Free Health Essays - Childhood Obesity Parents
Introduction
Childhood obesity is rapidly becoming the crisis of the next generation. Nearly all public health officials express a major concern for the growing number of obese children in the United States. The obesity rate among children ages eight to twelve years has exponentially increased, quadrupling since the 1980’s (Small, Anderson, & Mazurek-Melnyk, 2007).
This disturbing trend continues to grow in all states, ethnicities, and socioeconomic statuses (Centers for Disease Control and Prevention [CDC], 2007 a). The implication is alarming considering the fact that obese children are more than twice as likely to develop hypertension, cardiovascular disease, Non-Insulin Dependent Diabetes Mellitus, depression, and a shortened life-span (Faith, Scanlon, Birch, Francis, & Sherry, 2004 b).
Many reasons for the escalation in childhood obesity have been indentified. A number of researchers and authors suggest that the main responsibility lies with parents (Small et al., 2007; Clark, Goyder, Bissell, Blank, & Peters, 2007; Faith et al., 2004 b; Howard, 2007; Regber, Berg-Kelly, & Marild, 2007). Parents are highly influential and often establish their children’s life-long eating habits (Clark et al., 2007).
A variety of feeding styles used by parents have been correlated to children’s weight. Growing evidence suggests that the feeding styles associated with child weight gain include restriction, reinforcement, force, and no control (Small et al., 2007; Clark et al., 2007; Faith et al., 2004 b; Howard, 2007; Regber et al., 2007). Restriction is thought to have the strongest association with an increase in child preference and intake of “forbidden” foods, as well as child weight gain (Regber et al., 2007). This article will address each of these four feeding styles and examine restriction in detail, including the reasons parents implement restriction, and its relationship to child weight.
A systematic search was conducted to collect literature reviews and original research documents on parental role in childhood obesity, child feeding behaviors, and child weight status. This search utilized electronic databases including Medline, PubMed, and CINAHL. Sources were limited to the English language and studies conducted in humans.
The following key terms were used in a variety of combinations: feeding styles, eating patterns, parent control, restriction, childhood obesity, child weight, and calorie intake. The main objective of this review is to identify the parental feeding styles that impact children’s calorie intake, to evaluate the evidence linking parental restriction to child weight gain, and to disclose recommended parental feeding styles that may prevent childhood obesity.
Childhood Obesity
The prevalence of obesity is considered a global epidemic which is spreading through all ethnicities and socioeconomic statuses (Regber et al., 2007). Just like an infectious disease, the obesity epidemic is expanding in all age groups, including children as young as the age two (CDC, 2007 b).
Most experts agree that management of childhood obesity must include environmental, biological, and behavioral factors (Klazine et al., 2007; Regber et al., 2007; Small et al., 2002). Regber et al. (2007) suggests that environmental aspects, including parental influences, have the greatest impact on childhood obesity rates and should be the focus of prevention efforts. To begin, a clear understanding of childhood obesity and its surrounding issues must be established (Regber et al., 2007).
Childhood Obesity Definition
Childhood obesity is a term that is often used without clear understanding. Direct Body Mass Index (BMI) measurements should not be used to define childhood obesity because it fails to account for age and gender differences in child body development, and cannot predict morbidity (Howard, 2007). Instead, the CDC (2007 b) recommends using BMI to determine a percentile ranking of weight to height among children ages 2 to 19 years.
The percentile ranking is found using male and female United States growth charts, last updated by the CDC in 2000. A child who is at or above the 95th percentile is defined as obese. Any child in the 85th to 94th percentile is considered overweight and at risk for obesity. (National Center for Health Statistics [NCHS], 2005).
Howard (2007) suggests the most accurate way to determine if a child is obese is to follow the Healthy People 2010 guidelines of assessing child weight. These guidelines not only consider BMI percentiles, but also sexual maturity and percent of body fat (Howard, 2007). However, for the purposes of this review only BMI percentile will be used to define childhood obesity because the majority of research was based on this definition.
Importance of Addressing Childhood Obesity
Childhood obesity is a major public health concern. For the first time in United States history, the youngest generation is predicted to have a shorter life span than their parents (Catalano& Bruckner, 2006). This will undoubtedly take a toll on the population’s health status and society as a whole (Howard, 2007). Childhood obesity trends, health concerns, and societal impacts give insight into the impending crisis and manifest why this issue cannot be ignored.
Childhood Obesity Trends. Growing evidence indicates that obesity among children around the world is dramatically inclining (Anderson & Butcher, 2006). In the United States alone, forty-four states reported more than 20% of its population as obese in the year 2006 (CDC, 2007 a). The NCHS (2005) reported that more than 16% of children ages 6 to 19 years are overweight in the United States.
This is a significant 12% increase from 1965 when it was estimated that only 4% of U.S. children were overweight (Howard, 2007). The effect is even greater when measuring young children ages two to five, who showed a 14% increase (from 7% to 21%) in overweight prevalence. This is the largest increase in preschool weight yet (Small et al., 2007).
Obesity rates among boys and girls show no significant differences and the average BMI has increased for both genders. Over a 30-year span the average body weight for a male or female child 4’6” tall increased by nearly three pounds, from 113.6 to 116.1 pounds (Anderson & Butcher, 2006). Using the BMI percentile guidelines established by the CDC, approximately one in seven children is now considered obese (Small et al., 2007). As depicted in Figure 1, the percentage of the U.S. obese population has increased in all age groups (Anderson & Butcher, 2006).
Although the patterns of childhood obesity differ among countries, the overall trend remains the same: more and more children are falling into the obese range (Anderson & Butcher, 2006). the percent increase of childhood obesity during a ten-year period in Germany, England, China, and the United States. The rate of childhood obesity varies between countries due to different ethnic and racial groups. Ethnic groups have unique weight conceptions, biological factors, socioeconomic statuses, food sources, and education levels, all of which impact obesity rates (Anderson & Butcher, 2006).
Figure 2. Percentage of obese children ages 2-19 worldwide. Data from Anderson & Butcher (2006).
