated their child's liking for each. Caregivers fed the SQ-LNS version to which their child was randomized until the child refused to eat more. Acceptance was measured as total grams consumed. Mixed-effects linear models tested the change in SQ-LNS consumed between baseline and postexposure by the SQ-LNS version and number of home exposures. Covariates included the amount of SQ-LNS consumed at baseline, child BMI z-score, child age, and breastfeeding experience.

RESULTS

Children's acceptance of both SQ-LNS versions increased from baseline to postexposure (β, 0.71 g; 95% CI: 0.54-0.89 g; P = 0.04), regardless of SQ-LNS version (P = 0.88) or number of home exposures (P = 0.55). Caregivers rated children's liking of unsweetened SQ-LNS higher at baseline (P = 0.02). Children with lower liking ratings at baseline showed the greatest increases in acceptance between baseline and postexposure (P = 0.01).

CONCLUSIONS

Children's acceptance of SQ-LNS increased with repeated exposure, whether offered the sweetened or unsweetened version, providing preliminary support that adding sugar to SQ-LNS may not improve acceptance in young children. Children who initially like the supplement less may need repeated experience to learn to accept SQ-LNS. This trial was registered at clinicaltrials.gov as NCT04544332.

Maternal feeding style and child weight status among Hispanic families with low-income levels: a longitudinal study of the direction of effects

BACKGROUND

The home environment is a central and modifiable influence on the development of childhood obesity. Evidence supports the central role of parents in shaping problematic child eating behaviors and excess weight. Most studies of feeding emphasize parent-driven influences without taking into account the child's role in eating interactions. Few studies have addressed the bi-directional nature of feeding dynamics in studies of young children.

METHODS

The goals of this study were: 1) to examine if parental feeding styles during preschool (4-5 years) predict child weight status at 7-9 years, and 2) to examine the direction of effects between parental feeding styles and child weight status over time. Participants were part of a larger longitudinal study of Hispanic Head Start families living in the West South Central United States. Data from mother/child dyads were collected at three time points: Time 1 (ages 4-5), Time 2 (ages 5 ½-6 ½), and at Time 3 (ages 7-9). Only data from the Times 1 and 3 were used in the current analyses. A total of 128 mothers and their children had data on all variables needed for the analyses. Assessments included parent-reported feeding styles, feeding practices, acculturation, child eating behaviors, and child height and weight. Hierarchical regression was used to examine the first aim; a cross-lagged panel analysis examined the second aim.

RESULTS

An indulgent parental feeding style at ages 4-5 was associated with increased child BMI z-score at ages 7-9. Indulgent feeding significantly contributed to child BMI z-score beyond demographics, baseline child BMI z-score, parental acculturation, and child eating behaviors. Regarding the direction of effects in parental feeding interactions, the cross-lagged analyses showed that both indulgent feeding style and authoritative feeding style at Time 1 positively predicted child BMI z-scores at Time 3. Child effects were significant as well. Child BMI z-score at Time 1 positively predicted indulgent feeding and negatively predicted authoritarian feeding at Time 3.

CONCLUSIONS

Indulgent feeding should be addressed in future family-focused childhood obesity initiatives focused on young children and their parents.

General Parenting and Hispanic Mothers' Feeding Practices and Styles

Previous research has shown that general parenting styles, general parenting dimensions, maternal feeding styles, and maternal feeding practices all show specific relationships with the weight status of young children. This study examined the relationships between general parenting and maternal feeding styles/practices in a sample of 187 Hispanic mothers with low incomes. As part of a larger study, mothers of preschool children were recruited through Head Start programs and completed validated questionnaires assessing their general parenting, feeding styles, and feeding practices. Results identified numerous associations between general parenting dimensions and specific feeding practices: i.e., maternal nurturance was positively associated with healthy eating guidance and feeding responsiveness; inconsistency was positively associated with restriction for weight and promotion of overconsumption; follow through on discipline was positively associated with monitoring, healthy eating guidance, and feeding responsiveness; and family organization was positively associated with monitoring and healthy eating guidance. General parenting styles were associated with feeding practices as well, with authoritative mothers showing the highest levels of healthy eating guidance and authoritarian mothers showing the lowest levels of monitoring. There were no significant associations between mothers' general parenting styles and mothers' feeding styles. Implications of these findings for the prevention of childhood obesity are considered.

Observations of Maternal Feeding Practices and Styles and Young Children's Obesity Risk: A Longitudinal Study of Hispanic Mothers with Low Incomes

Background: Maternal feeding practices and styles are well-established correlates of children's BMI z-scores in the preschool years. Most studies, however, are cross-sectional, using maternal self-reports to examine feeding. This study examined, over a 3½-year period, the relationship between observed and self-reported feeding practices/styles and children's BMI z-scores in a sample of Hispanic mothers with low incomes and their preschool children. Methods: One hundred eighty-seven mothers were observed feeding their 4- to 5-year old during a buffet meal in a laboratory setting and completed self-report measures on their feeding practices and styles. Children's BMI z-scores were assessed at this visit and 3½ years later. Results: Consistent with previous research, observed and self-reported pressure to eat and/or authoritarian feeding were negatively associated with children's BMI z-scores at the first time point; observed discouraging eating was positively associated. However, children's BMI z-scores 3½ years later, controlling for Time 1 BMI z-scores, were positively associated with observed pressure to eat. Observed maternal reasoning and self-reported monitoring of children's eating behavior at Time 1 were negatively associated with later BMI z-scores. Only self-reported feeding styles predicted later children's BMI z-scores, with indulgent and authoritative styles positively associated with children's BMI z-scores at the third time point. Conclusions: These findings demonstrate that mothers who ignore their children's fullness cues and pressure them to eat have children who are at greater risk for the development of later obesity. Implications for the development of family-focused childhood obesity prevention programs are discussed.

Does eating in the absence of hunger extend to healthy snacks in children?

OBJECTIVES

To assess if eating in the absence of hunger (EAH) extends to healthier snacks and examine the relationship between the home food environment and EAH in children with normal weight (NW) or overweight/obesity (OB) who are at low risk (LR) or high risk (HR) for obesity based on maternal obesity.

METHODS

EAH was assessed after lunch and dinner when children received either low energy dense fruit snacks or high energy dense sweet/savoury snacks. The availability of obesogenic foods in the home was assessed by the Home Food Inventory.

RESULTS

Data showed significant main effects of risk group (P=.0003) and snack type (P < .001). EAH was significantly greater in HR-OB (284±8 kcal) than LR-NW (249±9 kcal) or HR-NW (251±8 kcal) children. Serving fruit rather than sweet/savoury snacks reduced energy intake, on average, by 60% (223 kcal) across risk groups. For each unit increase in the obesogenic home food environment, EAH of sweet/savoury snacks decreased by 1.83 calories.

