• Maternal factors were studied and risk was assessed – Antenatal: • Maternal Age, Height, Weight, BMI (early pregnancy) • Parity, smoking, weight gain in pregnancy, HTN, DM – Postnatal: • Breastfeeding/formula feeding status at 6 and 12 weeks recorded • Timing of solid food introduction • Of the Maternal factors the most important factor that differentiated between growth trajectories was maternal BMI in early pregnancy, not maternal weight gain! – More kids in the accelerated and high growth trajectories Giles et al., 2015
Main Outcomes, Giles • Low trajectory group associated with reduced height and weight at 9 years – Slightly below the mean compared to intermediate • High and Accelerating trajectories were associated with increased overweight and obesity at 9 years – High: fourfold increase in odds of overweight or obesity by 9 years – Accelerated: 15 fold increase in the odds of overweight or obesity by 9 years • Maternal obesity in early pregnancy was associated with a fourfold risk of membership of the accelerating trajectory group Giles et al., 2015
Impact of Prenatal Influences • Excess maternal weight and weight gain • Premature birth +/- not conclusive • Maternal stress • Gestational diabetes (even controlled) • Smoking during pregnancy (results in low birth weight but later obesity)
ANSWER QUESTIONS #6-7 Giles et al., 2015 Giles et al., 2015
#6 The article describes four distinct growth trajectories noted in early childhood. Which of the trajectories is correlated with increased odds of overweight/obesity by the age of 9? A. High and Accelerated Growth trajectories B. High Growth trajectory only C. High and intermediate growth trajectories D. Low Growth trajectory only
#7 Of the antenatal and postnatal exposures considered, the most important factor that differentiated growth trajectories and showed a four-fold higher risk of the accelerated trajectory was: A. Maternal Diabetes B. Maternal tobacco use C. Hypertension in pregnancy D. Elevated maternal BMI in early pregnancy
BIRCH, L. L., AND A. E. DOUB. "LEARNING TO EAT: BIRTH TO AGE 2 Y." AMERICAN JOURNAL OF CLINICAL NUTRITION , 2014.
Learning to eat: birth to age 2 yr. Infants and toddlers’ experiences and learning within the caregiver - • child feeding relationship shape the development of eating behavior • Rapid brain growth and developmental milestones in first 2 years • Parent feeding practices play a critical role in food preferences and eating behaviors – What, when, and how parents feed • Parents have the opportunity to establish healthy dietary patterns but the persistence of traditional feeding practices is problematic. – Transition to table food diet is typically complete by 2 years – These were protective in times of food scarcity Feeding to Soothe: Now an overabundance of food, promote excessive energy intake • • Pressuring children to eat: promotes dislike of foods and preference for energy dense and sweet, food less likely to be eaten Feeding frequently or in large portions-decrease variety, eat fewer vegetables • • Offering preferred foods- evidence shows infants and preschoolers will eat more when given larger portions of preferred foods – These practices compromise development of self-regulation Birch & Doub, 2014
Learning to eat: birth to age 2 yr. Familiarization • Familiar is preferred, unfamiliar will be avoided or disliked • Milk is most familiar. When weaning, all things measured by this – Formula flavors – Breastmilk provides a variety of flavors • Infants reactions to foods introduced at weaning shapes the development of likes and dislikes for table food – Early exposure and repetition – With increasing age neophobia to novel foods and flavors increases until middle childhood • Understanding this helps see that this is a normal response not just “picky eating” • Infants also have unlearned preferences for sweet and salty and rejection of bitter and sour – Can be modified with repetition – Easy to establish unhealthy patterns if one forgets the importance of familiarization Birch & Doub, 2014
Learning to eat: birth to age 2 yr. • Associative Learning – Association of the food or flavor with the affect generated • Associations with emotional tone during feeding can shape food likes and dislikes – Pairing of novel flavors with familiar ones can influence development of food preferences • Unfamiliar flavor becomes associated with the preferred flavor, increasing liking of the new flavor, even by itself – Tasting the food is necessary to alter preference and intake • Yet children hesitate to taste. Flavor- flavor conditioning increases child’s willingness to taste novel food. Birch & Doub, 2014
Learning to eat: birth to age 2 yr. • Observational Learning – Social influence provides tool for promoting tasting and intake of novel foods • Children show tendency to taste unfamiliar food more readily when they observe adults eating them than when offered alone to the child Birch & Doub, 2014
HOW DO WE INSPIRE PARENTS TO BUILD A GOOD NUTRITION FOUNDATION?
