A Peer Reviewed Publication of the College of Allied Health & Nursing at Nova Southeastern University Dedicated to allied health professional practice and education http://ijahsp.nova.edu Vol. 7 No. 1 ISSN 1540-580X Childhood Obesity: Is Parental Nurturing to Blame? Julia D. La Rocca, RN, PA-C Physician Assistant, Davie, Florida United States CITATION: La Rocca, JD. Childhood obesity: Is parental nurturing to blame? The Internet Journal of Allied Health Sciences and Practice. Jan 2009, Volume 7 Number 1. ABSTRACT Childhood obesity has become a growing epidemic, and parents are to blame. In the United States alone the reports of obesity have continued to increase in over thirty-one states, with Washington D.C. being among the highest. Major contributing factors to this steady incline are lack of exercise and nutrition. There has also been an increase in prevalence among the minorities to include African Americans and Hispanic children. Alarmingly, obese children are at risk for developing medical and psychological consequences if left untreated. Are parental nurturing influences responsible for this growing epidemic in children? This clinical review article will objectively compare journal articles related to the impact of parental nurturing influences on a child's weight. INTRODUCTION The etiology of obesity in children is multifactorial in nature. Genetics are estimated to contribute between five and twenty-five percent of the risk for obesity.1 Other contributing factors are linked to dietary patterns, physical activity, television watching, and parent-child relationships. Obesity is non-discriminating among boys and girls and occurs in all ages, races, and ethnic groups.1 According to the Institute of Medicine (2004), parents (defined broadly to include primary caregivers) have a profound influence on children by promoting certain values and attitudes, by rewarding or reinforcing specific behaviors, and by serving as role models. These values start during the first years of life, and can promote healthy lifestyles for children if implemented correctly by parents.2 LITERATURE REVIEW It has also been theorized that children are more likely to be obese if their parents are obese. Is this contributed through genes or family lifestyles and behaviors? Are we feeding children too much food, or not enough food? Whatever the case, it’s evident that more research is needed relating to this specific topic. The South Dakota Children Health Study (SDCHS) conducted research pertaining to the influence of parents’ eating behaviors and child feeding practices on children’s weight status. Their objective was to investigate the effects of the parents eating behaviors, child feeding practices, and body mass index (BMI) on percentage body fat and BMI in their children.3 The National Blood and Heart Institute (2007) defines BMI as the appropriate relationship between height and weight.4 A healthy person should have a BMI of less than 25. People who are overweight might have too much body weight for their height (BMI > 25<30). People who are obese almost always have a large amount of body fat in relation to their weight (BMI >30). There are exceptions to these guidelines when dealing with athletes or persons with increased muscle mass. Since muscle weighs more than fat, these types of people would not be considered obese from the perspective of health risk. In children, the term obesity is used to refer to children and youth between the ages of 2 and 18 years old who have a BMI equal to or greater than 95th percentile of the age-gender-specific BMI, as developed by the Center for Disease Control and Prevention (CDC).5.6 A body mass index that is above the 85th percentile for a child’s age puts the child at risk for becoming overweight. The same guidelines exceptions apply for muscle mass and athletes in children as with adults. The South Dakota Children Health Study investigated the relationship between the parent and children BMI. The parents’ BMI © The Internet Journal of Allied Health Sciences and Practice, 2009 Childhood Obesity: Is Parental Nurturing To Blame? 2 was calculated from self-reported height and weight. The children’s percentage of body fat was assessed using BMI and dual energy X-ray (DXA). Each parent was then asked to complete two questionnaires which measured dimensions of parents’ eating behaviors and child feeding practices. Seventeen percent of the mothers and 24% of the fathers in the study were obese (BMI>30), and 30% of the mothers and 46% of the fathers were overweight (25>BMI<30).2 The results of the study concluded that overall, mothers had a stronger influence over their children’s weight and seem to be more concerned about their children’s eating behaviors than fathers. However, fathers did play a role in imposing child feeding practices. The children’s results concluded that the girls had a slightly lower BMI than boys, but with a higher percentage of fat. Both sons’ and daughters’ percentage of fat was related to mother’s BMI. No relations were found between father’s BMI and daughters’ and sons’ weight status. Girls had a greater BMI if either parent reported being overweight as a child, and both girls and boys were likely to be overweight if their mother believed they had risky eating habits (fussiness, eating too much, etc.) Girls with fathers who were controlling had a higher percentage fat; these fathers were also more concerned about their daughter’s future health.2 DISCUSSION If parents, especially mothers, are the key in helping to reduce the risk of overweight and obese children, then what type