Tanja V.E. Kral

Evaluating Parents and Adult Caregivers as ‘Agents of Change’ for Treating Obese Children – Evidence for Parent Behavior Change Strategies and Research Gaps: A Scientific Statement from the American Heart Association

This scientific statement addresses parents and adult caregivers (PACs) as “agents of change” for obese children, evaluating the strength of evidence that particular parenting strategies can leverage behavior change and reduce positive energy balance in obese youth. The statement has 3 specific aims. The first is to review core behavior change strategies for PACs as used in family-based treatment programs and to provide a resource list. The second is to evaluate the strength of evidence that greater parental “involvement” in treatment is associated with better reductions in child overweight. The third is to identify research gaps and new opportunities for the field. This review yielded limited and inconsistent evidence from randomized controlled clinical trials that greater PAC involvement necessarily is associated with better child outcomes. For example, only 17% of the intervention studies reported differential improvements in child overweight as a function of parental involvement in treatment. On the other hand, greater parental adherence with core behavior change strategies predicted better child weight outcomes after 2 and 5 years in some studies. Thus, the literature lacks conclusive evidence that one particular parenting strategy or approach causally is superior to others in which children have a greater focus in treatment. A number of research gaps were identified, including the assessment of refined parenting phenotypes, cultural tailoring of interventions, examination of family relationships, and incorporation of new technologies. A conceptual model is proposed to stimulate research identifying the determinants of PAC feeding and physical activity parenting practices, the results of which may inform new treatments. The statement addresses the need for innovative research to advance the scope and potency of PAC treatments for childhood obesity.

Super-size me: Portion size effects on young children's eating.

Large portions of energy-dense foods are believed to favor obesity-promoting eating behaviors in young children. The following review presents evidence on food portion size effects on childrens eating behavior and eating regulation, with comparison of findings to adult studies of portion size. Individual differences in childrens susceptibility to portion size, particularly associations with weight status, are addressed. Finally, potential mechanisms of effects and strategies to offset the intake promoting effects of portion size are considered.

Eating behaviors of children in the context of their family environment

Both a family history of obesity and early childhood obesity have been identified as strong predictors of adult obesity risk. The finding that parental obesity, maternal obesity in particular, increases a childs risk for developing obesity suggests that either shared genes, or environment, or likely a combination of both may promote overeating and excessive weight gain in children. Parents not only create food environments for childrens early experiences with food and eating, but they also influence their childrens eating by modeling their own eating behaviors, taste preferences, and food choices. Thus, it is important to identify intermediary behavioral eating traits which promote overeating and obesity in children and to determine the extent to which associations between eating traits and excessive weight gain in children may be influenced by genetic factors, environmental factors, or both. Behavioral genetic methods can be used to help partition genetic and environmental sources of variability in behavioral traits. The focus of this paper is to review and discuss findings from both short-term experimental and prospective cohort studies on eating behaviors of children at various stages in their lives. Select child eating traits and parent-child resemblances in eating will be further examined in the context of childrens home environment and their familial predisposition to obesity. The paper represents an invited review by a symposium, award winner or keynote speaker at the Society for the Study of Ingestive Behavior [SSIB] Annual Meeting in Portland, July 2009.

Stress-induced eating in restrained eaters may not be caused by stress or restraint

Restrained eaters tend to increase and unrestrained eaters to decrease their food intake when stressed. This relationship, though robust, does not appear to be caused by restrained eating or by stress per se. For restraint, evidence indicates that none of the common operationalizations of restraint can account for restraint-related effects that have been examined to date. It is therefore unlikely that restraint is responsible for stress-induced eating in restrained eaters. Rather, behavioral and physiological data suggest that restrained eating may be a proxy risk factor for vulnerability to weight gain. For stress, a variety of minimally stressful perturbations (e.g. non-threatening cognitive loads) have been shown to elicit increased intake in restrained eaters. Thus, the negative affect created by manipulations used to create stress (e.g. scary movies, failure at a task) does not appear to be necessary to provoke overeating. An adequate explanation for stress-induced eating in restrained eaters remains elusive.

Effects of Doubling the Portion Size of Fruit and Vegetable Side Dishes on Children's Intake at a Meal

Increasing the portion size of energy‐dense entrées has been shown to increase childrens energy intake during a meal. It remains to be investigated whether serving larger portions to children can be used to promote intake of more healthful foods, such as fruits and vegetables (F&V). The aim of the present study was to examine the effects of increasing the portion size of F&V side dishes on childrens intake. Forty‐three children (22 boys, 21 girls), aged 5–6 years, were served dinner once a week for 2 weeks. Each dinner consisted of pasta with tomato sauce, three F&V side dishes (broccoli, carrots, and applesauce), and milk. The portion size of the F&V was doubled between experimental conditions whereas the size of the pasta remained constant. Doubling the portion size of the side dishes resulted in a 43% increase in childrens intake of the fruit side dish (P = 0.001), but did not affect childrens intake of the two vegetable side dishes (P > 0.60). Further, when the portion size of F&V side dishes was doubled, children ate significantly less of the pasta (P = 0.04). The difference in meal energy intake between portion size conditions (19.5 ± 16.3 kcal) was not significant (P = 0.24). Although more studies are needed to understand whether increases in portion size can influence vegetable intake, children did eat more in response to a large quantity of a preferred low energy‐dense fruit side dish at meals. Thus variations in portion size can be used strategically to help children achieve the recommended intake of fruits.