CONCLUSIONS

Offering low energy dense snacks after a meal can moderate EAH and increase children's intake of healthy foods. Increased access to obesogenic foods in the home may reduce the salience of high energy dense snacks when they become available in other settings.

Positive parenting approaches and their association with child eating and weight: A narrative review from infancy to adolescence

Parents play a critical role in the development of children's eating behaviours and weight status, serving as providers, models and regulators of the food environment. Many research reviews have focused on the robust body of evidence on coercive control in feeding: how parenting practices such as restriction and pressure to eat increase children's risk for developing undesirable eating behaviours and unhealthy weight outcomes. Fewer reviews adopt a strengths-based perspective focusing on the ways that parents can actively support the development of healthy eating behaviours and weight trajectories. Emerging research on such positive parenting styles and practices offers solutions beyond the avoidance of coercive control, as well as opportunities to highlight parallels between research on food parenting and the broader, well-established developmental literature on positive parenting. The focus of this review is to summarize what is known regarding benefits of positive parenting styles and practices for child eating and weight outcomes and discuss recommendations for future research. Current evidence supports starting with responsive feeding and parenting during infancy and incorporating structure and limit setting in early childhood, with monitoring and mealtime structure remaining important during middle childhood and adolescence. Areas for future research include: (1) further examination of the implications of identified food parenting practices and styles among diverse groups and caregivers; (2) increased consideration of child factors (eg, temperament) as moderators or mediators; and (3) further clarification of the relationship between general parenting and food parenting.

Low-Income Latina Mothers' Scaffolding of Preschoolers' Behavior in a Stressful Situation and Children's Self-Regulation: A Longitudinal Study

OBJECTIVE

Maternal control and directiveness in Latina/o families often do not show the negative associations with child adjustment seen in European American samples. This study tested the self-determination hypotheses that Latina maternal involvement and structure would be positively associated with preschool children's later self-regulation, whereas directiveness and control would show negative relations.

DESIGN

At Time 1, 130 low-income Latina mothers were observed helping their 4- to 5-year-old children complete a stressful task. Maternal strategies for scaffolding children's responses to stress were examined with detailed event coding. At Time 1 and Time 2 18 months later, a delay of gratification task assessed children's self-regulation.

RESULTS

Children's Time 2 ability to delay gratification at 5½ to 6½ years (controlling for delay of gratification at ages 4 to 5) was predicted by Time 1 maternal scaffolding strategies. Children showing the greatest delay gratification at Time 2 (controlling for delay of gratification at Time 1) had mothers who used instructive praise and nonverbal autonomy-promoting scaffolding strategies at Time 1. Negative predictors included nonverbal attention directing and restriction.

CONCLUSIONS

The findings highlight the importance of physical guidance in Latina/o families and suggest that highly directive maternal strategies may not interfere with the development of self-regulation as is often found in European American families. These findings will be useful in developing interventions to promote self-regulation in Latina/o children from low-income families.

What Should I Eat and Why? The Environmental, Genetic, and Behavioral Determinants of Food Choice: Summary from a Pennington Scientific Symposium

This review details the proceedings of a Pennington Biomedical scientific symposium titled, "What Should I Eat and Why? The Environmental, Genetic, and Behavioral Determinants of Food Choice." The symposium was designed to review the literature about energy homeostasis, particularly related to food choice and feeding behaviors, from psychology to physiology. This review discusses the intrinsic determinants of food choice, including biological mechanisms (genetics), peripheral and central signals, brain correlates, and the potential role of the microbiome. This review also address the extrinsic determinants (environment) of food choice within our physical and social environments. Finally, this review reports the current treatment practices for the clinical management of eating-induced overweight and obesity. An improved understanding of these determinants will inform best practices for the clinical treatment and prevention of obesity. Strategies paired with systemic shifts in our public health policies and changes in our "obesogenic" environment will be most effective at attenuating the obesity epidemic.

Examination of different definitions of snacking frequency and associations with weight status among U.S. adults

Snacks, while widely consumed in the United States (U.S.), do not have a standard definition, complicating research to understand associations, if any, with weight status. Therefore, the purpose of this study was to examine the association between snacking frequency and weight status using various snacking definitions that exist in the scientific literature among U.S. adults (NHANES 2013–2016; ≥20y n = 9,711). Four event-based snacking definitions were operationalized including participant-defined snacks, eating events outside of meals, and operationally defined snacks based on absolute thresholds of energy consumed (>50 kcal). Weight status was examined using body mass index (BMI), waist circumference, and sagittal abdominal diameter risk. Logistic regression models examined snacking frequency and associations with weight status. Outcomes varied by the definition of a snack employed, but the majority of findings were null. Mean energy from snacks was significantly higher among women with obesity compared to women with normal weight when a snack was defined as any event outside of a typical mealtime (i.e. other than breakfast, lunch, dinner, super, brunch), regardless of whether or not it contributed ≥50 kcal. Further investigation into ingestive behaviors that may influence the relationship between snacking frequency and weight status is needed.

Caregiver Influences on Eating Behaviors in Young Children: A Scientific Statement From the American Heart Association

A substantial body of research suggests that efforts to prevent pediatric obesity may benefit from targeting not just what a child eats, but how they eat. Specifically, child obesity prevention should include a component that addresses reasons why children have differing abilities to start and stop eating in response to internal cues of hunger and satiety, a construct known as eating self‐regulation. This review summarizes current knowledge regarding how caregivers can be an important influence on children's eating self‐regulation during early childhood. First, we discuss the evidence supporting an association between caregiver feeding and child eating self‐regulation. Second, we discuss what implications the current evidence has for actions caregivers may be able to take to support children's eating self‐regulation. Finally, we consider the broader social, economic, and cultural context around the feeding environment relationship and how this intersects with the implementation of any actions. As far as we are aware, this is the first American Heart Association (AHA) scientific statement to focus on a psychobehavioral approach to reducing obesity risk in young children. It is anticipated that the timely information provided in this review can be used not only by caregivers within the immediate and extended family but also by a broad range of community‐based care providers.

Breakfast in the Classroom Initiative and Students' Breakfast Consumption Behaviors: A Group Randomized Trial

Objectives. To identify the effect of a Breakfast in the Classroom (BIC) initiative on the foods and drinks students consume in the morning.Methods. Sixteen public schools in Philadelphia, Pennsylvania, that provide universal breakfast participated in a group randomized trial to examine the effects of BIC with complementary nutrition promotion between 2013 and 2016. Control schools (n = 8) offered breakfast in the cafeteria before school. Baseline data were collected from 1362 students in grades 4 to 6. Endpoint data were collected after 2.5 years. Students self-reported the foods and drinks they consumed in the morning.Results. At endpoint, there was no effect of the intervention on breakfast skipping. Nearly 30% of intervention students consumed breakfast foods or drinks from multiple locations, as compared with 21% of control students. A greater proportion of intervention students than control students consumed 100% juice, and a smaller proportion consumed sugar-sweetened beverages and foods high in saturated fat and added sugar.Conclusions. A BIC initiative led to improvements in the types of foods and drinks students consumed in the morning. However, the program did not reduce breakfast skipping and increased the number of locations where students ate.