Focus on Lifelong Habits….Not Weight • Enhancing patient-provider relations through parent-child engagement • Innovative, sustainable approach to build healthy habits
Mealtime is Playtime • Sight • Smell • Taste • Texture • Sound • Qualities • Fine motor skills • Exploration • Independence
Sensory Education & Exploration Instead of asking children if they like what they’ ve tasted, ask them to taste the food and tell you what they think: • Taste • Texture • Aroma • Appearance Sound • • Temperature
The Benefits of Sensory Education • Eliminates the thumbs-up/thumbs-down dismissal of food. • Helps develop awareness about different properties of food. • Allows for incremental exposure to difficult foods. Keeps kids open to multiple tastings. • • Takes the focus off fruits and vegetables (less pressure=more success). Fun! •
ANSWER QUESTIONS #8-16 Birch & Doub et al., 2014
#8 The article discusses how parenting and feeding approaches may: A. Impede the development of self-regulation and the acceptance of a variety of foods and flavors necessary for a healthy diet B. Improve fruit and vegetable intake C. Promote restrictive practices in feeding D. Encourage the child to have the same likes and dislikes as the parent
#9 The article states that the parent-child feeding relationships shapes the development of eating behavior. At what age is the transition typically completed from breast milk or formula to table foods only? A. 18 months B. 12 months C. 2 Years D. 3 Years
#10 Three important factors in the development of feeding practices include parents' decisions regarding: A. When and where children eat B. What children eat C. Why, for how long, and what children eat D. What, when, and how children eat
#11 Traditional feeding practices that developed in the context of food scarcity over centuries that are still practiced today include all of the following EXCEPT: A. Feeding to soothe B. Pressuring children to eat what is given to them C. Feeding frequently and offering large portions D. Offering preferred foods E. Eating small amounts to conserve food over time
#12 Pressure of children to eat 'healthy foods' has been associated with all of the following EXCEPT: A. A trial and error method that results in learning to taste new foods B. Dislike for the healthy foods C. Greater consumption of energy-dense sweet snacks D. Decreased likelihood of the healthy food to be eaten
#13 Which of the following is true regarding the familiarization process? A. The neophobic response in the toddler years is concerning in the development of picky eaters B. There is no link between early food preferences and food preference later in life C. Infants’ reactions to foods introduced at weaning shapes the development of likes and dislikes for table foods D. timing of the familiarization process is not important in the development of food and flavor preferences
#14 Which of the following is true regarding associative learning and feeding? A. Associations with emotional tone of social interactions during feeding can shape food likes and dislikes B. Pressure to eat can be beneficial in getting children to learn to like new foods C. Pairing of novel flavors with familiar flavors does not have an effect on the development of food preferences D. Flavor- flavor learning decreases children’s willingness to taste a novel food
#15 Which of the following is true regarding observational learning and feeding? A. Feeding behaviors do not change when children are eating in the presence of adults B. Modeling has little to no effect on the feeding behavior of children C. Children show a tendency to taste unfamiliar foods when they observe adults eating them D. Social effects of eating primarily change mood but not food consumption
#16 What contribution does breastfeeding have in the introduction and familiarization of food to infants? A. breastfeeding provides repeated exposure to a variety of flavors which increases the acceptance of initially rejected flavors B. breast milk is sweet, which makes it difficult to introduce vegetable flavors to infants beginning pureed foods C. breastfeeding increases the bond between mother and infant, making the infant trust the mother more regarding the introduction of new foods D. breastfeeding or formula feeding has no effect on the familiarization of new tastes or foods to infants
ANZMAN, S L, B Y ROLLINS, AND L L BIRCH. REVIEW ARTICLE "PARENTAL INFLUENCE ON CHILDREN'S EARLY EATING ENVIRONMENTS AND OBESITY RISK: IMPLICATIONS FOR PREVENTION." INT J OBES RELAT METAB DISORD INTERNATIONAL JOURNAL OF OBESITY , 2010, 1116-124.