The United States, which is ethnically diverse, also displays different obesity patterns among racial groups. In 2004, 15.4% of Non-Hispanic white female children in the U.S. were considered obese, followed by 14.1% of Hispanics and 25.4% of African-Americans (CDC, 2007b). The obesity rates among male children of different ethnic groups are much closer. In 2004, 19.1% of Non-Hispanic White, 18.5% of African-American, and 18.3% of Hispanic male children were above the 95th percentile for BMI. Overall, these three ethnic groups are considered at highest risk for childhood obesity not only in the U.S. but worldwide (CDC, 2007 b).
Health Concerns. Obesity is associated with a vast number of health disabilities and chronic disorders. For this reason, Healthy People 2010, national goals designed to improve the overall health of United States citizens, designated the reduction of childhood obesity as one of its main objectives. Decreasing childhood obesity rates would successfully “increase quality years of life and eliminate health disparities” (Howard, 2007).
Obesity can be dangerous and life threatening not only to adults, but to children as well. The longer a person lives in an obese state, the more years of life they may lose (Small et al., 2007). Coronary artery disease, non-insulin dependent diabetes mellitus, sleep apnea, dyslipidemia, and hypertension are only a few of the health complications that can arise from obesity (Faith et al., 2004 b).
One of the most alarming health disparities secondary to obesity in children is type II diabetes, which has higher rates than ever before. The CDC recently reported that 85% of children with type II diabetes are overweight or obese (CDC, 2007 b). Furthermore, this condition puts children at an increased risk for blindness, nerve damage, and kidney failure (Small et al., 2007).
Being overweight during childhood is directly correlated to being overweight during adulthood (Small et al., 2007). Howard (2007) noted that the problem of excessive weight in children is not something that will go away as they grow. In fact a group of researchers found that 52% obese children ages three to six were still obese at 25 years (Anderson & Butcher, 2006).
A significant difference was shown when only 12% of non-obese children were obese at 25 years (Anderson & Butcher, 2006). In addition, obese children are presented with the immediate consequence of social discrimination, which can lead to poor self-esteem, depression, and even mental illness (Howard, 2007).
The depression rate among obese children is escalating, which in turn increases their likelihood for developing eating disorders and a lifetime of unhealthy weight management (Regber et al., 2007). The health problems associated with obesity are expected to intensify as children grow older and gain weight (Howard, 2007).
Societal Impacts. Childhood obesity takes a large toll on all of society. In 2002, medical expenses accounting for obesity and related complications reached $92.6 billion dollars in the United States (CDC, 2007 a). This included both direct and indirect costs of obesity. Direct costs refer to preventative, diagnostic, and treatment expenses.
Indirect costs refer to physical inactivity, decreased work productivity, disability, and mortality expenses due to obesity (NCHS, 2005). These indirect costs accounted for a $28 billion dollar expenditure in 2005 for California alone. States nationwide are experiencing these vast expenses, creating economic burdens on their populations.
Obesity has driven up the cost of health care, affecting everyone. There are simply not enough resources to address the obesity epidemic (Anderson & Butcher, 2006). Low and middle class families find it difficult to afford health insurance. In 2001, approximately 44,000 children had no medical insurance or regular source of medical care (CDC, 2007 a). Lack of health care allows the obesity problem to escalate. Many authors suggest that childhood obesity prevention efforts are the most effective because they are the least economically burdensome, cheapest to fund, and will decrease expenditure of health care in the long-run (Small et al., 2007).
Childhood obesity also leads to social isolation (Howard, 2007). Overweight children are often ostracized, and develop poor interaction skills and experience a sense of failure. These children will not learn how to work well with others and do not develop leadership skills (Anderson & Butcher, 2006). Eventually this will impact the work force by decreasing efficiency of productivity, team work, and management competence (Small et al., 2007).
Some researchers found that obese adolescents had completed fewer years of education, married less, and earned a lower income than non-obese peers (Regber et al., 2007). For these reasons the United States economy is facing a potential downward spiral. This outlook may be avoided by increasing obesity prevention efforts in future generations (Klazine et al, 2007).
Parental Contributions to Childhood Obesity
Parents have a key role in preventing and addressing childhood obesity. Many authors claim that parents have the most influential position in developing and maintaining healthy life-styles in their children (Anderson & Butcher, 2006; Clark et al., 2007; Howard, 2007; Regber et al., 2007; Small et al., 2007).
In addition, parents are role models and create a supportive environment in which children can develop healthful patterns (Clark et al., 2007). Parents are also responsible for both diet and physical activity behaviors among children and have the ability to influence either of these facets (Small et al., 2007).
Parental Diet Influences on Children
Parents impact their child’s dietary selection, portion size, and consumption rate. If a child is influenced to increase these behaviors, it may lead to excessive weight gain. These significant dietary influences on children stem from the parental functions of being role models and the sole providers of food (Howard, 2007).
Dietary Role Models. A child will likely develop a diet similar to the one their parents have and children commonly share the same food preferences and dislikes as their parents (Small et al., 2007). Research has determined that parental dietary habits are strongly associated with the amount and source of calories children consume (Small et al., 2007).
This correlation is greatest among young children, ages two to five years. Bad eating habits usually start well before a child enters kindergarten and these habits come directly from the parents themselves (Clark et al., 2007). A study in Australia found that adolescents associated their parent’s negative concepts about food with their personal diet and food selections (Howard, 2007).
Parents who are not in tune with their own health and nutrition cannot expect their children to develop healthy diets. In fact, children with one or more obese parents are four to five times more likely to be obese themselves during adulthood (Small et al., 2007). Clark et al. (2007) claims that parents who are aware of dietary benefits and detriments are more likely to instill healthy food choices in their children. Parents who consume at least three fruits and vegetables a day will likely have children who consume more fruits and vegetables on average than their school-aged peers (Regber et al., 2007).