A Pilot Study of Neural Correlates of Loss of Control Eating in Children With Overweight/Obesity: Probing Intermittent Access to Food as a Means of Eliciting Disinhibited Eating

Objective

Neural substrates of loss of control (LOC) eating are undercharacterized. We aimed to model intermittent access to food to elicit disinhibited eating in youth undergoing neuroimaging, given evidence that restricted food access may increase subsequent food intake via enhancing reward value of food and diminishing eating-related self-control.

Methods

Participants were 18 preadolescents (aged 9-12 years) who were overweight/obese with recent LOC eating (OW-LOC; n = 6); overweight/obese with no history of LOC eating (OW-CON; n = 5); or non-overweight with no history of LOC eating (NW-CON; n = 7). Participants underwent functional magnetic resonance imaging during a simulated food restriction paradigm in which they were alternately given restricted or unrestricted access to milkshake solutions.

Results

There were no significant main effects of restricted versus unrestricted access to milkshake flavors. Group main effects revealed increased activation for OW-LOC relative to OW-CON in areas related to attentional processes (right middle frontal gyrus), inhibitory control/attentional shifts (right and left cuneus), and emotion regulation (left cingulate gyrus); and for OW-LOC relative to NW-CON in areas related to response inhibition (right inferior frontal gyrus). Significant block type × group interaction effects were found for the right middle frontal gyrus, left cingulate gyrus, and left cuneus, but these appeared to be accounted for primarily by group.

Discussion

There were clear group differences in neural activity in brain regions related to self-regulation during a food restriction paradigm. Elevations in these regions among OW-LOC relative to OW-CON and NW-CON, respectively, may suggest that youth with LOC eating expended more cognitive effort to regulate ingestive behavior.

Associations between Snacking and Weight Status among Adolescents 12-19 Years in the United States

Snacking is a significant contributor to energy intake among adolescents, but its association with weight status is unclear. To elucidate this association, data from 6545 adolescents (12-19 years) in the 2005-2016 National Health and Nutrition Examination Survey (NHANES) were analyzed. The mean number of daily snack occasions, mean snack size, and mean snack energy density were examined by weight classification (body mass index (BMI)-for-age percentiles: normal weight (NW) <85th; overweight (OW) ≥85th to <95th; obese (OB) ≥95th). Models included all snacking parameters, mean meal size, demographic characteristics, survey cycle year, and dietary reporting accuracy. Adolescents with NW consumed fewer snacks daily (1.69 (0.02) snacks/day) and smaller snacks per occasion (262.32 (4.41) calories (kcal)/snack) compared to adolescents with OW (1.85 (0.05) snacks/day, p = 0.005; 305.41 (8.84) kcal/snack, p < 0.001), and OB (1.97 (0.05) snacks/day; 339.60 (10.12) kcal/snack, both p < 0.001). Adolescents with OW and OB also consumed more added sugar, saturated fat and sodium from snacks, but had lower mean energy density per snack compared to snacks consumed by NW adolescents. US adolescents with OW and OB consume more snacks daily and more calories at each snacking occasion compared to adolescents with NW. Future studies should examine the prospective associations between snacking and weight status and impact on overall diet quality.

Effect of a Breakfast in the Classroom Initiative on Obesity in Urban School-aged Children: A Cluster Randomized Clinical Trial

IMPORTANCE

Serving breakfast in the classroom is promoted to increase participation in the federal School Breakfast Program. However, little is known about the effect of breakfast in the classroom on children's weight status.

OBJECTIVE

To evaluate the effect of a breakfast in the classroom initiative, which combined breakfast in the classroom with breakfast-specific nutrition education, on overweight and obesity among urban children in low-income communities.

DESIGN, SETTING, AND PARTICIPANTS

A cluster-randomized clinical trial among 1362 fourth- through sixth-grade students from low-income urban communities across 2.5 years. Sixteen kindergarten through eighth grade Philadelphia public schools with universal breakfast participated. Participants were recruited in September 2013, and the intervention began in January 2014. Data analysis took place from April 1, 2018, to August 30, 2018.

INTERVENTIONS

Intervention schools received a program that included breakfast in the classroom and breakfast-specific nutrition education. Control schools continued breakfast before school in the cafeteria and standard nutrition education.

MAIN OUTCOMES AND MEASURES

The primary outcome was the combined incidence of overweight and obesity. Secondary outcomes included the combined prevalence of overweight and obesity, incidence and prevalence of obesity, changes in body mass index (BMI) z score, and School Breakfast Program participation.

RESULTS

Among the 1362 students, mean (SD) age was 10.8 (0.96) years and 700 (51.4%) were female; 907 (66.6%) were black, 233 (17.1%) were Hispanic, 100 (7.3%) were white, 83 (6.1%) were Asian, and 39 were of multiple or other race/ethnicity. After 2.5 years, students in intervention schools had participated in the School Breakfast Program 53.8% of days, compared with 24.9% of days among students in control schools (β = 0.33; 95% CI, 0.22-0.42). There was no difference between intervention and control schools in the combined incidence of overweight and obesity after 2.5 years (11.7% vs 9.3%; odds ratio [OR] 1.31; 95% CI, 0.85-2.02; P = .22). However, the incidence (11.6% vs 4.4%; OR, 2.43; 95% CI, 1.47-4.00) and prevalence (28.0% vs 21.2%; OR, 1.46; 95% CI, 1.11-1.92) of obesity were higher in intervention schools than in control schools after 2.5 years.

CONCLUSIONS AND RELEVANCE

A breakfast in the classroom initiative increased participation in the School Breakfast Program and did not affect the combined incidence of overweight and obesity. However, the initiative had an unintended consequence of increasing incident and prevalent obesity. Further research is needed to identify approaches to increase participation in the School Breakfast Program that do not increase obesity among students.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01924130.

Title: efficacy of a food parenting intervention for mothers with low income to reduce preschooler's solid fat and added sugar intakes: a randomized controlled trial

Background

Few interventions have shown efficacy to influence key energy balance behaviors during the preschool years.

Objective

A randomized controlled trial (RCT) was used to evaluate the efficacy of Food, Fun, and Families (FFF), a 12 week authoritative food parenting intervention for mothers with low-income levels, to reduce preschool-aged children’s intake of calories from solid fat and added sugar (SoFAS).

Methods

Mothers were randomly assigned to receive FFF (n = 59) or to a delayed treatment control (n = 60). The primary outcome was children’s daily energy intake from SoFAS at the end of the 12 week intervention, controlling for baseline levels, assessed by 24-h dietary recalls. Secondary outcomes included children’s daily energy intake, children’s BMI z-scores, and meal observations of maternal food parenting practices targeted in FFF (e.g. providing guided choices).