of prevention approaches are appropriate and when should they be initiated? Fundamentally, obesity arises from an excess of energy intake compared with energy overtime.7 However, do dietary factors during the infancy stages of child development set the stage for future obesity? Birch states that fat cells (adipose tissue) develop in an infant during pregnancy and are distributed during childhood. Additionally, he states that once this adipose tissue develops in the body, it remain there for life.8 If this is true, then maybe parents should start teaching proper eating habits at the beginning of a child’s life. Research informing effective early obesity prevention is one solution in helping to reduce obesity among children. We should begin by focusing on the baby’s gestational growth inside the mother’s womb. Boyles reports that early research suggests that babies born to untreated gestational diabetic mothers have nearly double the normal risk of becoming obese during childhood.5 Apparently, high blood sugar during pregnancy results in overfed babies in the womb. These overfed babies become metabolically imprinted or programmed in becoming obese. Fortunately, children with mothers who received adequate treatment of gestational diabetes had no further predicted risk than non-diabetic mother’s babies for obesity. Research is currently being performed today evaluating the benefits of breast milk over formula fed children in the prevention of obesity. It is hypothesized that breastfed infants benefit from the hormonal effects that may influence long-term energy metabolism and behavior.7 What has been established is that the benefit of breast milk compared to infant formula is greater, especially in helping to boost an infant’s immunity.7 It is then pragmatic to believe that breastfed infants obtain the right amount of fats, protein, vitamin, and minerals that will promote a healthy metabolism later in life, thereby minimizing the risk for future obesity. A child’s feeding practice is a combination of the food and portion sizes that children are offered, the frequency of eating occasions, and the social contexts in which eating occurs.8 This role is very critical in helping to structure a child’s eating habits and environment. Overnutrition seems to surpass undernutrition in today’s society. Infants and young children are completely dependent on their parents and other caregivers to provide them food. With this being said, it is time that parents and caregivers start becoming a positive role model in their children’s life, and start taking full responsibility for what, how much, and when they are feeding their children. Parents who eat healthy foods set an example and their children are more likely to follow that example than not. POTENTIAL SOLUTION Forcing the child to “clean your plate” may contribute to obesity. If a child continues to be forced into overfilling his or her stomach, then the child is not able to determine when he or she is full, and thus overeats. Bribing your child into clearing his or her plate is also discouraged. If the child continually lacks interest in the meal being provided, it is recommended that the food be removed and the meal time declared over. Do not introduce foods without overall nutritional value simply to provide calories. Do not worry; children will eat when they are hungry! 8 Being overly discouraging of and restrictive of high preference snacks (such as junk food) by parents is not recommended either. Surprisingly, too much parental feeding restrictions have been found to be associated with increased child eating and weight status.9 A restrictive diet may make the child feel deprived or neglected, and exacerbate the overeating problem. Children of parents who continued to restrict access of high preference snacks to their children were more likely to select these foods and in higher quantities when access was unlimited, as opposed to non-restrictive parents.9 The American Heart Association (AHA) set up specific dietary guidelines for parents and caregivers to follow in helping to © The Internet Journal of Allied Health Sciences and Practice, 2009 Childhood Obesity: Is Parental Nurturing To Blame? 3 promote cardiovascular health for infants, children, and adolescents. They too recommend breast feeding for optimal growth and development for the first four to six months after birth. One percent or skim milk is recommended after one year of age because of its low fat content. Parents are also recommended to introduce one-hundred percent juice only after six months of age, and no more than four to six ounces should be given daily. Sadly, so many children today are consuming too many calories via the consumption of whole milk, soda, and fruit and juice drinks, and this is affecting their weight and overall health. In helping to prevent childhood obesity, AHA recommends that parents should keep total fat intake between thirty and thirty-five percent for children 2-3 years of age, and twenty-five to thirty-five of calories for children and adolescence 4-18 years of age.10 It is also recommended that most fats should come from sources of polyunsaturated and monounsaturated fatty acids such as fish, nuts, and vegetable oils. Various dietary and calorie breakdown recommendations by age and gender are presented in Table 1. Table 1: Daily Estimated Calories and Recommended Servings for Grains, Fruits, Vegetables, and Milk/Dairy by Age and Gender10 1 Year 2–3 Years 4–8 Years 9–13 Years 14–18 Years Calories† 900 kcal 1000 kcal Female 1200 kcal 1600 kcal 1800 kcal Male 1400 kcal 1800 kcal 2200 kcal