Dietary Providers. According to Howard (2007), parents act as the “gate-keepers” of food, determining what type of food and when food is available. Parents who present a variety of healthy food to their children are reinforcing healthy behaviors that will likely last throughout adulthood. On the other hand, parents who do not expose children to a variety of foods are setting them up for developing neophobia (Cooke, Carnell & Wardle, 2006).
Neophobia is the fear of trying new foods and is associated with pickiness of food selection. Children with neophobia are less likely to receive a well-balanced nourishment of micronutrients. For instance, children 4 to 5 years old with neophobia consume fewer fruits, vegetables, and less protein, but more snack foods (Cooke et al., 2006).
Parents are also responsible for how much food children consume. They determine the portion size of meals and snacks. The amount of food that parents provide is what children will come to regard as a normal portion size. Obviously, this becomes a problem when parents provide too much food, compelling their children to consume excess calories. The skewed impression of portion sizes often remains with children into adulthood, and increases the likelihood of becoming obese in childhood and later on in life (Regber et al., 2007).
Table 1.
Nutrition facts of selected fast food meals popular among adolescents.
The parental role as the dietary provider for children has changed within the last 30 years. The number of children with both parents working has increase by more than 10% since the 1970’s. This employment trend is responsible for a decreased amount of time parents have for food preparation (Howard, 2007). Anderson and Butcher (2006) noted that every additional ten hours a mother spends at work per week, her child’s risk of becoming obese is increased by 1%.
This is largely because mothers who work longer hours, do not have the time to arrange family dinners, and rely more often on unhealthy fast food options. In 1978 families ate out only 17% of the time. Today eating out has increased to 34% of the time (Flax, 2003). Additionally, parents are often unaware of the nutritious facts of fast food items, and allow their children to consume high fat, high calorie, supersized meals.
Table 1 displays the nutritious facts of particular fast food meals that are popular among adolescents. Considering that the average person should consume 2000 calories and 60 grams of fat a day, it is frightening to learn what one fast food meal contains. It is no wonder that America’s children have a weight problem!
Parents have the ability to modify children’s diets and make a significant difference in their nutritional status (Anderson, & Butcher, 2006). Regular family meal patterns provide children with structure, regulation, and encourage well-balance diets (Howard, 2007). Howard (2007) recommends that parents establish family dinners at least five times per week, which will allow children to experience a positive ambiance regarding diet variety and health.
Parental Physical Activity Influences on Children
Within the last 30 years, there has been a significant decrease in the amount of physical activity in which average children partake (Anderson & Butcher, 2006). This is yet another compelling factor leading to childhood obesity that parents have the ability to control.
Physical activity promotes an increase in lean body mass, lipolysis, and metabolic rate, all of which help prevent excessive weight gain (Anderson & Butcher, 2006). Parents have the responsibility to develop physical activity behaviors and attitudes for their children by functioning as role models, arranging opportunities, and placing regulations on inactive hobbies.
Physical Activity Role Models. Children not only look to their parents as dietary role models, but as role models for physical activity as well. Parental interest in sports and activities will likely be passed onto children. The more a parent partakes in a physical activity, the more likely the child will regard the particular activity as a valuable hobby (Anderson & Butcher, 2006). Children pick up on cues that their parents display.
Parents who strive to be healthy and exercise regularly impart these values to their children (Howard, 2007). A study examining the relationship of physical activity among fathers and their children found a significant association between the amount of cardiovascular exercise in the father and the child. Over a three year period, the same study concluded that the extent of child participation in sports was directly dependent on the father’s perceived value of that sport (Yang, Telema, & Laakso, 1996).
Parental Responsibility to Encourage Physical Activity. Parents can promote physical activity by creating a supportive environment for their child. According to Regber et al. (2007) parents are in charge of a child’s microenvironment and have the capability to dictate physical activity behaviors. It is the parents’ responsibility to promote active play, including free time choices, lessons (such as dance or karate), and/or team sports (Regber et al., 2007). Kindergarten children who partake in at least three hours of active play per day have an increased likelihood for being moderately or highly physically active as an adult (Yang et al., 1996).
Parents also have the responsibility to set guidelines about sedentary hobbies. In today’s world many children are glued to television sets, video games, and computers, all of which require no physical exertion. In fact, children between the ages 2 and 11 years watch an average of 20 hours of television per week (Brown & Ogden, 2004). This inactivity consumes a large portion of children’s discretionary time, further limiting time spent in healthy, physical activity. Parents who do not limit the time allotted to these sedentary hobbies are promoting weight gain in their children. Proper parental control over children’s activity levels will help prevent the onset of obesity (Anderson, Butcher, 2006).
Parental Feeding Styles
Parents aim to provide their children with the best possible nourishment and consequently adopt a particular feeding philosophy and style based on what they believe is best. A variety of parental feeding styles have been identified. Growing research suggests that particular feeding styles, while well-intended, may lead to adverse outcomes (Birch, Fisher, & Davidson, 2003). Carnell and Wardle (2007) point out that the way parents feed their children manipulates how much food they consume and what type of food they favor.
Certain feeding styles may directly impact a child’s weight (Faith et al., 2004 b). In particular, the feeding styles of force, reinforcement, no control, and restriction can lead to increased child BMI and may be a primary factor to the rising rates of childhood obesity (Birch et al., 2003; Carnell & Wardle, 2007; Faith et al., 2004 b; Fisher & Birch, 1999; Johannsen, Johannsen, & Specker, 2006).
Pertinent Feeding Styles Related to Child Weight
Force, reinforcement, and no control over food are pertinent feeding styles that are believed to influence child weight (Carnell & Wardle, 2007; Faith et al., 2004 a; Johannsen et al., 2006; Powers et al., 2006; Spruiht-Metz et al., 2002; Wardle et al., 2002). Parental force is the act of pressuring a child to eat certain foods, such as fruits or vegetables. Parents adopt this method as an attempt to control child intake of healthy foods (Clark et al., 2007).