Results

Participating mothers were predominantly African American (91%), with 39% educated beyond high school and 66% unemployed. Baseline demographics and child SoFAS intakes did not differ by group. Lost to follow-up was 13% and did not differ between groups. At post-intervention, FFF children consumed ~ 94 kcal or 23% less daily energy from SoFAS than children in the control group, adjusting for baseline levels (307.8 (95%CI = 274.1, 341.5) kcal vs. 401.9 (95%CI = 369.8, 433.9) kcal, FFF vs. control; p < 0.001). FFF mothers also displayed a greater number of authoritative parenting practices when observed post-intervention with their child at a buffet-style meal (Wilcoxon z = − 2.54, p = 0.012). Neither child total daily energy intake nor BMI z-scores differed between groups post-intervention.

Conclusions

Findings demonstrate the initial efficacy of an authoritative food parenting intervention for families with low-income to reduce SoFAS intake in early childhood. Additional research is needed to evaluate longer-term effects on diet and growth.

Trial registration

Retrospectively registered at ClinicalTrials.gov: #NCT03646201.

Identifying behavioral phenotypes for childhood obesity

Existing programs which aim to prevent and treat childhood obesity often do not take into account individual variation and the underlying mechanisms that impact child eating behavior. Individual differences in children's appetitive traits have been shown to appear as early as during infancy and become more pronounced as children grow older and become more exposed to the obesogenic food environment. Differences in genetic predispositions interacting with factors in children's early environment account in part for individual differences in appetitive traits. It is very likely that obesogenic eating phenotypes manifest themselves before the onset of childhood obesity. If so, identifying these phenotypes early is expected to move primary prevention strategies in a new direction and holds great potential to significantly enhance our ability to prevent childhood obesity. The aim of this narrative review is to discuss the role of behavioral phenotyping as an innovative approach for the development of more personalized obesity prevention and treatment interventions that are tailored to children's individual predispositions. We describe several examples of appetitive traits which have been linked to overeating and excess weight gain in children and thus may represent modifiable risk factors for future interventions. The review concludes with a comprehensive synthesis of opportunities for future human ingestive behavior research on identifying behavioral phenotypes for childhood obesity.

Daily Snacking Occasions and Weight Status Among US Children Aged 1 to 5 Years

OBJECTIVE

To characterize associations of snacking frequency with weight status among US children aged 1 to 5 years.

METHODS

Participants were children (n = 4,669) aged 1 to 5 years in the 2005 to 2014 National Health and Nutrition Examination Survey (NHANES). Snacking was assessed by two 24-hour dietary recalls using definitions that considered "snack" occasions as well as other foods/beverages consumed between meals. Overweight/obesity (OW/OB) was defined using percentile cutoffs: ≥ 97.7th weight-for-length (< 2 years) cutoff and the ≥ 85th BMI-for-age (≥ 2 years) cutoff. Linear/logistic regressions evaluated snacking based on daily occasions and relative to current recommendations (two to three snacks per day).

RESULTS

During 2005 to 2014, US children aged 1 to 5 years consumed, on average, two to three snacks daily. Children with normal weight in both age groups tended to snack less frequently than children with OW/OB when considering all foods/beverages eaten between meals (P < 0.01-0.12). Across most snacking definitions, children < 2 years who snacked more frequently than recommended had greater odds of having OW/OB (P < 0.01-0.12) and consumed greater daily snack energy than those who snacked within recommendations (all P < 0.01). Recommendations did not clearly delineate weight status among children aged 2 to 5 years.

CONCLUSIONS

Snacking frequency and weight are positively associated among US children 1 to 5 years old, with most consistent associations seen among children < 2 years old and when considering all foods/beverages consumed between meals.

Development and preliminary validation of the Parenting around SNAcking Questionnaire (P-SNAQ)

Snacking makes significant contributions to children's dietary intake but is poorly understood from a parenting perspective. This research was designed to develop and evaluate the psychometrics of a theoretically grounded, empirically-informed measure of snack parenting. The Parenting around SNAcking Questionnaire (P-SNAQ) was developed using a conceptual model derived from current theory and mixed-methods research to include 20 hypothesized snack parenting practices along 4 parenting dimensions (autonomy support, structure, coercive control and permissiveness). Expert panel evaluation and cognitive interviews were used to refine items and construct definitions. The initial instrument of 105 items was administered to an ethnically diverse, low-income sample of 305 parents (92% mothers) of children aged 1-6 y participating in three existing cohort studies. The sample was randomly split into two equal samples. Exploratory factor analysis was conducted with the first sample to identify snack parenting practices within each parenting dimension, followed by confirmatory factor analysis with the second sample to test the hypothesized factor structure. Internal consistency of sub-scales and associations with existing measures of food parenting practices and styles and child weight status were evaluated. The final P-SNAQ scale included 51 items reflecting 14 snack parenting practices across four parenting dimensions. The factor structure of the P-SNAQ was consistent with prior theoretical frameworks. Internal consistency coefficients were good to very good for 12 out of 14 scales and subscale scores were moderately correlated with previously validated measures. In conclusion, initial evidence suggests that P-SNAQ is a psychometrically sound measure for evaluating a wide range of snack parenting practices in young children.

Brain response to food cues varying in portion size is associated with individual differences in the portion size effect in children

Large portions promote intake of energy dense foods (i.e., the portion size effect--PSE), but the neurobiological drivers of this effect are not known. We tested the association between blood oxygen level dependent (BOLD) brain response to food images varied by portion size (PS) and energy density (ED) and children's intake at test-meals of high- and low-ED foods served at varying portions. Children (N = 47; age 7-10 years) participated in a within-subjects, crossover study consisting of 4 meals of increasing PS of high- and low-ED foods and 1 fMRI to evaluate food images at 2 levels of PS (Large, Small) and 2 levels of ED (High, Low). Contrast values between PS conditions (e.g., Large PS - Small PS) were calculated from BOLD signal in brain regions implicated in cognitive control and reward and input as covariates in mixed models to determine if they moderated the PSE curve. Results showed a significant effect of PS on intake. Responses to Large relative to Small PS in brain regions implicated in salience (e.g., ventromedial prefrontal cortex and orbitofrontal cortex) were positively associated with the linear slope (i.e., increase in intake from baseline) of the PSE curve, but negatively associated with the quadratic coefficient for the total meal. Responses to Large PS High ED relative to Small PS High ED cues in regions associated with cognitive control (e.g., dorsolateral prefrontal cortex) were negatively associated with the linear slope of the PSE curve for high-ED foods. Brain responses to PS cues were associated with individual differences in children's susceptibility to overeating from large portions. Responses in food salience regions positively associated with PSE susceptibility while activation in control regions negatively associated with PSE susceptibility.

