Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight

Although a large body of research has assessed direct genetic links between parent and child weight status, relatively little research has assessed the extent to which parents (particularly parents who are overweight) select environments that promote overweight among their children. Parents provide food environments for their children's early experiences with food and eating. These family eating environments include parents' own eating behaviors and child-feeding practices. Results of the limited research on behavioral mediators of familial patterns of overweight indicate that parents' own eating behaviors and their parenting practices influence the development of children's eating behaviors, mediating familial patterns of overweight. In particular, parents who are overweight, who have problems controlling their own food intake, or who are concerned about their children's risk for overweight may adopt controlling child-feeding practices in an attempt to prevent overweight in their children. Unfortunately, research reveals that these parental control attempts may interact with genetic predispositions to promote the development of problematic eating styles and childhood overweight. Although the authors have argued that behavioral mediators of family resemblances in weight status, such as parents' disinhibited or binge eating and parenting practices are shaped largely by environmental factors, individual differences in these behaviors also have genetic bases. A primary public health goal should be the development of family-based prevention programs for childhood overweight. The findings reviewed here suggest that effective prevention programs must focus on providing anticipatory guidance on parenting to foster patterns of preference and food selection in children more consistent with healthy diets and promote children's ability to self-regulate intake. Guidance for parents should include information on how children develop patterns of food intake in the family context. Practical advice for parents includes how to foster children's preferences for healthy foods and how to promote acceptance of new foods by children. Parents need to understand the costs of coercive feeding practices and be given alternatives to restricting food and pressuring children to eat. Providing parents with easy-to-use information regarding appropriate portion sizes for children is also essential as are suggestions on the timing and frequency of meals and snacks. Especially during early and middle childhood, family environments are the key contents for the development of food preferences, patterns of food intake, eating styles, and the development of activity preferences and patterns that shape children's developing weight status. Designing effective prevention programs will, however, require more complete knowledge than currently available regarding behavioral intermediaries that foster overweight, including the family factors that shape activity patterns, meals taken away from home, the impact of stress on family members' eating styles, food intake, activity patterns, and weight gain. The research presented here provides an example of how ideas regarding the effects of environmental factors and behavioral mediators on childhood overweight can be investigated. Such research requires the development of reliable and valid measures of environmental variables and behaviors. Because childhood overweight is a multifactorial problem, additional research is needed to develop and test theoretic models describing how a wide range of environmental factors and behavioral intermediaries can work in concert with genetic predispositions to promote the development of childhood overweight. The crucial test of these theoretic models will be in preventive interventions.     

Prevention of pediatric overweight and obesity

The dramatic increase in the prevalence of childhood overweight and its resultant comorbidities are associated with significant health and financial burdens, warranting strong and comprehensive prevention efforts. This statement proposes strategies for early identification of excessive weight gain by using body mass index, for dietary and physical activity interventions during health supervision encounters, and for advocacy and research.     

The role of parents in preventing childhood obesity

As researchers continue to analyze the role of parenting both in the development of childhood overweight and in obesity prevention, studies of child nutrition and growth are detailing the ways in which parents affect their children's development of food- and activity-related behaviors. Ana Lindsay, Katarina Sussner, Juhee Kim, and Steven Gortmaker argue that interventions aimed at preventing childhood overweight and obesity should involve parents as important forces for change in their children's behaviors. The authors begin by reviewing evidence on how parents can help their children develop and maintain healthful eating and physical activity habits, thereby ultimately helping prevent childhood overweight and obesity. They show how important it is for parents to understand how their roles in preventing obesity change as their children move through critical developmental periods, from before birth and through adolescence. They point out that researchers, policymakers, and practitioners should also make use of such information to develop more effective interventions and educational programs that address childhood obesity right where it starts-at home. The authors review research evaluating school-based obesity-prevention interventions that include components targeted at parents. Although much research has been done on how parents shape their children's eating and physical activity habits, surprisingly few high-quality data exist on the effectiveness of such programs. The authors call for more programs and cost-effectiveness studies aimed at improving parents' ability to shape healthful eating and physical activity behaviors in their children. The authors conclude that preventing and controlling childhood obesity will require multifaceted and community-wide programs and policies, with parents having a critical role to play. Successful intervention efforts, they argue, must involve and work directly with parents from the earliest stages of child development to support healthful practices both in and outside of the home.     