But, this may actually be influencing children to dislike these foods (Carnell & Wardle, 2007). In a college survey, 72% of students conveyed that being forced to eat a certain food as a child left them with bad memories and a current dislike of that food (Clark et al., 2007). This experience may affect one’s nutritional status and weight for life (Carnell & Wardle, 2007). Forceful eating methods can also disrupt a child’s natural satiety cues and teach them to eat when they’re not hungry, thus leading to weight gain (Carnell & Wardle, 2007).
Johannsen et al., (2006) concluded that overweight girls ages 3 to 5 were more likely to have fathers who displayed forceful eating patterns. Studies have found that maternal pressure to eat can elicit positive correlations with child fat intake (p < 0.05) and adiposity (p < 0.001) (Clark et al., 2007). However, Powers et al. (2006) found an opposite association between maternal pressure and child BMI z-scores (r = -0.16, p < 0.01). Data on forceful eating and child weight remains inconclusive and further studies are needed to determine if parental force is a response to child weight or if child weight is indeed a response to parental force (Carnell & Wardle, 2007).
Reinforcement is another common parental feeding style that may have unintended consequences on child weight. Reinforcement is sometimes referred to as bribery because the child is rewarded for eating (Brown & Ogden, 2004). Using dessert as bribery may lead children to believe that healthy food is not as desirable as dessert, which in turn, reinforces a preference for these foods (Carnell & Wardle, 2007). As children mature they may independently choose to eat more desserts and reward foods (Brown & Ogden, 2004).
Children may also subconsciously relate eating dessert as a way to reward themselves, a practice which may affect their eating behaviors into adulthood (Wardle et al., 2002). Brown and Ogden (2004) found that parents who used food reinforcement had children who were more dissatisfied with their bodies than those who did not. Reinforcement of food was also positively correlated with the BMIs in twins (r = 0.19) (Faith et al., 2004 b).
Parents who display no control over their children’s eating habits also influence their child’s weight status (Carnell & Wardle, 2007; Faith et al., 2004 a). Parents may not regulate or control their children’s food intake out of neglect, lack of knowledge, or because they believe children should make their own dietary decisions (Faith et al., 2004 a). However, Carnell and Wardle (2007) observed higher BMIs in children given no food control.
Also, decreased control over fat intake was associated with higher child BMI z-scores after two years (P = 0.009) (Faith et al., 2004 a). Research in this area is limited but most studies indicate a positive correlation between no control and child weight. Further research is needed to reveal possible confounding factors and other relationships (Carnell & Wardle, 2007).
Due to the overwhelming observations about the parental feeding style of restriction and child weight gain, researchers are now focusing their efforts in this area (Clark et al., 2007). This review will now analyze several studies and address parental feeding restrictions in depth. Restriction
Parental restriction of food has been a popular study area among researchers in the past decade. Most authors define the act of restriction as purposely limiting access or intake of certain foods over a period of time (Birch et al., 2003; Carnell & Wardle, 2007; Faith et al., 2004b; Fisher & Birch, 1999). It may refer to not offering children food items, forbidding children to eat food items, or not allowing food items in the household at all.
Restriction must not be confused with food regulation. Parents who regulate child food consumption may also limit child intake of certain foods, however, they are considered to be more supervisory than controlling. Food regulation places boundaries on children that specifies how much and when food may be consumed.
Restriction does this in a much more restraining and oppressive way. Often the goal of restriction is for the child to completely avoid consumption of certain foods (Birch et al., 2003). A collection of recent studies have helped researchers come to understand the intentions of parents when restricting food and how this may directly affect child eating behaviors and weight.
Reasons Parents Use Restrictive Feeding Styles. The parental feeding style of restriction is used as an attempt to limit fats, sweets, and other non-nutritious foods. Every parent wants their children to grow up strong and healthy. In an attempt to assure this, some parents restrict all unhealthy foods (Fisher & Birch, 1999). However, this approach may actually backfire. Forbidden foods may become even more desirable. Then, when children are old enough to access restricted foods on their own, their choices may be out of control.
This could trigger the beginning of life-long weight related health problems (Clark et al, 2007; Faith et al., 2004 b). Outside environmental factors may also influence parents to use restrictive feeding styles. Ethnicity, race, income, education level, weight status, and the gender of children all may be responsible for creating food restriction responses in parents (Birch et al., 2003).
Ethnicity and race play a major role in predicting parental feeding styles. Each ethnic group has a different set of societal values that are significant to them. Birch et al. (2003) claimed that thinness and physical attractiveness are high among Caucasian goals. Therefore, parents using food restriction in this group are more likely to do so in an attempt to prevent their children from gaining excessive weight and having to endure ridicule by society (Birch et al., 2003).
On the other hand, Hispanics and African Americans do not perceive thinness as a value. Simultaneously, these ethnic groups have a higher prevalence of overweight and obesity (CDC, 2007 a). In general, Hispanic and African American parents do not believe that overweight children have health risks or societal disadvantages. In fact, increased child weight is viewed as a sign of wealth and health. For these reasons, the parents in these ethnic groups do not usually adopt restrictive feeding styles (Birch et al., 2003).
Income levels can also induce parents to use restriction as a means of promoting child health. Low income families are more likely to rely on cheaper meals. However, less expensive meals are usually less healthy so nutrition is compromised. Children from lower income families are less likely to be restricted from unhealthy foods because this is what the family can afford (Clark et al, 2007).
In addition, parents who earn less money often have less education and are not as aware of the health risks associated with unhealthful foods (Birch et al., 2003). This is yet another reason they are less likely to develop restrictive feeding practices. Fisher and Birch (1999) reported that parents with higher education levels scored higher levels of restriction on the Child Feeding Questionnaire (CFQ).
Food restriction may also correlate to the weight status of both the parent and child. If parents have personal health and weight problems, they are more likely to restrict food to help prevent their children from developing similar conditions (Fisher & Birch, 1999). A child’s weight can also predict the degree of parental food restriction (Faith et al., 2004 a). Several authors suggest that parents of children who have a higher percentage of body fat are more likely to restrict food as a means of helping them lose weight (Birch et al., 2003; Carnell & Wardle, 2007; Fisher & Birch, 1999; Faith et al., 2004 a).