Parental Influence on Children’s Eating Environments and Obesity Risk: Implications for Preventions Key Points • Parents have a high degree of control over their child’s eating environment • Parents’ own food preferences, intake patterns and eating behaviors greatly influence their children • Observational learning greatly affects children’s intake • Pressure, coercion, food restriction and strict meal time without hunger are counterproductive Anzman et al., 2010
Observational Studies Support • Early periods in eating transition and development show promise for targets in obesity prevention • Most notably post-natal suckling to solids but also baby food to table food • Repeated exposure to a variety of solid foods increasing acceptance of fruits and vegetables in childhood Anzman et al., 2010
ANSWER QUESTIONS #17-19 Anzman et al., 2010
#17 Traditional feeding practices to promote healthy eating support the positive influence of: A. Observational learning B. Coercion techniques C. Food restriction D. Strict meal schedule even in the absence of hunger
#18 Observational studies support the hypothesis that childhood obesity can be prevented by: A. Inattention to gestational weight gain B. Parents serving only the foods that they like C. Targeting the periods of developmental milestones like post-natal suckling to solid food transition D. Limited exposure to a variety of foods
#19 Research reveals that infants who are repeatedly exposed to a variety of solid foods during infancy showed: A. Restrictive taste preferences B. Less acceptance to fruits and vegetables in childhood C. More acceptance to fruits and vegetables in childhood D. More food allergies
MONTAÑO, Z., JD SMITH, TJ DISHION, DS SHAW, AND MN WILSON. "LONGITUDINAL RELATIONS BETWEEN OBSERVED PARENTING BEHAVIORS AND DIETARY QUALITY OF MEALS FROM AGES 2 TO 5." APPETITE , 2015, 324-29.
Longitudinal relations between observed parenting behaviors and dietary quality of meal from ages 2-5 • 731 culturally diverse, low income WIC families with children ages 2, randomized, controlled trial- half reg WIC, half intervention group • Intervention=Yearly home visits- ages 2, 3 , 4 or 5 assessment of positive behavior support defined as skillful behavior management and structuring of daily activities • Positive behavior support from parents helped predict dietary quality- video taped prep & meal Montaño et al., 2015
ANSWER QUESTION #20 Montaño et al., 2010
#20 Predictive measures of a child's dietary quality are related to: A. Positive interactive support of parents B. Duration of meals C. Clear expectations prior to the meal D. Controlling the child’s intake
BERGE, J. M., S. G. ROWLEY, A. TROFHOLZ, C. HANSON, M. RUETER, R. F. MACLEHOSE, AND D. NEUMARK-SZTAINER. "CHILDHOOD OBESITY AND INTERPERSONAL DYNAMICS DURING FAMILY MEALS." PEDIATRICS , 2014, 923-32.
Childhood Obesity and Interpersonal Dynamics During Family Meals. • Cross sectional study 120 children (mean age 9 yrs) and parents (mean age 35 yrs) • Low income within minority communities in Minneapolis/St Paul • Testing main hypothesis of Family Systems Theory • 2 home visits Day 1 and Day 10 • 8 day direct observational study w/ video of family meals, interviews, three 24 hr dietary recall • During family meals- measured types of food, length of meal, interpersonal communication and parental food control evaluated Berge et al., 2014
Family Systems Theory • Multiple levels of family influence - parent – child - child – sibling • Interpersonal communication matters in the context of food related dynamics • Impact of positive communication= group enjoyment, quality relationships can lessen incidence of overwt/obesity vs. negative factors=hostility, stress, intrusiveness, level of distractions & inconsistent discipline Berge et al., 2014
Conclusions • Less overweight/obesity children within positive family meal environment • Characteristics than can influence success include: - Length of meal – 20 minutes - Presence and engagement of family members - Positive interpersonal communication - Minimal distractions Berge et al., 2014
ANSWER QUESTIONS #21-23 Berge et al., 2014 Berge et al., 2014
#21 What is the main hypothesis of this study based on the Family Systems Theory? A. Positive interpersonal food related dynamics are good for families but have no impact on weight B. Positive interpersonal food related dynamics can lessen incidence of overweight/obesity C. Positive interpersonal food related dynamics work best with strict parental control
#22 The characteristics that influence the success of family meals include all the following EXCEPT? A. People present at the meal B. Television viewing during the meal C. Electronics used during the meal D. Length of the meal E. “Cleaning the plate”
#23 Family meals can be structured in hopes of preventing obesity by all of the following EXCEPT? A. Keep the meal short i.e. 20 minutes B. Include multiple family members with at least one parent C. Foster communication without electronic distractions D. Maintain a positive attitude encouraging group enjoyment E. Requiring all participants to eat their vegetables served
Discussion • Questions or Comments? • How do you foresee integrating this into your daily practice? Strengths and Challenges of doing so? • Biological Break
GREGORY, J. E., S. J. PAXTON, AND A. M. BROZOVIC. "PRESSURE TO EAT AND RESTRICTION ARE ASSOCIATED WITH CHILD EATING BEHAVIOURS AND MATERNAL CONCERN ABOUT CHILD WEIGHT, BUT NOT CHILD BODY MASS INDEX, IN 2- TO 4-YEAR-OLD CHILDREN." APPETITE : 550-56.