Breakfast Quality Varies by Location among Low-Income Ethnically Diverse Children in Public Urban Schools

OBJECTIVE

To evaluate breakfast location and children's food choices.

METHODS

Cross-sectional analysis of 1,371 fourth- through sixth-grade students in 2013. Foods and beverages in 17 categories characterized breakfast choices: (1) ≥ 1 fruits or vegetables, (2) ≥ 1 foods high in saturated fats and added sugars (SFAS), and (3) meeting School Breakfast Program (SBP) requirements.

RESULTS

Among breakfast eaters (n = 1,133; 82.6%), 46.0% ate at home, 13.1% ate at school, 41.0% ate at multiple locations; and 21.8% ate at a corner store. Those eating at school were more likely to consume ≥1 fruit or vegetable (odds ratio [OR] = 1.90; 95% confidence interval [CI], 1.26-2.87), less likely to eat ≥1 SFAS food (OR = 0.46; 95% CI, 0.22-0.94), and more likely to meet SBP requirements (OR = 2.47; 95% CI, 1.42-4.29). Those eating at corner stores (n = 247) were more likely to consume high-SFAS foods (63.9% vs 9.2%; P < .001).

CONCLUSIONS AND IMPLICATIONS

Eating school breakfast increased the odds of consuming fruit, choosing lower SFAS, and meeting nutritional requirements of the SBP relative to other locations.

How to bridge the intention-behavior gap in food parenting: Automatic constructs and underlying techniques

Although parents often report positive intentions to promote and create a healthy food environment for their children (e.g., setting limits to snacks offered), they also experience difficulties in translating these intentions into actual behaviors. In this position paper, we argue that automatic processes explain an important part of the gap between parents' intentions and their actual food parenting behaviors. We provide a conceptual framework in which we hypothesize that automatic effects on food parenting occur through two key interrelated constructs: habits (key outcome construct) and volitional regulation behaviors (key mediating construct). Moreover, we discuss potentially important impulse-focused techniques that may directly change habits (e.g., nudging; inhibitory control training) or indirectly through volitional regulation behaviors (e.g., implementation intentions; mental contrasting). We make use of the literature on the role of intention-behavior discordance in general health behaviors and discuss implications for food parenting practices. Our framework provides a dual process view towards food parenting and may help to explain when and why parents are likely to engage in (un)healthy food parenting behaviors. In addition, this framework may hopefully stimulate research on (combinations of old and) new techniques to promote good food parenting behaviors.

Food portion size and energy density evoke different patterns of brain activation in children

BACKGROUND

Large portions of food promote intake, but the mechanisms that drive this effect are unclear. Previous neuroimaging studies have identified the brain-reward and decision-making systems that are involved in the response to the energy density (ED) (kilocalories per gram) of foods, but few studies have examined the brain response to the food portion size (PS).

OBJECTIVE

We used functional MRI (fMRI) to determine the brain response to food images that differed in PSs (large and small) and ED (high and low).

DESIGN

Block-design fMRI was used to assess the blood oxygen level-dependent (BOLD) response to images in 36 children (7-10 y old; girls: 50%), which was tested after a 2-h fast. Pre-fMRI fullness and liking were rated on visual analog scales. A whole-brain cluster-corrected analysis was used to compare BOLD activation for main effects of the PS, ED, and their interaction. Secondary analyses were used to associate BOLD contrast values with appetitive traits and laboratory intake from meals for which the portions of all foods were increased.

RESULTS

Compared with small-PS cues, large-PS cues were associated with decreased activation in the inferior frontal gyrus (P < 0.01). Compared with low-ED cues, high-ED cues were associated with increased activation in multiple regions (e.g., in the caudate, cingulate, and precentral gyrus) and decreased activation in the insula and superior temporal gyrus (P < 0.01 for all). A PS × ED interaction was shown in the superior temporal gyrus (P < 0.01). BOLD contrast values for high-ED cues compared with low-ED cues in the insula, declive, and precentral gyrus were negatively related to appetitive traits (P < 0.05). There were no associations between the brain response to the PS and either appetitive traits or intake.

CONCLUSIONS

Cues regarding food PS may be processed in the lateral prefrontal cortex, which is a region that is implicated in cognitive control, whereas ED activates multiple areas involved in sensory and reward processing. Possible implications include the development of interventions that target decision-making and reward systems differently to moderate overeating.

Alternatives to restrictive feeding practices to promote self-regulation in childhood: a developmental perspective

Intake of energy-dense snack foods is high among US children. Although the use of restrictive feeding practices has been shown to be counterproductive, there is very limited evidence for effective alternatives to restriction that help children moderate their intake of these foods and that facilitate the development of self-regulation in childhood. The developmental literature on parenting and child outcomes may provide insights into alternatives to restrictive feeding practices. This review paper uses a model of parental control from the child development and parenting literatures to (i) operationally define restrictive feeding practices; (ii) summarize current evidence for antecedents and effects of parental restriction use on children's eating behaviours and weight status, and (iii) highlight alternative feeding practices that may facilitate the development of children's self-regulation and moderate children's intake of palatable snack foods. We also discuss recent empirical evidence highlighting the role of child temperament and food motivation related behaviours as factors that prompt parents to use restrictive feeding practices and, yet, may increase children's dysregulated intake of forbidden foods.

Breakfast-Skipping and Selecting Low-Nutritional-Quality Foods for Breakfast Are Common among Low-Income Urban Children, Regardless of Food Security Status

BACKGROUND

Universal access to the School Breakfast Program (SBP) is intended to help low-income and food-insecure students overcome barriers to eating breakfast. However, SBP participation is often still low despite universal access. Further information is needed with regard to these children's breakfast behaviors, and in particular breakfast behaviors among youth from food-insecure families, to inform effective breakfast interventions.

OBJECTIVES

The objective of this study was to examine breakfast behaviors among a large sample of urban students with universal access to the SBP and to identify differences in breakfast behaviors among children from food-secure compared with food-insecure households.

METHODS

A cross-sectional study of 821 fourth- through sixth-grade students and their parents from 16 schools was conducted. Students reported the foods/drinks selected and location of obtaining food/drink on the morning of data collection, parents reported household food security status using the 6-item Food Security Survey Module, and the school district provided SBP participation data during the fall semester of 2013. Multivariable linear regression models accounting for school-level clustering were used to examine differences in breakfast behaviors across 3 levels of household food security: food secure, low food secure, and very low food secure.

RESULTS

Students participated in the SBP 31.2% of possible days, with 13% never participating in the SBP. One-fifth (19.4%) of students purchased something from a corner store for breakfast, and 16.9% skipped breakfast. Forty-six percent of students were food insecure; few differences in breakfast behaviors were observed across levels of food security.