In these cases, parents are using restriction in response to their health concerns. Parents who develop restriction due to weight concerns are especially responsive to their daughter’s weight. Some studies have found slight gender differences in the degree of food restriction, with girls experiencing more food restriction on average than boys (Carnell & Wardle, 2007; Birch et al., 2003; Faith et al., 2004 a). It is possible that parents become overprotective of daughters because social values lead them to believe overweight girls are more likely to be ostracized, and develop further health problems and reclusion (Carnell et al., 2007; Birch et al., 2003).
Affects of Restriction on Child Weight. Many experts have found an association between child weight status and the parental use of restrictive feeding. Faith et al. (2004 a) conducted a prospective study which found a specific link between parental restriction of food and increase in children BMI z-scores at ages 3, 5, and 7 years.
This study set out to determine if continuous parental feeding styles over a four year period could predict child BMI. The researchers hypothesized that a significant association would be found between food restriction and child BMI after two-year increments (Faith et al., 2004 a).
The study recruited 57 Caucasian families enrolled in the Infant Growth Study to participate. To control for predisposition to obesity, each child was determined to be at high or low risk for obesity by assessing the mother’s weight before pregnancy; if the mother had a BMI above the 66th percentile, the child was considered to be high risk for obesity and if she had a BMI under the 33rd percentile the child was low risk.
Child BMI was measured in two-year intervals at 3, 5, and 7 years of age. Parental restriction was measured each year using the Child Feeding Questionnaire (CFQ), a common tool that has been validated for study purposes and ranks the degree of restriction on a scale of eight. There was no significant difference between parental use of restriction among children in the low and high risk groups for obesity (P < .05).
Correlation analyses and multiple-regressions were calculated for each group at age five to determine if CFQ scores were related to increased child BMI z-scores two years later. If the parent CFQ score of restriction did not remain stable from age three to five, the data were considered inconclusive because parental restriction could have been a direct response to child weight gain (Faith et al., 2004 a).
Once the data were collected and analyzed using correlations, Faith et al. (2004 a) found that higher CFQ scores of restriction predicted an increased child BMI z-score after two years for children at high risk for obesity. The correlation data between restriction and child BMI for both high and low risk groups can be found in table 2. For low risk children, parental restriction had a negative correlation with child BMI z-scores, however, it was not considered significant (P<.05). On the other hand, a significant positive correlation for child BMI z-scores and restriction was found for high risk children (P = 0.05). This means an increase in BMI z-scores at age seven was related to strengthened food restriction at age five (Faith et al., 2004 a). restriction scores and Child BMI z-scores.
Data from Faith et al., 2004.
Multiple regression data analysis was used to identify if the observed child weight at age seven was related to more than one independent variable. Parental weight concerns, initial child weight, and parental sense of responsibility were analyzed to find any associations to child weight gain. However, these variables were concluded to be insignificant (P < 0.05).
The regression coefficients for the variables These coefficients represent how much (in percent) each variable was responsible for the BMI z-scores measured at age seven. Higher levels of restriction during meals accounted for an average of 30% of the weight gain observed in children from both low and high risk groups ( 29% for low risk children, P = 0.03 and 31% for high risk children, P = 0.08). (Faith et al., 2004 a).
Faith’s et al. (2004 a) research has strengths and limitations. A longitudinal design allowed comparing continuous parental feeding styles to child BMI across four years. Cross-sectional studies are unable to consider the duration of restriction and therefore, cannot determine the long term affects of restriction on child weight. Faith’s et al. (2004 a) study also controlled for child predisposition to obesity by categorizing children into high and low risk groups. This prevented a cofounding factor from skewing the results. (Faith et al., 2004 a).
The weaknesses of this study begin with the sample population and include some uncontrollable factors. The sample used did not represent a diverse background; all families were Caucasian and had moderate to high educations. Consequently, the findings of this study cannot be applied to other ethnicities or educational levels (Faith et al., 2004 a). The sample size was also relatively small, so the results may differ if testing larger groups. The larger the sample size the less the results are due to chance (Faith et al., 2004 a).
Some uncontrollable factors within the study design may have also skewed the results. Parental restrictions were not measured before age three, so earlier parental feeding styles could not be taken into consideration. These earlier patterns may have had some affects on the children that dictated the path of their weight. The study design could not account for this, so the results may have been due to feeding styles during the first three years of life (Faith et al., 2004 a).
After all, several authors suggest that parents have the strongest influence over eating behaviors during the youngest years of childhood (Clark et al., 2007). Furthermore, the level of restriction parents used could have been a direct response to the initial child weight. This would mean that increased child weight was not an outcome of restriction, but that restriction was the outcome of increasing child weight (Faith et al., 2004 a).
In conclusion, Faith’s et al. (2004 a) research supports the results of other cohort studies and strengthens the existing belief that restrictive feeding practices could increase child weight in the long run (Faith et al., 2004 a). However, a single study cannot identify exact correlations and other studies must be considered.
Carnell and Wardle (2007) conducted a similar study that found no relationship between CFQ restriction and child BMI z-scores. One particular objective of this study was to identify any existing associations between parental food restriction and child adiposity. The researchers hypothesized that parental feeding and child weight would show a positive or null association (Carnell & Wardle, 2007).
Carnell and Wardle (2007) assessed 439 families in London with children three to five years of age. The sample included mostly Caucasian, but also some Indian and Black families. There was no significant difference between education levels. The parents completed the CFQ survey and were scored by their degree of restrictive practices. At the same time, the children’s height and weight were measured to calculate BMI z-scores.
Children were divided into three groups; normal/low weight (< 50th BMI percentile), normal/midweight (> 50th BMI percentile without any evidence of obesity), and overweight/obese (determined by International Obesity Task Force criteria for obesity). Among the group, 86 children were found to be overweight and 38 obese.