• Feeding strategies that parents use to control the quantity and content of their children’s food intake may influence the child’s eating behavior • Parents are more likely to use higher levels of control over child feeding when they are concerned about their child’s weight – Disrupts a child’s ability to self -regulate their eating – May exacerbate problem eating behavior • Pressure to eat more leads to reduced food consumption • Restriction of snack foods leads to increased preference for the food – However, modeled healthy eating has been found to increase intake of foods being modeled Gregory et al., 2010
Two Main Aims 1. Explore maternal feeding practices and concern about child weight (overweight or underweight) – Directive measures-pressure to eat and restriction – Non-directive measures-monitoring intake of unhealthy foods and modeling 2. Test whether this concern impacted child eating behaviors and/or BMI Measures Participants were mothers of children aged 2-4; given • questionnaires at home • Demographics • Concern about child weight • Feeding practices • Child eating behavior Gregory et al., 2010
• Key Findings – Pressure to eat was significantly positively associated with maternal concern about child underweight – Pressure to eat was associated with higher child fussiness – Restriction was significantly positively associated with maternal concern about child overweight – Mothers were not influenced by the child’s actual weight status, but their concern instead • Pressure to eat and restriction were associated with concern about child weight and eating behaviors but not with the child’s BMI directly Gregory et al., 2010
ANSWER QUESTIONS #24-27 Gregory et al., 2010 Gregory et al., 2010
#24 Parents attempts to restrict unhealthy foods and promote healthy foods can result in: A. Disruption of the child’s ability to self -regulate their eating and can exacerbate the problematic eating behavior B. Limitation of unhealthy foods and exclusion of those foods from the child’s diet C. Improved vegetable consumption D. Acceptable role modeling of feeding behavior for children
#25 The study discussed two primary aims. These were: A. To explore maternal feeding practices and concerns about child’s weight, and test whether this concern impacted child eating behaviors and/or BMI B. To explore food restriction and maternal factors related to food intake, and BMI of children as a result C. To explore relationships in maternal feeding as a child with choices made as an adult and their impact on BMI D. To focus on restriction of food and it’s effects on BMI alone
#26 There is a direct association between maternal concern for their child being underweight and: A. The child’s actual weight status B. Higher levels of food fussiness C. Failure to thrive in the child D. Decreased use of pressure to eat
#27 Overall study findings concluded that generally: A. Parents use feeding practices to control their child’s actual weight status B. Parents use of pressure to eat and restriction were directly related to the child’s actual weight C. Pressure to eat and restriction were associated with concern about child weight and eating behaviors but not with the child’s BMI D. The child’s BMI could be positively impacted by parental use of pressure to eat or restriction practices
"LOOK AT NUTRIENT DENSITY WHEN TALKING ABOUT HEALTHY DIET." AAP NEWS , 2015, 31. AAP COMMITTEE ON NUTRITION.
