Childhood obesity prevention is a national priority

Childhood obesity remains at alarmingly high levels despite extensive prevention efforts. The most recent surveys indicate 17.2% of children ages 2 to 19 years are obese (Ogden et al., 2016). In young children, ages 2-5 years, prevalence is estimated at 9.4 %; 17.4% in children 6-11 years of age; and in adolescents, it is 20.6%. The significantly higher rates in older children and adolescents are a predictable consequence of years of poor diet quality and physical inactivity that follow from a pattern established in early childhood (Dubois, Farmer, Manon, & Peterson, 2007; Park, Li, & Birch, 2015). This trajectory underscores the need for early and sustained intervention. Development of obesity by age 5 has been associated with a four-fold increase in obesity risk in adolescence (Cunningham et al., 2014) which is predictive of adult obesity and other chronic disease risk. Moreover, significant disparities in childhood obesity prevalence and risk factors for obesity development have been identified for multiple racial/ethnical minority groups and for children from low-income backgrounds, among other sociodemographic factors (Datar & Chung, 2015; Dixon et al., 2012; Ogden et al., 2016. Evidence suggests these disparities are present by the preschool years (Taveras et al., 2013; Baidal et al., 2016), highlighting the importance of early life experiences for child health.

Poor diet and low levels of physical activity are critical factors that underlie excess weight gain and adiposity at all ages.  Multilevel, integrated behavioral interventions are critical for prevention of childhood obesity; interventions addressing both energy (and nutrient) intake and energy expenditure represent some of the most viable options for child and adolescent obesity prevention given the risks of pharmacological and surgical interventions. Beyond the context of obesity prevention, it is well known that adequate nutrition and physical activity are paramount for optimal growth and development. For this reason, caloric restriction is contraindicated in young children. Instead, dietary interventions must focus on manipulating dietary energy through food choices that improve diet quality within the recommended levels of total energy intake. Similarly, physical activity interventions must elicit significant energy expenditure through developmentally appropriate and enjoyable activities that target motor skill development, which in turn supports and motivates ongoing participation. Single factor interventions have not been as successful as interventions that address diet and physical activity; moreover, interventions that include a parent/caregiver have had the largest impact on child weight (McGovern et al., 2008).  In addition to considering integration of multiple facets of obesity prevention, opportunities for healthy diet and age-appropriate physical activity must be presented throughout the day and in all environments where children spend significant parts of their day, all of which represents a significant challenge for planning interventions. Integrating physical activity habits with healthy eating in young children to reduce the incidence of obesity requires both caregiver and teacher influences, as well as direct education of young children themselves. Intervention programs designed for young audiences require targeted and structured teaching strategies that match the developmental stage of the child’s social, emotional, cognitive and physical abilities. While systematic correlational research confirms the importance of an integrated approach (Musaad et al., 2017), integrated curricula are scarce, and few parents and early care and education providers have the requisite knowledge, training, and support to provide and model quality nutritional choices and developmentally appropriate physical activity for young children. Therefore, the development and dissemination of appropriate integrated curricula for parents/caregivers represent critical needs and a novel approach in the obesity prevention field.

Physical activity quality and duration are both important for obesity prevention

Contrary to the popular belief that children in child care programs are generally active, there is evidence to suggest that activity levels in these programs vary greatly with levels in some programs being quite low (Cardon, Van Cauwenberghe, Labarque, Haerens, & De Bourdeaudhuij, 2008; Pate et al., 2004). An older systematic review of 39 studies showed that nearly half of pre-school children ages 3 to 5 years old do not engage in sufficient physical activity (Tucker, 2008). Other work has shown that physical activity levels decline steadily after age six (Tudor-Locke, Johnson, & Katzmarzyk, 2010). As far as preschoolers are concerned, more recent research reveals (1) only a very few program differences – such as attending Head Start -- appear associated with increased physical activity in children (Swyden, Sisson, Lora, Castle, & Copeland, 2017); (2) preschool children whose in-preschool activity levels are below recommended levels are more active outside of preschool, raising questions about preschool barriers to physical activity (O’Neill, Pfeiffer, Dowda, & Pate,2016); and (3) randomized controlled trials to increase physical activity levels or decrease sedentary activity in preschool classrooms have mixed or nonsignificant results, even those with multilevel strategies (e.g., DeCraemer et al., 2016) Thus, the call for intentional teacher activities, both indoors and outdoors, along with strategic adult involvement in the home setting as critical to promote meaningful physical activity (Brown 2009) has been heeded but more work is needed to identify those intervention components that are successful for increasing physical activity and how to integrate what occurs inside and outside of the preschool classroom. This may include promoting opportunities for movement skills that focus on physical skill development and self-efficacy, also called “physical literacy”, which is critical to maintaining an active lifestyle beyond the early years. Specifically, motor skills are acquired in a predictable pattern, and fundamental gross motor movements that form the basis for games, dance, sports, and other physical activities that emerge later must be learned in the early years of life. Research has shown primary school children who are proficient in motor skills are more likely to engage in vigorous physical activity (Wrotniak, Epstein, Dorn, Jones, & Kondilis 2006). Children who do not master basic movements and body control will have difficulty exhibiting the motor skills needed to engage in physical activity later in life and may gravitate away from active “play” and instead choose sedentary hobbies (Stodden et al., 2008).