CONCLUSIONS

Despite universal access to the SBP, participation in the SBP is low. Breakfast skipping and selection of foods of low nutritional quality in the morning are common, regardless of household food security status. Additional novel implementation of the SBP and addressing students' breakfast preferences may be necessary to further reduce barriers to students obtaining a free, healthful breakfast. This trial was registered at clinicaltrials.gov as NCT01924130.

Fundamental constructs in food parenting practices: a content map to guide future research

Although research shows that "food parenting practices" can impact children's diet and eating habits, current understanding of the impact of specific practices has been limited by inconsistencies in terminology and definitions. This article represents a critical appraisal of food parenting practices, including clear terminology and definitions, by a working group of content experts. The result of this effort was the development of a content map for future research that presents 3 overarching, higher-order food parenting constructs--coercive control, structure, and autonomy support--as well as specific practice subconstructs. Coercive control includes restriction, pressure to eat, threats and bribes, and using food to control negative emotions. Structure includes rules and limits, limited/guided choices, monitoring, meal- and snacktime routines, modeling, food availability and accessibility, food preparation, and unstructured practices. Autonomy support includes nutrition education, child involvement, encouragement, praise, reasoning, and negotiation. Literature on each construct is reviewed, and directions for future research are offered. Clear terminology and definitions should facilitate cross-study comparisons and minimize conflicting findings resulting from previous discrepancies in construct operationalization.

Next Steps for Science and Policy on Promoting Vegetable Consumption among US Infants and Young Children

Vegetables are an important part of a healthy diet for infants and young children, but they are poorly accepted and underconsumed. This paper highlights major themes and research needs for understanding how to raise children to consume and enjoy vegetables as part of a healthful diet. A range of factors impedes US infants and young children from eating as many vegetables as experts consider optimal for child nutrition, health, and development. Barriers include biological and behavioral issues relating to infant and child development, household- and family-related barriers, obstacles in the larger community, economic limitations, and some government policies and programs. These barriers must be removed to encourage children to eat more vegetables. Research gaps also must be filled. We summarize the basic and applied research that is needed to craft more effective messages, devise strategies for parents and other child caretakers to take within households, develop action in the larger community, and modify some government policies and programs.

Genetic and epigenetic associations to obesity-related appetite phenotypes among African-American children

BACKGROUND

Genetic and epigenetic variations may be an important contributer to altered eating behaviors in childhood which may lead to weight gain and obesity later in life.

OBJECTIVE

This study aimed to evaluate epigenetic as well as genetic associations with appetite in young children.

SUBJECTS AND METHODS

Participants were 32 non-obese and 32 obese African-American children aged 5-6 years. Saliva was collected from each child, and RNA and DNA were extracted for analysis. Individuals were genotyped for eating- and obesity-associated single nucleotide polymorphisms in seven candidate genes (FTO, MAOA, SH2B1, LEPR, DNMT3B, BDNF and CCKAR), and DNA methylation levels were measured in the upstream promoter region of each. Transcript levels of MAOA and FTO were also assessed. The Children's Eating Behavior Questionnaire (CEBQ) was used to assess the aspects of appetite. Child obesity was assessed using measured height and weight, and percent body fat was measured by dual-energy X-ray absorptiometry.

RESULTS

Food responsiveness was higher and satiety responsiveness was lower among obese than non-obese female children (P = 0.001 and P = 0.031), but did not differ among male children. Epigenetic analysis of the BDNF promoter revealed associations with altered satiety responsiveness among female children (P < 0.01).

CONCLUSION

The findings provide new evidence of epigenetic associations with altered appetite among young African-American girls.

Parenting around child snacking: development of a theoretically-guided, empirically informed conceptual model

BACKGROUND

Snacking contributes to excessive energy intakes in children. Yet factors shaping child snacking are virtually unstudied. This study examines food parenting practices specific to child snacking among low-income caregivers.

METHODS

Semi-structured interviews were conducted in English or Spanish with 60 low-income caregivers of preschool-aged children (18 non-Hispanic white, 22 African American/Black, 20 Hispanic; 92% mothers). A structured interview guide was used to solicit caregivers' definitions of snacking and strategies they use to decide what, when and how much snack their child eats. Interviews were audio-recorded, transcribed verbatim and analyzed using an iterative theory-based and grounded approach. A conceptual model of food parenting specific to child snacking was developed to summarize the findings and inform future research.

RESULTS

Caregivers' descriptions of food parenting practices specific to child snacking were consistent with previous models of food parenting developed based on expert opinion [1, 2]. A few noteworthy differences however emerged. More than half of participants mentioned permissive feeding approaches (e.g., my child is the boss when it comes to snacks). As a result, permissive feeding was included as a higher order feeding dimension in the resulting model. In addition, a number of novel feeding approaches specific to child snacking emerged including child-centered provision of snacks (i.e., responding to a child's hunger cues when making decisions about snacks), parent unilateral decision making (i.e., making decisions about a child's snacks without any input from the child), and excessive monitoring of snacks (i.e., monitoring all snacks provided to and consumed by the child). The resulting conceptual model includes four higher order feeding dimensions including autonomy support, coercive control, structure and permissiveness and 20 sub-dimensions.

CONCLUSIONS

This study formulates a language around food parenting practices specific to child snacking, identifies dominant constructs, and proposes a conceptual framework to guide future research.

Individual differences in susceptibility to large portion sizes among obese and normal-weight children

OBJECTIVE

Determine the association of children's susceptibility to large food portion sizes with appetite regulation and obesity.

METHODS

Normal-weight and obese non-Hispanic black children (n = 100) aged 5-6 years were observed in four dinner conditions of varying portion size; portions of all foods (except milk) offered were: 100% (677 kcal), 150% (1015 kcal), 200% (1353 kcal), or 250% (1691 kcal) of those in the reference condition (100%). Condition order was randomly assigned to 2-4 children who ate together at each meal. Child height and weight were measured and caregiver reports of child appetite were obtained. Hierarchical growth curve models were used to estimate associations of meal energy intake with portion size condition, child weight status, and appetite regulation traits, controlling for demographics.

RESULTS

Total energy intake increased across conditions of increasing food portion size (P < 0.001). The effect of portion size condition on total energy intake varied with food responsiveness (P = 0.05) and satiety responsiveness (P < 0.05), but not weight status (P = 0.682). Children with lower satiety responsiveness and greater food responsiveness showed greater increases in meal energy across conditions.

CONCLUSIONS

Children with poorer appetite regulation may be more vulnerable to obesogenic dietary environments offering large food portions than other children.

Eating- and weight-related parenting of adolescents in the context of food insecurity

BACKGROUND

Food insecurity is hypothesized to influence mothers' use of parenting strategies to regulate children's eating. Little is known about the parenting practices directed toward adolescents in food-insecure households.

OBJECTIVE

Our aim was to examine the differences in use of eating- and weight-related parenting practices among mothers of adolescents by household food-security status.