The collected data were used to calculate correlation values between CFQ scores and child BMI z-scores. An ANOVA test was also completed to examine the relationship between parent CFQ scores and the child weight groups. The correlation measurements were repeated for boys and girls to identify any gender differences. (Carnell & Wardle, 2007).
The calculated correlation values did not display any significant relationships between parent CFQ restrictive scores and child BMI z-scores (r = 0.03, p = 0.517) (Carnell & Wardle, 2007). Table 3 displays all correlation values found during the study. A slightly higher correlation was identified for girls than for boys when comparing CFQ restriction scores and BMI z-scores (r = 0.16 for girls, r = -0.05 for boys).
However, because the correlation values fell outside the confidence interval, this difference was considered insignificant (Carnell & Wardle, 2007). One possible explanation for this observance could be that parents are more likely to restrict food for girls since thinness is perceived as a higher societal value for women (Carnell & Wardle, 2007; Birch et al., 2003; Faith et al., 2004a).
The results from the ANOVA test in Carnell’s and Wardle’s (2007) study also showed no associations. This revealed that parental food restriction did not differ among child weight groups. The average CFQ score for parents with normal/ low weight children was 2.48, whereas the average score for parents with normal/mid weight children was 2.37 and 2.5 for overweight children (p = 0.249). Parents of overweight children were not considered to use restriction more than parents of non-overweight children (Carnell & Wardle, 2007).
Carnell and Wardle’s (2007) study displayed certain strengths and weaknesses. The researchers were careful to control for potential confounding factors. The BMI z-scores of children whose parents did not complete the CFQ were compared to those who did fill out the CFQ. No significant difference was found, indicating that parents who turned in the CFQ were not enticed to do so because of their child’s weight (Carnell & Wardle, 2007).
Another strength of the study included the large sample size and diversity of racial groups. However, because this study was conducted in the United Kingdom its results can only be applied there. The United States has different cultural values and it is possible that parents may begin to use restriction at younger ages to achieve the societal value of thinness (Carnell & Wardle, 2007).
Also, because the children sampled were so young, the effects of restriction on child weight may not have developed yet. Different results could have been found in older samples. Lastly, because this study was a cross-sectional design, it is unable to detect long-term relationships and predict future correlations (Carnell & Wardle, 2007).
Faith’s et al. (2004 a) and Carnell’s and Wardle’s (2007) studies set out to test the same research question and shared the same variables of interest. However, the primary outcomes from each study found very different associations between the degree of parental food restriction and child BMI z-scores.
One explanation for this could be the difference in study design and samples. Faith’s et al. (2004 a) study was longitudinal and, therefore more likely to detect any relationships that develop over a period of time (Faith et al., 2004 a). Carnell and Wardle’s (2007) study on the other hand, was cross-sectional and could only identify relationships already in existence. This may explain why they were unable to observe any significant correlations (Carnell & Wardle, 2007). Both Faith et al. (2004 a) and Carnell and Wardle (2007) failed to account for dietary intake in children.
These studies could have been improved by measuring food intake in children and correlating this to parent CFQ restrictive scores. This would have assured that child BMI increase was caused by excess energy intake and not other factors such as decreased physical activity or genetics (Faith et al., 2004 a). Until further studies are completed to account for this factor, the actual relationship between parental restriction and child weight remains debatable.
One study that did measure the dietary intake in children while examining the effects of food restriction was conducted by Fisher and Birch (1999). Two separate experiments were performed to observe child responses to food restriction within and outside restricted environments. Fisher and Birch (1999) hypothesized that restriction of food would ultimately increase child “subsequent behavioral responses to, selection of, and intake of the restricted food” (Fisher & Birch, 1999).
Experiment one was designed to examine the relationship between food restriction and child eating behaviors within and outside restrictive environments (Fisher & Birch, 1999). Children were exposed to five weeks of restriction to a selected snack food and their behavioral responses, food selection, and intake were measured before, during, and after this time. The children sampled ranged from 3 to 5 years old and were not considered ethnically diverse.
In addition to the five week restriction period, children participated in snack sessions where they were allowed free access to any foods presented. Eventually they were told could no longer consume a specific food item and immediate behavioral responses within this restricted environment were recorded. Food selection and intake of the target food was recorded later in an unrestricted environment. (Fisher & Birch, 1999).
Experiment two was designed differently to examine the relationship between food restriction and child eating behaviors only within a restricted environment (Fisher & Birch, 1999). A group of 3 to 6 year-old children participated in eight snack sessions, four of which no food was restricted and four of which food was restricted. During each restricted snack session, the children were allowed access to the restricted food for only five minutes.
During this time the children’s food intake and selection was recorded. Behavioral responses, including positive/negative comments about restriction or the food, and requests for the food, were recorded throughout the entire session. Experiment two also tested the possibility that parental restriction was a direct response to personal or child weight by collecting weight measurements and correlating them with parental restrictive scores found by the Eating Inventory Questionnaire (Fisher & Birch, 1999).
Fisher and Birch (1999) concluded that both experiments showed a significant relationship between food restriction and increased child behavioral responses. This association can be viewed in Figure 4. Children in both studies said more positive comments about the restricted food and requested it more often during the restriction periods. No gender or age differences were found (P = 0.16) (Fisher & Birch, 1999).
Experiment one in Fisher’s and Birch’s study (1999) revealed no significant correlations outside a restrictive environment between food restriction and child intake and selection of the food. In addition, no difference was found in child behavioral response, food intake, or selection from before and after the five week restriction period.
Experiment two found a significantly higher intake of restricted food during the five minute free access snack period compared to the completely free access snack sessions held before (P < 0.001). Experiment two also determined that initial child weight, but not parental weight, was a key factor in the parental decisions to use restrictive feeding styles (Fisher & Birch, 1999).
The combination of experiment one and two allowed Fisher and Birch (1999) to develop a strong framework. Together the studies explored the direct dietary influences that restriction produced. The key differences between the experiments also allowed researchers to observe children from both within and outside restrictive environments (Fisher & Birch, 1999). Table 4 compares the two experiments.