Delivery of physical activity lessons in childhood has other important benefits, such as improvements in academic achievement (Donnelly et al, 2016). Many studies have demonstrated that regular cardiovascular activities, such as running, positively influence cognition, brain structure and function (Donnelly et al, 2016). Moreover, motor-demanding exercises, such as those requiring balance, have been shown to have additional benefits including better performance in concentration and attention to task not achieved by cardiorespiratory activities alone (Koutsandréou et al., 2008, 2016).

Diet quality is an essential factor for childhood obesity prevention

Diet quality is an important factor in preventing childhood obesity. Although there is not a universal definition for diet quality (Alkerwi, 2014), practical applications are widely used that encompass a healthful diet. This includes adhering to concepts presented in the U.S. Department of Health and Human Services and U.S. Department of Agriculture 2015–2020 Dietary Guidelines for Americans (2015) and the Healthy Eating Index (U.S. Department of Agriculture Center for Nutrition Policy and Promotion, 2013), such as decreasing consumption of high energy-density and low nutrient-density foods (e.g., cookies, candy and other sweets, sugar sweetened beverages) and increasing low-energy-density and high nutrient-density foods, such as fruits, vegetables, and lean proteins (Altman et al., 2015). Perry et al. (2015) investigated the relation between dietary quality and childhood overweight and obesity in the nationally representative Growing Up Ireland study of 8,568 school children aged 9 years and their families. Child heights and weights were measured, resulting in valid BMI (Body Mass Index = Weight (kg)/Height² (m²) data for 8,136 of the children; parents completed a 20-item food frequency questionnaire of foods consumed in the past 24 hours. After adjusting for gender, parent’s education, physical activity and television viewing, child obesity was significantly associated with poor diet quality with odds of obesity being 56% higher in those children in the lowest versus highest quintile of diet quality (Perry et al., 2015). Such a striking difference emphasizes the importance of continuing to include diet quality in obesity prevention programming.   

Because young children depend on parents/caregivers for sustenance, it is important to explore relationships between dietary intakes of children and parents (Robinson, Rollo, Watson, Burrows, & Collins, 2015) and the associations of parenting style and child feeding behaviors (Collins, Duncanson, & Burrows, 2014). Hubbs-Tait, Kennedy, Page, Topham, and Harrist (2008) investigated the relationship of parental feeding practices and parenting styles and concluded that parental feeding practices with young children predicted parenting style and interventions that do not address underlying parenting styles would likely not be successful (Hubbs-Tait et al., 2008).

Dietary intakes and food preferences of children are influenced by their parents’ food preferences (Patrick & Nicklas, 2005), which affect the overall quality of children’s diets. Patrick and Nicklas (2005) reported parents’ food experiences and their beliefs about which foods were healthy were related to their children’s food intake. Additionally, the physical and social environment is an important contributor to children’s eating patterns that should be considered when planning interventions, and parents’ behaviors, attitudes, and feeding styles are known to contribute to the social food environment. A recent study investigated the association between parental practices and children’s diet quality and body weight status (Faught, Vander Ploeg, Chu, Storey, & Veugelers, 2015). Higher quality diets of children were related to higher parental encouragement and concern about healthy eating practices These investigators stated “…health promotion initiatives that engage parents to consistently and effectively encourage and care about healthy eating may result in improvement of dietary outcomes of children and reduction of the prevalence of childhood obesity” (Faught et al. 2015, p. 827). Therefore, the role of the parent and parental food intake should be considered in approaches to childhood obesity prevention.