A review of risk factors for overweight in preschool children: a policy perspective.

An increasing number of preschool children are becoming overweight. Although many risk factors have been identified for school-age children, less is known about this young age group. Ecological models have been developed to illustrate how individual characteristics, family characteristics, community-level factors, and policies may influence weight gain. We used this model to review factors that influence overweight in children, aged six months to five years, which are amenable to policy intervention in resource-rich countries. We found strong evidence for a direct association between childhood overweight and maternal prepregnancy body size, maternal smoking during pregnancy, and children's television/media use; strong evidence for an inverse relationship between breastfeeding and overweight, and moderate evidence for children's physical activity. There was limited research on community-level factors, policies and interventions. Future policies and interventions should be subject to evaluation and aim to support parents and young children to develop health-related behaviours that may prevent early childhood overweight.     

YMCA program for childhood obesity: a case series

Family-based behavioral interventions for treatment of childhood obesity have rarely been tested for effectiveness in community settings. The aim of the study was to evaluate the effectiveness of a community-based program for obese children designed to stabilize or reduce body weight. Obese children from our pediatric practice who were active in the program were evaluated. Weight gain during the time of the study was compared with mean weight gain for a group of obese-matched controls who did not participate in the program. Mean weight gain for subjects was 0.28 kg/mo compared with a weight gain for controls of 0.62 kg/mo. Between the first and last visits, 43% (15/35) of the subjects experienced clinically significant differences in weight gain compared with controls. Eight patients lost weight. A YMCA weight management program, which included group counseling, nutrition education, physical activity, and gift card incentives, resulted in favorable changes in overweight children.     

A pediatric-focused review of the performance incentive literature

PURPOSE OF REVIEW: This article seeks to provide a pediatric-focused review of the performance incentive literature. The article will begin with an overview of the performance incentive literature within and outside of healthcare. The review will then detail the pediatric-specific literature, reflect on the breadth and focus of this literature compared with that for adult programs in medicine and school/teacher accountability efforts, and identify three concerning knowledge gaps. RECENT FINDINGS: The pediatric performance incentive literature is small, totaling five empirical studies. This literature indicates that performance incentives alone have not been effective at improving incentivized aspects of pediatric healthcare. Only one study evaluates whether pediatric performance incentives improve healthcare for children with significant health conditions. No studies investigate whether this strategy yields negative unintended consequences for children and adolescents or how risk adjustment can augment pediatric performance incentive efforts or attenuate unintended effects. SUMMARY: If approached to participate in or inform performance incentive efforts, pediatricians should appreciate the limitations of the existing empirical literature and ask proponents about their plans for monitoring and/or guarding against potentially negative unintended consequences. Numerous stakeholders are optimistic that this strategy will improve healthcare quality, but the empirical evidence suggests that skepticism is appropriate.     

The consequences of childhood overweight and obesity

Researchers are only gradually becoming aware of the gravity of the risk that overweight and obesity pose for children's health. In this article Stephen Daniels documents the heavy toll that the obesity epidemic is taking on the health of the nation's children. He discusses both the immediate risks associated with childhood obesity and the longer-term risk that obese children and adolescents will become obese adults and suffer other health problems as a result. Daniels notes that many obesity-related health conditions once thought applicable only to adults are now being seen in children and with increasing frequency. Examples include high blood pressure, early symptoms of hardening of the arteries, type 2 diabetes, nonalcoholic fatty liver disease, polycystic ovary disorder, and disordered breathing during sleep. He systematically surveys the body's systems, showing how obesity in adulthood can damage each and how childhood obesity exacerbates the damage. He explains that obesity can harm the cardiovascular system and that being overweight during childhood can accelerate the development of heart disease. The processes that lead to a heart attack or stroke start in childhood and often take decades to progress to the point of overt disease. Obesity in childhood, adolescence, and young adulthood may accelerate these processes. Daniels shows how much the same generalization applies to other obesity-related disorders-metabolic, digestive, respiratory, skeletal, and psychosocial-that are appearing in children either for the first time or with greater severity or prevalence. Daniels notes that the possibility has even been raised that the increasing prevalence and severity of childhood obesity may reverse the modern era's steady increase in life expectancy, with today's youth on average living less healthy and ultimately shorter lives than their parents-the first such reversal in lifespan in modern history. Such a possibility, he concludes, makes obesity in children an issue of utmost public health concern.     