Look at nutrient density when talking about healthy diet • “Commentary” from the AAP Policy Statement on Snacks, Sweetened Beverages, Added Sugars, and Schools • Policy Statement focuses on competitive school foods considering 5 attributes – Selected from the 5 food groups (vegetables, fruits, grains, low- fat dairy, quality protein) – Promote a broad variety of food experiences – Avoid highly processed foods; use fresh when possible – Use the minimum amount of added sugar necessary to promote palatability and consumption – Adheres to USDA nutrition standards and portion sizes AAP News, 2015
• Commentary discusses errors of the past and new approaches – Elimination of foods that are deemed a high health risk – Low cholesterol, low fat, low sugar fads were ineffective and leave people confused • Focus instead on nutrient density – Foods are a blend of nutrients – It’s impractical to omit “bad” foods from the diet – “Forbidden” ingredients used in moderation improve the taste and enhance desirability of high-nutrient foods • Emphasis on nutrient- dense foods allow “all foods to fit” in a dietary pattern when portion and proportion are appropriate – Focus instead on gradual improvements without asking for abrupt change in dietary habit • Change to sweetened whole grain cereal with fiber from a sugary breakfast cereal AAP News, 2015
ANSWER QUESTIONS #28-29 AAP News, 2015
#28 The primary benefit of taking a nutrient-dense approach is: A. The ability to drastically change the diet quickly B. To focus on getting exactly the number of required nutrients from each food group each day C. Its ability to encourage gradual improvement in dietary choices without abruptly changing all dietary habits D. To better understand the food categories and necessary nutrients
#29 Emphasis on nutrient-dense foods and drinks allows an 'all foods fit' approach as long as: A. Portion and proportion are appropriate B. Portion sizes have calories exactly measured C. Excess sugar can be removed from the diet altogether D. Fatty foods are limited as much as possible
GINSBURG, K. R. "THE IMPORTANCE OF PLAY IN PROMOTING HEALTHY CHILD DEVELOPMENT AND MAINTAINING STRONG PARENT- CHILD BONDS." PEDIATRICS , 2007, 182-91.
The importance of play in promoting healthy child development and maintaining strong parent-child bonds. • Play has been recognized by the United Nations High Commission for Human Rights as the right of every child • Children are being raised in hurried and pressured style – may limit the protective benefits they would gain from child- driven play – Early focus on academic readiness Ginsburg, 2007
The importance of play in promoting healthy child development and maintaining strong parent-child bonds. The Benefits of Play • Play is important for healthy brain development – Practice adult roles – Work in groups – Negotiate – Resolve conflicts – Learn self-advocacy skills • Play should be primarily child-led – Adult led can cause kids to lose creativity, leadership, and group skills – Unstructured play builds healthy active bodies • Increased physical activity levels with unstructured play Ginsburg, 2007
The importance of play in promoting healthy child development and maintaining strong parent-child bonds. The Benefits of Play • Play and the Parent Relationship – Developmental trajectory is “critically mediated” by appropriate affective relationships with loving caregivers that relate to their children through play – Parents can see the world through the child’s eyes • Reduced Child driven play has potential repercussions Ginsburg, 2007
The importance of play in promoting healthy child development and maintaining strong parent-child bonds. What factors have changed the routine of childhood? • More families with single household head or 2 working parents • Fewer multi-generational households, resulting in more child-care • Parents have become increasingly efficient in managing work and home schedules – Strive to give children every possible opportunity and “make the most of their time” – “Professionalization of parenthood” The college admissions process • – Parents feel compelled to help their child build a strong resume – Students feel the need to do more and take more difficult classes Decreased play time at school to support academics • • Decrease play time at home due to passive activity • Safety Ginsburg, 2007
The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Why is it a problem? Some children can excel in this faster paced lifestyle • – Even these children need time to decompress This hurried lifestyle can be a source of stress and anxiety, and may • contribute to depression – Parents need to balance allowing the child to achieve his/her potential without pushing beyond child’s comfort limits • Increased pressures of adolescence have left some young people less equipped to manage the transition to college – Linked to highly critical parents that pressure to excel – American College Health Assoc. reports: • 61% college students had feelings of hopelessness during previous year • 45% were so depressed they had trouble functioning • 9% had suicidal ideation • Perfection at all costs mentality – Increased cheating in college – Despite grade inflation, students more stressed about scores Ginsburg, 2007
The importance of play in promoting healthy child development and maintaining strong parent-child bonds. What is a pediatrician to do? • Promote free play as a healthy essential part of childhood • Emphasize that active child-centered play is a way of producing healthy bodies • Discuss the benefits of “true toys” like blocks and dolls that promote the use of imagination Educate families regarding increased resiliency developed through • free play and unscheduled time • Support parental nurturing and support through parents that share in this spontaneous play • Supporting children having an academic schedule that is appropriately challenging and extracurricular exposures that offer appropriate balance. • Encouraging parents to allow children to explore a variety of interests in a balanced way without feeling pressured to excel in each area. Ginsburg, 2007
Never Forget the Crucial Role of Play Essential skills: • Social • Emotional • Cognitive • Physical • Creative • Communication
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