Fat 30-40% kcal 30-35% kcal 25-35% kcal 25-35% kcal 25-35% kcal Milk/Dairy‡ 2 cups¶ 2 cups 2 cups 3 cups 3 cups Lean Meat/Beans€ Female Male 1.5 oz 2 oz Fruits§ Female Male 1 cup Vegetables§ Female Male 5 oz 3 oz 4 oz 1 cup 1.5 cups 5 oz 6 oz 1.5 cups 1.5 cups 2 cups 3/4 cup 1 cup 1 cup 1.5 cup 2 cups 2.5 cups 2.5 cups 3 cups Grains 2 oz 3 oz Female 4 oz 5 oz 6 oz Male 5 oz 6 oz 7 oz †Calorie estimates are based on a sedentary lifestyle. Increased physical activity will require additional calories: by 0-200 kcal/d if moderately physically active; and by 200–400 kcal/d if very physically active. ‡Milk listed is fat-free (except for children under the age of 2 years). If 1%, 2%, or whole-fat milk is substituted, this will utilize, for each cup, 19, 39, or 63 kcal of discretionary calories and add 2.6, 5.1, or 9.0 g of total fat, of which 1.3, 2.6, or 4.6 g are saturated fat. §Serving sizes are 1/4 cup for 1 year of age, 1/3 cup for 2 to 3 years of age, and 1/2 cup for 4 years of age. *A variety of vegetables should be selected from each subgroup over the week. *Half of all grains should be whole grains. ¶For 1-year-old children, calculations are based on 2% fat milk. If 2 cups of whole milk are substituted, 48 kcal of discretionary calories will be utilized. The American Academy of Pediatrics recommends that low-fat/reduced fat milk not be started before 2 years of age. Table used with permission from the AHA. ASSOCIATED RISK FACTORS In addition to inappropriate dietary intake, physical inactivity in children today also is linked to childhood obesity. Children and adolescents who watched the most television were more obese than peers who watched it less.1 In general, the more television a child watches, the greater chance he or she has in becoming obese. Other contributing factors to childhood inactivity are the use of video games or other electronic devices (i.e. computers, ipods). It is suggested that the potentially harmful nature of the aforementioned activities results from the combination of the small amount energy that is expended by the children combined with concurrent consumption of high-calorie snacks. © The Internet Journal of Allied Health Sciences and Practice, 2009 Childhood Obesity: Is Parental Nurturing To Blame? 4 POTENTIAL HEALTH RISKS The Institute of Medicine reported over the past three decades that the childhood obesity rate has more than doubled for preschool children aged 2-5 years and adolescents age 12-19 years; it has more than tripled for children aged 6-11 years.2 Presently, the numbers continue to rise, resulting in the growing epidemic of obesity. It is up to the parents and caregivers to teach children at an early age how to eat responsibly by controlling portion sizes and encouraging children to stop eating when they feel full.5 School-based education should also include proper nutrition and good exercise/activity habits. Parents should not only support and encourage their children to participate in extracurricular and recreational activities, but they should plan time for active family activities as well (i.e. family bike rides or walks). It is these types of learned behaviors that can positively impact a child and can lead to improved health throughout the child’s life. The Institute of Medicine reported that the cases of childhood obesity are rising such that a significant proportion of children are suffering the social, physical, and psychological consequence of this condition.2 Medically, obese children are susceptible to glucose intolerance, hypertension, hyperlipidemia, sleep apnea, gallstones, type II diabetes, metabolic syndrome, menstrual irregularities, and many other serious medical conditions. Psychologically, obese children are more likely to suffer from depression, anxiety, obsessive compulsive disorder, and low self esteem. Socially these children may become negatively stereotyped, discriminated, teased, or even bullied by other children.5 It is possible that childhood obesity may persist into adulthood, and may bring along with it all of the health, social, and psychological ramifications. Such conditions may eventually result in an increased risk of heart disease at an early age. Obese children are also more likely to become chemically dependent and possibly suicidal as a result of such psychological torment.2 POSSIBLE SOLUTION These health concerns discussed in this paper are immediate and warrant urgent preventive action starting today. Healthcare providers need to take a proactive role in screening and counseling at-risk children and families as soon as signs of risks are detected. It is the health care provider’s full responsibility to be aware of and encourage parents’ adherence to the current national recommendations for the prevention and treatment of childhood obesity. Additionally, it must be noted that preconceived notions regarding the health care providers’ own weight must not become barrier to adequately diagnosing and counseling at-risk children and families. Additionally, obesity among ethnic minorities is increasing. There is evidence today linking certain ethnic minority populations, children in low socioeconomic status families, and children in the country’s southern region, to higher rates of obesity than the rest of the population.5 Unfortunately, many ethnic minority cultures place strong emphasis on large, high fat, social meals. Complicating matters even more is the fact that the majority of these cultures consider having a full figure as attractive and normal. Furthermore, in low socioeconomic communities, barriers to combating obesity may be