Beverage Consumption Patterns of Children Born at Different Risk of Obesity

Background: Increased intake of sugar‐sweetened beverages and fruit juice has been associated with overweight in children.

Eating Behaviors, Diet Quality, and Gastrointestinal Symptoms in Children With Autism Spectrum Disorders: A Brief Review

Children with autism spectrum disorders (ASD) and their caregivers face unique challenges in the childrens daily eating routines and food intake patterns. The aim of this brief review is to describe eating behaviors of children with ASD, including increased food neophobia and food selectivity, and review findings on childrens diet quality, and gastrointestinal (GI) symptoms. Advancing knowledge about the interrelationships between these nutrition-related domains in children with ASD is expected to have important implications for clinical nursing practice and caregiver care.

Identification of an Obese Eating Style in 4‐year‐old Children Born at High and Low Risk for Obesity

This study tested whether childrens eating behavior and parental feeding prompts during a laboratory test meal differ among children born at high risk (HR) or low risk (LR) for obesity and are associated with excess child weight gain. At 4 years of age, 32 HR children (mean maternal prepregnancy BMI = 30.4 kg/m2) and 29 LR children (maternal BMI = 19.6 kg/m2) consumed a test meal in which their eating behavior was assessed, including rate of caloric consumption, mouthfuls/min, and requests for food. Parental prompts for the child to eat also were measured at year 4, and child body composition was measured at ages 4 and 6 years. T‐tests, and logistic and multiple regression analyses tested study aims. Results indicated that HR and LR children did not differ in eating rate or parental feeding prompts. Greater maternal BMI, child mouthfuls of food/min, and total caloric intake/min during the test meal predicted an increased risk of being overweight or obese at age 6, whereas greater active mealtime was associated with a reduced risk of being overweight or obese. Regression analyses indicated that only mouthfuls of food/min predicted changes in BMI from 4 to 6 years, and mouthfuls of food/min and gender predicted 2‐year changes in sum of skinfolds and total body fat. Thus, a rapid eating style, characterized by increased mouthfuls of food/min, may be a behavioral marker for the development of childhood obesity.

Caloric compensation and eating in the absence of hunger in 5- to 12-y-old weight-discordant siblings.

BACKGROUND An impaired ability to compensate for calories and increased eating in the absence of hunger (EAH) has been associated with increased energy intake and weight gain in unrelated children. OBJECTIVE The aims of this study were to compare caloric compensation [the percentage compensation index (%COMPX)] and EAH in weight-discordant siblings aged 5-12 y. DESIGN In a crossover, behavioral genetics design, 47 same-sex sibling pairs (53% female, 55% full siblings) were served dinner once a week for 3 wk. Across conditions, siblings were served the same dinner, but 25 min before dinner, they either consumed in full or did not consume 1 of 2 preloads that varied in energy density (ED; 0.57 or 0.97 kcal/g). On the day when no preload was consumed, EAH was assessed after dinner and defined as the number of calories consumed from snacks. RESULTS Overweight/obese siblings undercompensated [%COMPX: -48.8 ± 56.3 (mean ± SEM)] and therefore overate after the high-ED preload, whereas normal-weight siblings showed accurate compensation (%COMPX: 101.3 ± 51.9; P = 0.03). Furthermore, overweight/obese siblings consumed 34% more calories (93 kcal) in the absence of hunger than did normal-weight siblings (P = 0.01). Within-pair resemblances for %COMPX and EAH were stronger for full siblings (P < 0.049) than for half siblings (P > 0.23). CONCLUSIONS An impaired ability to regulate short-term energy intake, which includes incomplete adjustment for calorie differences in a preload and eating when satiated, may represent a behavioral phenotype for obesity in children. Future studies should test whether teaching children to focus on internal satiety cues may prevent at-risk children from overeating.

Effects of eating breakfast compared with skipping breakfast on ratings of appetite and intake at subsequent meals in 8- to 10-y-old children

BACKGROUND Cross-sectional data indicate an inverse relation between breakfast consumption and child weight. It has been suggested that skipping breakfast may adversely affect appetite in children, which could lead to overeating later in the day. OBJECTIVE The aim of this study was to test the effects of consuming breakfast compared with omitting breakfast on appetite ratings and energy intake at subsequent meals in 8- to 10-y-old children. DESIGN Twenty-one children participated in 2 test visits during which they were served either a compulsory breakfast or no breakfast. On both visits, subjects were also served lunch, which was consumed ad libitum. Subjects rated their appetite throughout the morning; parents completed food records that captured childrens intake for the remainder of the day. RESULTS There was no significant main effect of breakfast condition on energy intake at lunch (P = 0.36) or throughout the remainder of the day (P = 0.85). There was a significant main effect of breakfast condition (P = 0.04) on total daily energy intake, which indicated that on the day when the subjects did not eat breakfast, they consumed 362 fewer calories over the course of the day than when they did eat breakfast. On the day when no breakfast was served, subjects indicated that they were significantly hungrier, less full, and could consume more food before lunch than on the day when they did eat breakfast (P < 0.001). CONCLUSIONS Omitting breakfast affected childrens appetite ratings but not their energy intake at subsequent meals. The dissonance between childrens subjective ratings of prospective consumption and their actual intake should be further examined.