Healthy behavioral patterns rely on healthy relationships

The establishment of healthy patterns of eating and activity in early childhood depends not only on the eating and activity habits of parents and caregivers but also on the nature of the relationship they establish with their children (Saltzman, et al., 2016). These relationships are reflected in early parent-child feeding interactions (de Campora, Larciprete, Delogu, Meldolesi, & Giromini, 2016). Positive parent-child relationships are characterized by secure attachment (rather than insecure, anxious or disorganized attachment) and authoritative parenting styles (rather than authoritarian or permissive). Recent research has found links between attachment or attachment-related constructs and infant feeding/eating (de Campora et al., 2016) as well as child emotional eating (Hardman, Christiansen, & Wilkinson, 2016). For example, maternal attachment anxiety predicts child emotional over-eating (Hardman et al., 2016). Similarly authoritative parenting style is significantly associated with reduced child obesity/overweight (Olvera & Power, 2010; Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006; Shloim, Edelson, Martin, & Hetherington, 2015) and reduced child emotional eating (Topham et al., 2011).  

The importance of positive parent-child relationships for the prevention of obesity as identified by the observational studies discussed above has been recognized only recently, with seven child obesity intervention studies identified as emphasizing parenting in the first systematic review of the topic (Gerards, Sleddens, Dagnelie, de Vries, & Kremers, 2011). A more recent systematic review conducted by the Parenting Working Group of USDA Multistate W2005 (Hubbs-Tait, Kimble, Hingle, Novotny, & Fiese, 2016) identified 16 randomized or non-randomized child obesity prevention/intervention studies focused on parenting. Ten of the 16 studies found a significant effect of the intervention on child BMIz, BMI%, or weight, and eight of these 10 studies included parenting style or responsive parenting. Importantly, these effects were found mostly for children aged 6 and older, indicating a need to identify the most important relationship components to target in obesity prevention/intervention studies with younger children.

Child care providers are critical to child health and obesity prevention

In 2015, approximately 11 million children younger than age 5 were in some form of organized child care, which includes regulated home-based and center-based care, collectively referred to as early care and education (ECE) settings. Approximately 2.2 million people are practicing as ECE providers (Child Care Aware, 2016). On average, children in child care spend 36 hours per week in care outside the home, making ECE settings important venues for the development of healthy behaviors. To date, the majority of obesity prevention interventions have targeted school-age children, and few approaches have been considered in the ECE settings (Waters et al., 2011).

A recent review of interventions in early childhood suggests provider behaviors and interpersonal factors impact child health (Ward et al., 2015) in a manner similar to the parent-child relationship. For example, the authors cited numerous studies documenting how both positive behaviors of the ECE provider relating to food intake (e.g., eating with the children, allowing children to serve their own food) can have beneficial effects on child health behaviors, while negative provider behaviors (e.g., using food as a reward, scolding children for not finishing food on their plate) can promote development of unhealthy behaviors in children. Similar relationships regarding the physical activity behaviors of providers and children have been observed. However, the authors noted that very few interventions have targeted the relationship between provider behaviors and child health-related behaviors (Ward et al., 2015). In future research, significant attention should be paid to factors related to provider knowledge, attitudes, behaviors, and other relational factors with respect to early child health. Moreover, strategies targeting parent-child relationships should be considered for adaptation to the provider/child relationship, given the significant amount of time many U.S. children spend in the care of someone other than a parent or guardian.

W3005 objectives align with IOM goals, recommendations and actions for childhood obesity prevention

The proposed W3005 objectives of 1) identifying evidence-informed programs for healthy weight in childhood that focus on positive caregiver-child relationships, nutrition, and/or physical activity, 2) evaluating their quality and 3) integrating programs on positive caregiver-child relationships, nutrition, and physical activity to produce one or more synergistic programs for promoting healthy weight in childhood follow from the work of W2005 and align with identified national priorities. The 2011 report, Early Childhood Obesity Prevention Policies from the Institute of Medicine of the National Academies, recognizes the issues we outline above and makes recommendations for increasing physical activity in young children, decreasing sedentary behavior, and increasing healthy eating. The central role of parents and other caregivers in the home and early care and education care centers is emphasized, and the need to educate parents and train child care program staff to carry out these recommendations is highlighted. Despite comprehensive recommendations and potential actions, practitioners’ ability to implement them is limited in large part, we contend, due to a lack of programs that integrate recommended physical activity and nutrition practices for children (and the adults who must foster them) along with appropriate emphasis on parent/caregiver relationships that support adoption and maintenance of healthy behavior. W3005 objectives are designed to address this critical need.