DESIGN

This was a cross-sectional study.

PARTICIPANTS/SETTING

A sociodemographically diverse sample of mothers and adolescents from the Minneapolis/St Paul, MN, metropolitan area who participated in the Eating and Activity Among Teens 2010 and Project Families and Eating and Activity Among Teens studies in 2009 to 2010 (dyad n=2,087). Seventy percent of mothers identified as nonwhite.

MAIN OUTCOME MEASURES

We examined mother-reported use of parenting practices, including pressuring children to eat, restricting high-calorie foods, and encouraging dieting.

STATISTICAL ANALYSES PERFORMED

Logistic regression models were used to determine the predicted probabilities of parenting practices among food-secure, low food-secure, and very-low food-secure households. Sociodemographic characteristics, mothers' body mass index, and adolescents' body mass index-for-age percentile were examined as confounders.

RESULTS

In unadjusted models, food-insecure mothers were more likely than food-secure mothers to frequently encourage their children to diet, comment on their child's weight, be concerned about their child's weight, use restrictive feeding practices, and use pressured feeding practices. After adjustment for sociodemographic characteristics and mothers' and children's body mass index, compared to food-secure mothers, mothers with low food security were more likely to frequently comment on their sons' weight (41.5% vs 32.9%, prevalence difference=8.6; 95% CI 0.9 to 16.3) and mothers with very low food security were more likely to be concerned about their sons' weight (48.8% vs 35.1%; prevalence difference=13.7; 95% CI 3.5 to 23.9). Mothers with very low food security were more likely to frequently use restrictive feeding practices with their daughters compared to food-secure mothers (33.0% vs 20.5%; prevalence difference=12.4; 95% CI 4.2 to 20.7).

CONCLUSIONS

Interventions to improve food-insecure adolescents' eating behaviors may benefit from supporting mothers' use of health-promoting parenting practices.

Higher weight, lower education: a longitudinal association between adolescents' body mass index and their subsequent educational achievement level?

BACKGROUND

The purpose of this study was to examine the association between adolescents' body mass index (BMI) z-scores and their subsequent level of schooling, extending previous longitudinal research by using objectively measured weight and height data.

METHODS

A longitudinal study with 3 study waves (1-year intervals) involving 1248 Dutch adolescents (49% girls; mean age = 13.7 years) at schools providing different educational levels was used to determine adolescents who moved and did not move to a lower educational level in the first year, or in the second year, and to examine whether this movement could be predicted by BMI z-scores (zBMI), after controlling for a large range of potential confounding factors.

RESULTS

A total of 1164 Dutch adolescents continued in the same level of education, whereas 84 adolescents moved to a lower educational level (43 moved in the first and 41 in the second year). A higher zBMI significantly increased the risk of a general transition to a lower educational level, and of a transition in the first year, but not in the second year, after controlling for potential demographic, behavioral, and psychological confounds.

CONCLUSIONS

Findings suggest that a higher zBMI during adolescence immediately lowers educational achievement level during general secondary education.

Forefronts in portion size. An overview and synthesis of a roundtable discussion

Establishing eating habits in early life that include appropriate portion sizes of foods which are nutrient dense and low in energy density is considered important in the prevention of obesity in children. This special supplement presents the proceedings of a symposium focusing on advances in scientific understanding of the development of healthy food portion sizes in children and their families. Recent basic research highlights individual differences in children's responsiveness to portion size as well as potential mechanisms of portion size effects. Quantitative approaches highlight the influence of maternal serving in determining intake, while qualitative approaches seek to elaborate caregiver decisions around child portion sizes at meals and snacks. Family-based environmental interventions for child weight control involving food portion size are outlined. An overview of the overarching issues and roundtable discussion on the forefronts of portion size research are presented as well as policy considerations to promote healthy portion control.

"Snacks are not food". Low-income, urban mothers' perceptions of feeding snacks to their preschool-aged children

Snacking has become more frequent among US preschool-aged children in recent decades and represents a significant proportion of daily energy intake. Social influences on snacking among children, however, are not well understood. This qualitative research described low-income, urban mothers' perceptions of feeding snacks to their preschool-aged children using data from 7 focus groups with 32 participants. Focus group transcripts were analyzed using a constant comparative method to identify themes. Mothers described snacks as involving less preparation, balance, and sustenance than meals (Theme 1). Mothers also made reference to some snacks as not being "real food" (Theme 2). At the same time, snacks had significant hedonic value as reflected in mothers' enjoyment of those foods (Theme 3), the effectiveness of snacks to manage children's behavior (Theme 4), and the variety of restrictions that mothers placed on children's access to snacks, such as locking cabinets, offering small servings, and reducing the number of snacks in sight (Theme 5). Two overarching themes highlighted distinctions mothers made in feeding children snacks vs. meals as well as the powerful hedonic appeal of snacks for both mother and child. These observations suggest that low-income, urban mothers of preschool-aged children may perceive snacks as serving a more important role in managing children's behavior than in providing nutrition. Child feeding interventions should address non-food related ways of managing children's behavior as well as encouraging caregivers to see snacks as structured opportunities for nutrition and connecting with their children.

Breakfast patterns among low-income, ethnically-diverse 4th-6th grade children in an urban area

BACKGROUND

Increasing school breakfast participation has been advocated as a method to prevent childhood obesity. However, little is known about children's breakfast patterns outside of school (e.g., home, corner store). Policies that increase school breakfast participation without an understanding of children's breakfast habits outside of school may result in children consuming multiple breakfasts and may undermine efforts to prevent obesity. The aim of the current study was to describe morning food and drink consumption patterns among low-income, urban children and their associations with relative weight.

METHODS

A cross-sectional analysis was conducted of data obtained from 651 4th-6th graders (51.7% female, 61.2% African American, 10.7 years) in 2012. Students completed surveys at school that included all foods eaten and their locations that morning. Height and weight were measured by trained research staff.

RESULTS

On the day surveyed, 12.4% of youth reported not eating breakfast, 49.8% reported eating one breakfast, 25.5% reported eating two breakfasts, and 12.3% reported eating three or more breakfasts. The number of breakfasts consumed and BMI percentile showed a significant curvilinear relationship, with higher mean BMI percentiles observed among children who did not consume any breakfast and those who consumed ≥ 3 breakfasts. Sixth graders were significantly less likely to have consumed breakfast compared to younger children. A greater proportion of obese youth had no breakfast (18.0%) compared to healthy weight (10.1%) and overweight youth (10.7%, p = .01).

CONCLUSIONS

When promoting school breakfast, policies will need to be mindful of both over- and under-consumption to effectively address childhood obesity and food insecurity.

CLINICAL TRIAL REGISTRATION

NCT01924130 from http://clinicaltrials.gov/.