While the results from Fisher’s and Birch’s (1999) study supports the findings of other research, the study does have limitations. The samples used were small and not ethnically diverse, which makes applying the results difficult. It is possible that the study sample used was not a correct representation of children and families, which would have produced skewed results (Fisher & Birch, 1999).
Although both experiments in Fisher’s and Birch’s (1999) study exposed children to restricted food, the restriction was not initiated by parents. Many authors claim that parents have the strongest dietary influence on children, especially at young ages (Clark et al., 2007). This suggests the possibility parental food restriction could produce a much more profound affect than what Fisher and Birch (1999) observed. If the experiments were redone to have parents restrict food access, the relationships found may be considered more significant (Fisher & Birch, 1999).
Several researchers have explored the specific relationship between maternal restriction and child weight (Birch et al., 2003; Powers et al., 2006). Birch et al. (2003) conducted a study that focused on the maternal restrictive effects seen in girls ages 5 to 9 years. The study’s specific goals were to determine if maternal restriction promoted eating in the absence of hunger (EAH) among female children over a span of four years and whether this impacted the children’s weight. Birch et al. (2003) expected to see positive correlations between both aspects.
Birch et al. (2003) analyzed 197 females and their parents every two years, beginning when children were five years old. Each time the girls ate lunch under laboratory conditions and where then asked to rate how full they felt. Afterwards, they were offered a variety of snacks and toys to play with as the researcher watched from another room.
The amount and type of snacks the girls consumed was recorded. Child BMI percentiles were also measured and the level of maternal restriction was determined using the CFQ. Correlation analyses were used to distinguish relationships between maternal restriction and child EAH. Maternal restriction was also compared with initial child weight in a 2X2 factorial (Birch et al., 2003).
Overall the results from Birch et al. (2003) found that girls who experience higher levels of maternal restriction at the age five were significantly more likely to exhibit higher levels of EAH at age seven (p< 0.001) and nine (p< 0.01). Figure 5 shows the increase in EAH that was observed over the four year period for girls whose mothers displayed high levels of restriction.
Girls who were initially overweight and had restrictive mothers showed the greatest increase in EAH at age nine (p< 0.01). This represented that maternal restriction increased total calorie consumption in young girls. However, initial overweight status was significantly correlated with an increase in maternal use of food restriction, leading the researchers to question whether these results were due to parental concerns over child weight (Birch et al., 2003).
Child Age (years)
Birch et al. (2003) used their results to suggest that maternal restriction promotes overeating in young girls, which can impact their weight status throughout life (Birch et al., 2003). Because this study was well-controlled and longitudinally designed, this relationship is considered valid. These results also correspond with previous studies, signifying that a strong association between maternal restriction and child eating behaviors exists.
However, the Birch’s et al. (2003) study was limited by the sample used, which was primarily Caucasian families. The results of this study can only be applied to this ethnic group and cannot pertain to effects of restriction on male children. New studies on the impact of maternal restriction to both genders and other ethnic groups are needed (Birch et al., 2003).
Powers et al. (2006) also explored the impacts of maternal restriction on child weight and eating behaviors. This study was one of the first to consider the impact of maternal food restriction on weight in ethnic minorities, specifically low-income African-American children. Earlier studies on parental feeding styles mainly assessed non-Hispanic, middle or upper class children, so Powers et al. (2006) believed it was important to expand research to ethnic minorities (Powers et al., 2006).
The researchers intended to reveal the associations between maternal restriction and the BMI of African-American mothers and pre-school children. They purposed that higher levels of maternal restriction would be related to a higher “desire to drink” and “food responsiveness” in children, as well as child BMI (Powers et al., 2006).
Powers et al. (2006) sampled 296 low-income African-American mothers who attended Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The mothers were asked to respond to a survey that included questions from the CFQ and Children’s Eating Behavior Questionnaire (CEBQ), both of which were considered validated tools.
The survey allowed researchers to score the degree of maternal restriction and asses the children’s eating behaviors. Mothers were also asked to provide their height and weight to calculate their BMI and determine weight statuses.
The heights and weights of their children were gathered from WIC records, which were updated every six months. With this information, Powers et al. (2006) performed correlation analysis to identify any relationships and then linear regressions to control for the confounding factors of maternal education, income, employment, and marital status. (Powers et al., 2006).
The results from Powers et al. (2006) research found several relationships. The BMI of African- American mothers was significantly associated with their child’s BMI z-scores (r = 0.18, p = 0.002). However, the maternal use of restriction was not found to be related to maternal or child BMI, suggesting that restrictive practices among African-American mothers is not dependent upon personal or child weight statuses (Powers et al., 2006).
Maternal restrictive feeding practices was significantly correlated with child BMI z-scores before and after controlling for confounding factors, but only for obese mothers (r = 0.20, p = 0.03). Non-obese mothers displayed an opposite association; restriction was considered to be negatively correlated with child BMI z-scores (r = -0.16, p = 0.05). Linear regressions revealed that an increase in child “desire to drink” and “food responsiveness” was only found to be significant for restrictive practices among obese mothers (Powers et al., 2006).
Powers’ et al. (2006) study is a valuable resource for the associations between feeding practices in low-income African-American mothers and their children’s weight. This is not an ethnic or socioeconomic group that is usually included in samples, so this is considered a strong aspect of the study (Powers et al., 2006). However, the study also has weaknesses. The cross-sectional design places a limitation on the implication of the results, meaning it cannot be used to determine long-term relationships between maternal restriction and child BMI (Powers et al., 2006).
The researchers also revealed that the scale used to rank maternal restriction was not considered consistent among other tools. Because the questions used in the survey were designed for Caucasian parents, there may have been a cultural difference in interpreting the questions; African-American mothers may have understood the questions in another way and answered them differently. This would weaken the validity of the experiment (Powers et al., 2006).
In conclusion, Powers’ et al. (2006) study is only one of very few experiments on parental feeding styles in low-income African-American families, so further research within this specific sample needs to be completed to draw valid inferences (Powers et al., 2006).