Developing pre-school surveillance tools for adaptive functioning: Lessons for neuro-oncology

Advances in neuro-oncology have resulted in dramatic increases in the survival of children with pediatric brain tumors, including those with medulloblastoma, the most common early childhood central nervous system (CNS) malignancy. Because of this increased survival, there is heightened awareness and recognition that an understanding of the impact of treatments and interventions on children’s development, learning, and adaptive behaviors is essential for optimization of long-term outcomes. One of the major reasons for studying these outcomes is that the developing nervous system has its unique vulnerabilities with respect to the primary tumor, its complications (hydrocephalus, increased intracranial pressure, hazards of tumor resection), and the late effects of treatments on children’s developmental, learning, and adaptive status. In addition, very young children are especially vulnerable to the toxic effects of radiation and other therapies, highlighting the importance of measuring emerging communication, coordination, and social adaptive skills. Lastly, there is increased concern about the long-term consequences of chemotherapy on specific neural populations and neural connectivity that affect memory, learning, and executive function.The purpose of this article is to review ways of conceptualizing CNS adaptive functioning in children diagnosed with brain tumors in early childhood. The international classification of functioning (ICF) model will be used to describe the spectrum of health and developmental outcomes of child neurodisability. An integrated strategy of surveillance for motor, communicative, and adaptive skills that can be linked to neuropsychological assessments will also be highlighted. This health, development, and functional surveillance framework will help us better evaluate how our management impacts on child and family well-being and how our interventions lessen severe multiple motor, communicative, and neurobehavioral morbidities.     

Psychosocial aspects of childhood obesity

Rates of childhood obesity are increasing at alarming rates worldwide. This is especially alarming as obesity is associated with many physical and psychological consequences. A great number of studies indicate that obese children have an impaired psychological well-being (e.g., depression, self-esteem, and quality of life) compared to their non-overweight peers. There has been an overwhelming amount of research conducted in this area over the past few decades, and as such, this paper provides a summarized overview of the vast trove of available information on the psychosocial aspects of childhood obesity. In this paper we provide a summarized overview of: 1) psychosocial aspects that contribute to the onset of childhood obesity; 2) psychosocial consequences of childhood obesity; and 3) familial-based lifestyle behavior modification interventions for treating childhood obesity and its treatment success. Although it seems obvious that obese children and adolescents would likely be at higher risk for psychological problems, the mediating factors in the relationship between psychological problems and obesity are still not well established. Obesity is a complex disorder with an equally complex etiology, and is thus associated with complex behaviors and outcomes that make it difficult to study in children. It has been indicated that family-based lifestyle interventions can improve psychological well-being in obese children; however, not all children profit from these interventions. Interventions aimed at improving treatment results need further investigation. For example, interventions targeted specifically at groups that tend to be less successful in weight-loss programs and interventions providing long-term support to these individuals are recommended.     

Recommendations for prevention of childhood obesity

The majority of US youth are of healthy weight, but the majority of US adults are overweight or obese. Therefore, a major health challenge for most American children and adolescents is obesity prevention-today, and as they age into adulthood. In this report, we review the most recent evidence regarding many behavioral and practice interventions related to childhood obesity, and we present recommendations to health care providers. Because of the importance, we also suggest approaches that clinicians can use to encourage obesity prevention among children, including specific counseling strategies and practice-based, systems-level interventions. In addition, we suggest how clinicians may interact with and promote local and state policy initiatives designed to prevent obesity in their communities.     

