• 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
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
KRAMER, M., ET AL. “PROMOTION OF BREASTFEEDING INTERVENTION TRIAL (PROBIT), A RANDOMIZED TRIAL IN THE REPUBLIC OF BELARUS”, JAMA 2001; 285: 413-420.
PROBIT Promotion of Breastfeeding Intervention Trial • Effects of BF promotion on BF duration & health outcomes • Republic of Belarus • Cluster RCT 6/96-12/97 • BFHI vs non-BFHI hospital • 31 maternity hospitals and f/u clinics • 17,046 healthy mother-infant dyads – 12 mo f/u: 16,491 (96.7%) – 6.5 yr f/u: 13,889 (81.5%) – 13.5 yr f/u: 13,879 (81.4%) Kramer, et al. JAMA. 2001.
Impact of BFHI on Breastfeeding Exclusivity and Duration Babies born in BFHs achieved significant 50% increases in BF exclusivity and duration 40% during first year of life EBF 3 mo 30% • EBF at 3 and 6 mo EBF 6 mo 20% – 3 mo: 43.3% vs 6.4% Any BF 12 – 6 mo: 7.9% vs 0.6% 10% mo • Any BF at 12 mo 0% BFHI Control 19.7% vs 11.4% Kramer, et al. JAMA. 2001.
PROBIT and Obesity 6.5 yr: No differences in body mass index, waist • or hip circumference, triceps or subscapular skinfold thickness 11.5 yr: No differences in overweight or obesity, • or IGF-I levels Limited by low rates of obesity in Belarus as compared to US Kramer MS . Arch Gen Psychiatry. 2008.
AHRQ Review • Review of published literature in 2005 • Definitions • Exclusive vs. partial • Fed at the breast vs. fed breastmilk via an artificial source • Data combined from different studies • Focused on high level studies and meta analyses • Studies predominately observational in nature – Required comparison arm – Screened 9000 abstracts: • 29 systematic reviews that included 400 studies • 43 studies primarily infant and 43 primarily mother Ip et al . Evid Rep Technol Assess. 2007.
Benefits for Mothers and Infants Infant Mother Acute otitis media • Breast cancer Atopic dermatitis • Type 2 diabetes Asthma • Ovarian cancer Diabetes - Type 1 and 2 • Postpartum depression NEC Non-specific gastroenteritis Obesity Severe LRIs (RSV bronchiolitis; pneumonia) SIDS Ip et al . Evid Rep Technol Assess. 2007.
Benefits of Any and Exclusive BF Any Breastfeeding Risk Reduction Exclusive Breastfeeding Risk Reduction Acute Otitis Media (AOM) 23% AOM [> 3 mo EBF] 50% Asthma [>3 m0 +FH] 40% Atopic Dermatitis 32% [> 3 mo EBF] 42% [+FHx] Gastroenteritis 65% LRTI Hospital Admission 72% [> 4 mo EBF] Obesity 4% per mo SIDS 73% Leukemia [6 mo] 20% Type 1 Diabetes 60% Type 2 Diabetes 40% SIDS 36-45% Ip et al . Evid Rep Technol Assess. 2007. Kramer et al. Arch Gen Pyschiatry. 2008. Hauck et al. Pediatrics. 2011.
Lancet Breastfeeding Series 2016 • Systematic reviews: published & unpublished studies • 28 meta-analyses for outcomes associated w/ breastfeeding • National surveys & administrative data to help determine breastfeeding rates Victora CG, et al. Lancet. 2016;387:475-490.
Overweight or Obesity Never vs ever BF, longer vs shorter duration of EBF or longer vs shorter duration of any BF • Childhood, Adolescence, and Adulthood Overweight and Obesity : 13-26% decreased risk Victora CG, et al. Lancet. 2016;387:475-490.
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
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
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! Dina Rose PhD- It’s Not About the Broccoli
HOW DO WE HELP PARENTS ADDRESS PICKY EATERS ?
• Structuring the environment to set children up for success – Make sure the child is hungry – Sit the child at a table or in a high chair – Offer forced choices: You can have X or Y – Avoid asking if a child wants to try a food – Praise for being brave and trying a new food – Offer small tastes at first – Be persistent! Offer repeated exposures to the same food until it is tolerated at a meal
• Managing avoidance behaviors – Set a clear goal for how much the child needs to try – Require the child to stay seated until the goal is met – A timer can be set so refusal behaviors are not what lets the child out of the task – Provide positive attention when the child is sitting calmly and approaching the new food – Use planned ignoring for dawdling, verbal refusals, and other avoidance strategies – Might start with touching, kissing, or licking a food before working up to a bite
• Avoidant and Restrictive Food Intake Disorder is diagnosed in extreme cases of picky eating – Avoidance leads to restricting foods over time – Behaviors become difficult to manage – Incentives and exposure-based therapy often needed • ARFID behaviors can be driven by: – Sensory sensitivity – Lack of interest in eating – Fear of aversive consequences
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 – 2 yr f/u • 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
The Hunger Vital Sign A Simple Screen 1. “Within the past 12 mo, we worried whether our food would run out before we got money to buy more?” (Yes or No ) 2. “ Within the past 12 mo, the food we bought just didn’t last and we didn’t have money to get more?” (Yes or No ) Promoting Food Security for All Children . Pediatrics, November 2015 http://pediatrics.aappublications.org/content/136/5/e1431
Food Resources in Ohio Use Ohio AAP direct link to services: http://ohioaap.org/food-insecurity/ – Find local food pantries for immediate help – Provide information for WIC, SNAP, Pre- school & School Meal Programs, and the Summer Food Program for long-term help (OAAP Handout)
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
• Parents often worry about nutritional status and future health problems, regardless of actual weight – This can lead to pressure to eat or restriction of food (does not typically produce desired effects) – Parents may have history of picky eating/ overweight and want to similar prevent problems for their children • Parents get worn down by conflict or resistance at meal times -> leads to negative, coercive cycle
• Modeling and monitoring are effective but often underutilized and undervalued by parents – Monitoring should be paired with meal scheduling (in contrast to random restriction of food) – Modeling can be used to encourage healthy food choices and portion size • Pitfalls – Parents who think their child is underweight often encourage him/her to eat anything because it’s something – Can be difficult for parents to use modeling without pressuring
• Don’t expect parents to change practices right away- behavior change is hard! – Involves family routines, schedules, cultural factors, and meal habits – Incremental changes and problem-solving are beneficial – The whole family (which may include extended family) must be on board
"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- 2015 • 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 2017 -AAP Juice Policy change
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