Depressive symptoms in adolescence: a poor indicator of increases in body mass index

PURPOSE

The purpose of this study was to examine the association between depressive symptoms and subsequent body mass index (BMI) z scores among early-to-mid adolescents, extending previous research by using objectively measured weight and height data.

METHODS

Latent growth curve analysis was used to examine whether growth parameters of zBMI could be predicted by depressive symptoms (n = 2,051 adolescents, 48.5% female, at baseline; 1,465 with data at all three time points). Specifically, we tested whether depressive symptoms were associated with the initial assessment of BMI (intercept) as well as with changes in BMI over time (slope). Analyses were performed for the total group, and separately for boys and girls.

RESULTS

Depressive symptoms were not associated with the slope of zBMI. In girls, but not boys, depressive symptoms were positively associated with the intercept of zBMI.

CONCLUSIONS

Findings suggest that although depressive symptoms among females are associated with a higher zBMI, they do not predict excessive weight gain during early-to-mid adolescence.

Development of the responsiveness to child feeding cues scale

Parent-child feeding interactions during the first 2 years of life are thought to shape child appetite and obesity risk, but remain poorly studied. This research was designed to develop and assess the Responsiveness to Child Feeding Cues Scale (RCFCS), an observational measure of caregiver responsiveness to child feeding cues relevant to obesity. General responsiveness during feeding as well as maternal responsiveness to child hunger and fullness were rated during mid-morning feeding occasions by three trained coders using digital-recordings. Initial inter-rater reliability and criterion validity were evaluated in a sample of 144 ethnically-diverse mothers of healthy 7- to 24-month-old children. Maternal self-report of demographics and measurements of maternal/child anthropometrics were obtained. Inter-rater agreement for most variables was excellent (ICC>0.80). Mothers tended to be more responsive to child hunger than fullness cues (p<0.001). Feeding responsiveness dimensions were associated with demographics, including maternal education, maternal body mass index, child age, and aspects of child feeding, including breastfeeding duration, and self-feeding. The RCFCS is a reliable observational measure of responsive feeding for children <2 years of age that is relevant to obesity.

Plate size and children's appetite: effects of larger dishware on self-served portions and intake

OBJECTIVES

Dishware size is thought to influence eating behaviors, but effects on children's self-served portion sizes and intakes have not been studied. We aimed to evaluate whether larger dishware increased children's self-served portion sizes and intake during meals.

METHODS

A within-subjects experimental design was used to test the effects of dishware size (ie, plates and bowls) on children's self-served portion sizes and intakes in a naturalistic setting. Subjects were predominantly African American elementary school-aged children (n = 42) observed on repeated occasions during school lunch. Children served themselves an entree and side dishes using either child- or adult-size dishware, which represented a 100% increase in the surface area of plates and volume of bowls across conditions. Condition order was randomly assigned and counterbalanced across 2 first-grade classrooms. Entrées of amorphous and unit form were evaluated on separate days. Fruit and vegetable side dishes were evaluated at each meal. Fixed portions of milk and bread were provided at each meal.

RESULTS

Children served more energy (mean = 90.1 kcal, SE = 29.4 kcal) when using adult-size dishware. Adult-size dishware promoted energy intake indirectly, where every additional calorie served resulted in a 0.43-kcal increase in total energy intakes at lunch (t = 7.72, P = .001).

CONCLUSIONS

Children served themselves more with larger plates and bowls and consumed nearly 50% of the calories that they served. This provides new evidence that children's self-served portion sizes are influenced by size-related facets of their eating environments, which, in turn, may influence children's energy intake.

External influences on children's self-served portions at meals

OBJECTIVE

Large portions promote intake among children, but little is known about the external influences of the eating environment on children's self-selected portion sizes. This research experimentally tested effects of the amount of entree available and serving spoon size on children's self-served entree portions and intakes at dinner meals. A secondary objective was to identify child and family predictors of self-served entree portion sizes.

DESIGN

A 2 × 2 within-subjects design was used, in which the amount of a pasta entree available for self-serving (275 vs 550 g) and the serving spoon size (teaspoon vs tablespoon) were systematically varied. The serving bowl size and portion sizes of all other foods offered were held constant across conditions. Conditions were spaced 1 week apart and randomly assigned. Weighed self-served entree portions and food intakes as well as demographics, maternal feeding styles and child/maternal anthropometrics were measured.

SUBJECTS

Participants were 60 ethnically diverse children aged 4-6 years and their mothers.

RESULTS

Mixed models revealed that children served themselves 40% more entree when the amount available was doubled (P<0.0001) and 13% more when the serving spoon size was tripled (P<0.05). Serving spoon size and the amount of entree available indirectly influenced children's intake, with larger self-served portion sizes related to greater entree intakes (P<0.0001). Greater self-served portions and energy intakes at the meal were seen among those children whose mothers reported indulgent or authoritarian feeding styles (P<0.001).

CONCLUSION

Children's self-served portion sizes at meals are influenced by size-related facets of the eating environment and reflect maternal feeding styles.

A qualitative study of the aspirations and challenges of low-income mothers in feeding their preschool-aged children

BACKGROUND

The prevalence of obesity among preschool-aged children has increased, especially among those in low-income households. Two promising behavioral targets for preventing obesity include limiting children's portion sizes and their intake of foods high in solid fats and/or added sugars, but these approaches have not been studied in low-income preschoolers in the home setting. The purpose of this study was to understand the contextual factors that might influence how low-income mothers felt about addressing these behavioral targets and mothers' aspirations in feeding their children.

METHODS

We recruited 32 English-speaking women in Philadelphia, Pennsylvania who were eligible for the Supplemental Nutrition Assistance Program and who were the biologic mothers of children 36 to 66 months of age. Each mother participated in 1 of 7 focus groups and completed a brief socio-demographic questionnaire. Focus group questions centered on eating occasions, foods and drinks consumed in the home, and portion sizes. Each focus group lasted 90 minutes and was digitally recorded and transcribed verbatim. Three authors independently identified key themes and supporting quotations. Themes were condensed and modified through discussion among all authors.

RESULTS

Thirty-one mothers identified themselves as black, 15 had a high school education or less, and 22 lived with another adult. Six themes emerged, with three about aspirations mothers held in feeding their children and three about challenges to achieving these aspirations. Mothers' aspirations were to: 1) prevent hyperactivity and tooth decay by limiting children's sugar intake, 2) use feeding to teach their children life lessons about limit setting and structure, and 3) be responsive to children during mealtimes to guide decisions about portions. Especially around setting limits with sweets and snacks, mothers faced the challenges of: 1) being nagged by children's food requests, 2) being undermined by other adults in the family, and 3) having bad memories from childhood that made it hard to deny children's food requests.

CONCLUSIONS

Although the primary aspirations of low-income mothers in feeding their preschool-aged children were not focused on children's weight, these aspirations were compatible with obesity prevention strategies to limit children's portion sizes and their intake of solid fats and/or added sugars.