linked to the limited amount of safe recreational areas for children to utilize for play and exercise. For this reason, school physical education programs are even more crucial. Indeed, childhood obesity is easier to prevent than to treat.3 Childhood obesity research reports have concluded nationally that parents have a strong influence on whether their child is more likely to become obese; yet, what is the solution for the millions of children who are already affected? If this epidemic is to be overcome, than the community must unite for this cause! A continuum of interventions is needed from all aspects of the community today to help save our children. Until recently, the majority of school lunch programs were too high in saturated fat and cholesterol and too low in fiber, fruits, vegetables, and whole grains. Comically, school lunches were being referred to as “weapons of mass destruction.”11 Fortunately, the National School Lunch Program has already been scrutinized, and mandatory efforts to revise the school menus to healthier food and beverage selections are in effect nationwide today. A challenge that may arise from these menu changes is getting children to select and eat healthier foods that are now currently being offered. This is why it is crucial that children learn early what is considered healthy food. In addition to revisions to school menus, changes are also in progress addressing physical education classes in schools. A nationwide attempt to provide additional intense and effective physical education in school curriculum is under development. Recommendations to increase the amount of daily physical education have been proposed, but unfortunately are not yet forthcoming. Promisingly, many schools have been issued funding to help upgrade and purchase new gym equipment. Community involvement attempting to prevent and treat childhood obesity must also be mobilized. The Institute of Medicine © The Internet Journal of Allied Health Sciences and Practice, 2009 Childhood Obesity: Is Parental Nurturing To Blame? 5 suggest that more community efforts need to be implemented to help expand opportunities for physical activity in children.2 These suggestions include development of recreational facilities, parks, playgrounds, side walks and bike paths, routes for walking or bicycling to school, and safe streets and neighborhoods, especially for in high risk population. In addition, implementation of a diversity of recreational programs, youth organizations, and healthy-living pilot programs will also help to promote active lifestyles for both youth and families. It is every citizen’s responsibility to advocate for changes in policies affecting their neighborhoods so that positive changes can occur. 5 There is no question that the prevention and treatment of childhood obesity is one of the most important public health challenges today. Statistically, the prevalence of overweight and obesity in children continue to rise each year. Parents and primary caregivers must set a good example for children by modeling healthful eating behaviors and being physically active. The influential nurturing behaviors by parents can, without a doubt, positively or negatively impact a child’s risk in becoming overweight or obese. For this nation to overcome this emergent epidemic of childhood obesity, there must be a collaborative effort including parents, primary caregivers, teachers, schools, public health agencies, federal and local government, and local communities. Children are the future; families need to learn to nurture them in the best manner so that they can growth up and become healthy adults. REFERNCES 1. Kendall P, Wilken K, Serrano E. (2007, September 25). Childhood obesity. Retrieved November 29, 2007, from Colorado State University Web site: http://www.ext.colostate.edu/pubs/foodnut/09317.html 2. Focus on childhood obesity. (2004, September) Retrieved November 29, 2007, from Institute of Medicine Web site: http://www.iom.edu 3. Johannsen DL, Johannsen NM, Specker BL. Influence of parents' eating behaviors and child feeding practices on children's weight status. The North America Association fro the Study of Obesity, 2006:14;431-439. 4. Learn about BMI. Retrieved November 29, 2007, from National Heart and Blood Institute Web site: http://www.nhlbi.nih.gov/health/public/heart/obesity/wecan/learn-it/bmi-chart.htm 5. Boyles S.Gestational diabetes ups child obesity. (2007, August 28). Retrieved December 2, 2007, from MedicineNet.com Web site: http://www.medicinenet.com/script/main/art.asp?articlekey=83547 6. Defining childhood overweight. Retrieved July 27, 2008, from Center for Disease Control and Prevention Web site: http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/defining.htm 7. Gillman M. Breast-feeding and obesity. The Journal of Pediatrics, 2002:141(6);749-750. 8. Birch L. Child feeding practices and the etiology of obesity. Obesity, 2006:14;343-344. 9. Faith M, Scanlon K, Birch L, Francis L, Sherry B. Parent-child feeding strategies and their relationships to child eating and weight status. The North America Association for the Study of Obesity, 2004:12;1711-1722. 10. AHA (2007, December 3). Dietary guidelines for healthy children. Retrieved December 3, 2007, from American Heart Association Web site: http://www.americanheart.org/presenter.jhtml?identifier=4575 11. Muhammad N. (2003, March 25). School lunches: weapons of mass destruction? Retrieved July 27, 2008, from Final call.com Web site: http://www.finalcall.com/artman/publish/article_608.shtml © The Internet Journal of Allied Health Sciences and Practice, 2009