A holiday wish list for Canada’s Early Years System

The evidence is clear that early childhood interventions and supports have long-term health and social benefits – coordinated action is required to ensure that every Canadian child benefits. While many advances have been made to improve the chances for Canadian children to have a healthy opportunity for early childhood development, there is much to be done to ensure that they have the best opportunities possible. To ensure every child is able to reach their full potential, the following wishes are identified for Canadian children: a fairer share of the GDP for Canadian children; the development of a strong early years system; designation of a national lead on behalf of children and youth; a focus on prevention; and development of systems to monitor success and failure.     

The cost of childhood unintentional injuries and the value of prevention

Cost data are useful in comparing various health problems, assessing risks, setting research priorities, and selecting interventions that most efficiently reduce health burdens. Using analyses of national and state data sets, this article presents data on the frequency, costs, and quality-of-life losses associated with unintentional childhood injuries in 1996. The frequency, severity, potential for death and disability, and costs of unintentional injury make it a leading childhood health problem. Unintentional childhood injuries in 1996 resulted in an estimated $14 billion in lifetime medical spending, $1 billion in other resource costs, and $66 billion in present and future work losses. These injuries imposed quality-of-life losses equivalent to 92,400 child deaths. Since Medicaid and other government sources paid for 39% of the days children spent in hospitals due to unintentional injuries, the government has a financial interest in, and arguably a responsibility for, assuring the safety of disadvantaged children. Federal agencies, however, devote relatively few public dollars to injury prevention research and programming. Several proven child safety interventions cost less than the medical and other resource costs they save. Thus, governments, managed care companies, and third-party payers could save money by encouraging the routine use of selected child safety measures such as child safety seats, bicycle helmets, and smoke detectors. Yet, these and other proven injury prevention interventions are not universally implemented.     

Childhood health: trends and consequences over the life course

This article first documents evidence on the changing prevalence of childhood physical and mental health problems, focusing on the development of childhood health conditions in the United States. Authors Liam Delaney and James Smith present evidence on the changing prevalence of childhood chronic conditions over time using recalled data as well as contemporaneous accounts of these childhood health problems. The raw data from both sources show sharp increases in the prevalence of most childhood physical health problems (such as asthma, allergies, respiratory problems, and migraines) over time. However, inferring trends is difficult because such data are also consistent with improved detection of childhood disease, and many of the causes of childhood disease have not worsened over time. Conclusions about rapidly rising rates of childhood physical health problems over time are premature at best, especially concerning the magnitude of trends. Documenting real changes in the prevalence of specific diseases is a high-priority research topic. In contrast, the evidence is much stronger that childhood mental health problems are becoming worse. The authors next present new evidence on the effects of early childhood physical and mental problems on health and economic status in adulthood. They find that both childhood physical and mental health problems contribute significantly to poorer adult health. However, they also find that childhood mental health problems have much larger impacts than do childhood physical health problems on four critical areas of socioeconomic status as an adult: education, weeks worked per year, individual earnings, and family income. Finally, the authors examine evidence regarding the efficacy of early mental health treatment for children in terms of promoting good health later on. Existing studies suggest that a combination of cognitive behavioral therapy and medication appears to be effective in the treatment of both anxiety and depression in children. However, much more research is needed on the efficacy of these childhood interventions into adulthood. Clinical trials have been too short to evaluate the long-term impacts of various forms of treatment, and these impacts are definitively long term.     

The relationship between knowledge and reported behavior in childhood asthma

Numerous educational interventions have been developed and tested to improve management of childhood asthma. Most programs assume that knowledge about asthma is related to initiating and/or maintaining recommended management behaviors. Although this assumption is widely accepted, some available evidence casts doubt upon its validity. We investigated the relationship between asthma management behaviors and (1) knowledge about asthma, (2) behavioral adjustment, (3) anxiety, and (4) health locus of control. Data were collected on 91 children 7 to 12 years of age with moderately severe asthma. After adjusting for covariates, reported asthma management behavior was significantly related only to knowledge about asthma (p less than .05). The relationship between knowledge and behavior is nonlinear: accurate knowledge is related to engaging in more of the recommended behaviors, but only up to a moderate level of knowledge. Also, the relationship between knowledge and asthma management behavior was especially strong for children who scored lower on behavioral adjustment. These results suggest that children's knowledge about asthma can influence behavior, but only under certain conditions. Educational interventions for children whose knowledge is already adequate may not increase adherence to recommended practices.     