Although Birch’s et al. (2003) and Powers’ et al. (2006) studies included very different samples, the studies aimed to identify similar relationships. The variables of interest (maternal restriction, child eating behaviors, and child weight) were the same for both experiments. However, each study found different associations.
The aspects of the studies are compared in Table 5. The different results found in Powers et al. (2006) study could be explained by the cross-sectional design, which did not allow long-term effects to be measured. Birch et al. (2003) on the other hand, failed to account for ethnic minorities and cannot apply the results to any outside groups. The longitudinal design of Birch’s et al. (2003) study and the ethnic diversity of Powers’ et al. (2006) study need to be combined in future research to provide the best evidence and distinguish valid relationships between maternal restriction and child weight (Birch et al., 2003; Powers et al., 2006).
5.Experiments on the Affects of Maternal Restriction to Child Eating Behaviors and Weight Status.
Compiled from Birch et al. (2003) and Powers et al. (2006)
Restriction is one of the most widely studied parental feeding styles and has been shown to have the strongest correlation to childhood overweight (Clark et al., 2007). The studies reviewed above provide evidence of a direct relationship between parental food restriction, dietary behaviors in children, and child weight status.
Although each study had unique designs and outcomes, they all had one conclusion in common; parental restriction may produce unintended consequences in child weight (Birch et al., 2003; Carnell & Wardle, 2007; Fisher & Birch, 1999; Faith et al., 2004 a). Parents need to be aware of these possible consequences and know how to properly feed their children (Clark et al., 2007).
Recommended Parental Feeding Styles to Treat and Prevent Childhood Obesity
Although parents adapt certain feeding styles with the best intentions, they are often unaware of the reverse effects it may have on their children. Clark et al. (2007) suggests that parental feeding styles have a large influence on childhood obesity rates. They believe that by providing parents with the proper knowledge and guidance on feeding techniques, childhood obesity can be prevented (Clark et al., 2007).
Nearly all authors agree that parents need to be informed and directed on the best child feeding approaches to avoid excessive child weight gain and a life-time of complications (Clark et al., 2007; Regber et al., 2007; Birch et al., 2003). In order to do so, parents should avoid using restriction, reinforcement, and force when feeding their children (Clark et al., 2007). Some authors have identified alternate feeding methods.
Regber et al. (2007) suggests authoritative parenting is the best method to feed children. Authoritative parenting refers to an involved, consistent, and encouraging, yet firm style that allows children to develop self-confidence and independence. When applied to feeding, authoritative parenting can encourage children to eat healthier and correctly respond to their internal satiety cues (Regber et al., 2007). An authoritative parent would not use an excessive amount of restriction, reinforcement, or force while feeding children. They would also not be permissive nor have no control over their children’s diet (Regber et al., 2007).
In addition to authoritative parenting, parents can help their children develop life-long healthy eating behaviors by practicing a “division of responsibility” (Clark et al., 2007). With this, parents are responsible for deciding when and what food to offer their children. However, children are solely responsible for deciding how much they eat. This is much better solution to parental restriction and force because it allows children to properly control their food intake, which is a skill that is essential for life-long weight management (Clark et al., 2007).
Birch et al. (2003) warns parents not to rely on restriction, force, or reinforcement feeding styles, especially if they are concerned about their child’s weight. Instead parents should focus on encouraging their children to consume healthier foods and set limits on how much snack food can be consumed. They should also help children learn portion control by setting a plate with the proper amount of food. By letting children eat directly from the bag or container, parents are prompting their children to overeat (Birch et al., 2003).
Although alternative feeding approaches have been recommended by several experts, actual research has not identified any effective feeding style for all socioeconomic and ethnic groups. Studies must be conducted to determine the best feeding styles for all populations (Clark et al., 2007). Meanwhile, the most essential thing a parent can do is to be a good role model and set a good example. If parents develop their own healthy eating behaviors, chances are their children will follow (Small et al., 2007).
Summary and Further Research Needed
Dr. Julie Gerberding, the head of the CDC recently claimed “The biggest problem we face in America in not terrorism; the biggest problem is obesity” (CDC, 2007 a). Despite attempts to improve healthy lifestyles, obesity remains a serious dilemma in children and adolescents. The number of obese children has shown immense growth over a short period of time and if action is not taken, it will eventually dominate the nation (Small et al., 2007).
Parents must be aware and prepared to deal the problems of overweight children (Clark et al., 2007). Parents serve as dietary and physical activity role models. They have the ability to influence what their children like to eat, so they must repeatedly encourage healthy foods (Fisher & Birch, 1999). By adapting to certain feeding styles, parents can influence their children’s dietary behaviors and weight status (Faith et al., 2004 b).
It is important for parents to realize that not all feeding styles results in positive outcomes. Restriction, force, reinforcement, and no control over food have been shown to result in adverse consequences, such as child weight gain, an inability to respond to satiety cues, eating in the absence of hunger, and increased energy intake (Clark et al., 2007; Birch et al., 2003; Small et al., 2007).
With this, parents are setting up children for a life-time of dietary troubles, problems with weight management, and possibly a battle with obesity (Carnell & Wardle, 2007). Parents need to make informed decisions regarding their feeding practices to instill healthy habits within their children.
Evidence indicates that some feeding styles are potential risk factors to childhood obesity, and parents have the ability to control this (Faith et al., 2004 a). However, not all the relationships have been revealed and many questions remain (Powers et al., 2006). Further studies are needed to determine the functional relationship between cultural values, socioeconomic status, and parental feeding styles, especially restriction (Birch et al., 2003; Clark et al., 2007; Powers et al., 2006).
In addition, researchers have not yet explored the genetic influences on child eating behaviors and weight status (Carnell & Wardle, 2007). Longitudinal designs need to be used to assess the long-term effects on child weight and satiety cues (Fisher & Birch, 1999; Powers et al., 2006). Most importantly, practical and lucid guidelines need to be developed that can direct parents of all races to acquire the best feeding practices and deter childhood obesity.
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