Psychosocial issues in childhood cancer. An ecological framework for research

A number of psychosocial issues are evolving as childhood cancer becomes a chronic rather than a fatal condition. These include issues associated with extended hospitalization and social isolation, as well as long-term adjustment to survival that may involve recurrence of disease. Primary emphasis in current research and intervention is placed on how children and their families adapt to long-term survival. This article reviews the scope and limitations of previous research in this area, which focuses on the individual with little reference to the family, school, or social networks or to the interactions occurring among these arenas. An ecological model is suggested as the most useful perspective for enhancing our understanding of the impact of childhood cancer on the child, family, and community. Much of what is already known about how cancer and its treatment affect children and families is consistent with the propositions of an ecological model. The transactional, reciprocal, and interdependent nature of coping behaviors within a family system is perhaps the most obvious indicant of the need for multiple perspectives for understanding how families respond to the pressures of a chronic, but possibly life-threatening, illness. An ecological approach is timely, therefore, in that there is a need for psychological research and intervention directed beyond the immediate context of treatment to extended levels of social interaction and social systems.     

Prevention and Management of Childhood Obesity

Childhood obesity has been recognized as a global pandemic. Preventive strategies have proven to be the most effective public health intervention in curbing this pandemic. A multi-component approach involving dietary modification and advocacy for a healthy lifestyle comprising of regular physical activity, minimizing screen time and behavioral interventions have been found beneficial in preventing obesity. A life-cycle approach has been recommended where preventive interventions go as far back as affecting maternal, fetal and early childhood nutrition and lifestyle. Family, school and community involvement is important for long term results, so is the involvement of government in developing policies that help create an environment and opportunities for healthy diet and physical activity. Management of childhood obesity is challenging. It involves following a structured weight reduction programme individualized for every child, along with adoption of a healthy diet and life style. Anti-obesity drugs have a limited role in childhood years and are not recommended in younger children. Bariatric surgery is reserved for morbidly obese older adolescents but its long term safety data is limited in this age group.     

Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health

Advances in a wide range of biological, behavioral, and social sciences are expanding our understanding of how early environmental influences (the ecology) and genetic predispositions (the biologic program) affect learning capacities, adaptive behaviors, lifelong physical and mental health, and adult productivity. A supporting technical report from the American Academy of Pediatrics (AAP) presents an integrated ecobiodevelopmental framework to assist in translating these dramatic advances in developmental science into improved health across the life span. Pediatricians are now armed with new information about the adverse effects of toxic stress on brain development, as well as a deeper understanding of the early life origins of many adult diseases. As trusted authorities in child health and development, pediatric providers must now complement the early identification of developmental concerns with a greater focus on those interventions and community investments that reduce external threats to healthy brain growth. To this end, AAP endorses a developing leadership role for the entire pediatric community-one that mobilizes the scientific expertise of both basic and clinical researchers, the family-centered care of the pediatric medical home, and the public influence of AAP and its state chapters-to catalyze fundamental change in early childhood policy and services. AAP is committed to leveraging science to inform the development of innovative strategies to reduce the precipitants of toxic stress in young children and to mitigate their negative effects on the course of development and health across the life span.     

Behavioral health practices in the midst of black box warnings and mental health reform

A standard guide was readministered to 42 primary care pediatricians after community interventions to assess changes in their behavioral health practices. Among the outcome findings: increased screening of young children (6 months to 5 years); attention deficit hyperactivity disorder continued to be the most frequent diagnosis, with a high level of diagnostic comfort and use of stimulants; decreased comfort in the diagnosis and treatment of depression, with a significant decline in use of selective serotonin reuptake inhibitors; nearly all continued to offer nonmedication, behavioral health treatment; and a significant increase in use of social workers for community referrals. Structured interventions had limited influence on the process of change. Black box warnings exerted a powerful effect on prescribing practices. Systemic changes involving financial incentives, increased access to mental health providers, practice guidelines, and technology for continuing education may offer possibilities for changing practice patterns.