W2005: Parenting, energy dynamics, and lifestyle determinants of childhood obesity: New directions in prevention

(Multistate Research Project)

Status: Inactive/Terminating

W2005: Parenting, energy dynamics, and lifestyle determinants of childhood obesity: New directions in prevention

Duration: 10/01/2012 to 09/30/2017

Administrative Advisor(s):


NIFA Reps:


Statement of Issues and Justification

Obesity is an epidemic that is occurring even earlier in life than previously observed and impacting children as early as the preschool (ages 2-5) years (Gearhart et al., 2008). Among preschool-aged children, the obesity rate increased from 5% in the 1976-1980 NHANES to 10.4% in the 2007-2008 NHANES (Ogden & Carroll, 2010). While 10.4% of the nation's preschoolers are classified as obese with a body mass index (BMI, kg/m2) at the 95th percentile or higher, more than double that amount (21.2%) are overweight (BMI at the 85th percentile or higher (Ogden & Carroll, 2010). Overall, among children and adolescents aged 2-19 years, approximately 32% are overweight and 17% are obese (Ogden et al., 2010). The increasing number of younger children experiencing weight problems is especially alarming because it places them at risk for chronic diseases (Nelson et al., 2006).


The purpose of the proposed 2012-2017 W2005 Multistate Research project is to identify successful childhood obesity prevention strategies that include parenting and to translate those strategies for implementation by community and public health professionals. For young children, parents are role models and gatekeepers for food and physical activity. How can we help the parents provide the environment, support and example needed to help their children achieve a healthy weight? How can we help parents understand the dynamic nature of energy balance, which is impacted by the type and amount of food and physical activity their child receives? These are critical questions that can only be answered by a multistate and multidisciplinary team like the team comprising W2005 which includes experts in nutrition, physical activity, and parenting and child development.

Energy Balance: In the nutrition and physical activity area, energy balance is often used to understand obesity and body weight regulation. In the past, body weight was often described as a simple a balance between energy in and energy out. We now know that the factors that influence body weight are much more complicated. Energy balance is a complex interaction between energy intake, energy expenditure and body storage of energy that all interact to determine ones weight and body composition (e.g. the amount of fat or lean tissue an individual has). Each component of energy balance is influence by genetic and environmental factors. In addition, each component can be influenced by each other. Thus, changing one component can influence the others. For example, changing a childs physical activity can change energy intake by altering appetite  either increasing or decreasing  depending on the type, amount and intensity of the activity. Thus, our goal is to help parents have a better understanding of how they can positively influence their childs health and body weight relative to body height. These influences can last a lifetime and significantly alter their childrens health as adults.
Consequences: Childhood obesity is associated with a variety of immediate and long-term health consequences including psychosocial stress, asthma, sleep apnea, type 2 diabetes, fatty degeneration of the liver (hepatic steatosis), and cardiovascular disease risk factors such as high cholesterol, high blood pressure, and abnormal glucose tolerance (American Academy of Pediatrics, 2003; American Heart Association, 2011; Centers for Disease Control and Prevention, 2011a, 2011b). In addition to the physical consequences, obesity also affects children's psychological well being. Obese children were more likely to be socially isolated (Strauss & Pollack, 2003), had lower self-perceptions, and scored lower on self-worth compared to non-obese children (Braet et al., 1997). Also, overweight and obese children are more likely to become obese adults (Centers for Disease Control and Prevention, 2011b; Nicklas et al., 2001a).


Social and Biological Risk Factors. There are significant racial, ethnic, economic, and gender disparities in the prevalence of childhood obesity (Hudson, 2008; Ogden & Carroll, 2010) and non-Hispanic black girls and Hispanic boys are disproportionately affected (Centers for Disease Control and Prevention, 2011a). According to Hudson (2008), by age 6, the prevalence of obesity is disproportionately higher among black preschoolers than white preschoolers. According to the 2009 Pediatric Nutrition Surveillance System (Centers for Disease Control, 2009a), among low-income preschool children, obesity rates are highest among American Indian or Alaska Native children (20.7%) with other rates as follows: Hispanic (17.9%), non-Hispanic white (12.3%), non-Hispanic black (11.9%), and Asian/Pacific Islander (11.9%) children. Childhood and adolescent obesity rates are highest among non-Hispanic black girls (29.2%) and Mexican-American boys (26.8%), followed by non-Hispanic black boys (19.8%), Mexican-American girls (17.4%), non-Hispanic white boys (16.7%), and non-Hispanic white girls (14.5%) (Ogden & Carroll, 2010). Wang and Beydoun (2007) reported that minority and low-socioeconomic groups are disproportionately affected by overweight and obesity at all ages. According to Seith and Isakson (2011), the gap in overweight between poor and non-poor children is greatest among children in the preschool age range and the gap in obesity is greatest among adolescents aged 12 to 17 years. A much larger percentage (44.8%) of the nation's low-income children (living in households at less than 100% Federal Poverty Level) were overweight or obese in 2007, compared to 22.2% of the nation's higher income children (greater than 400% Federal Poverty Level) (National Initiative for Children's Healthcare Quality, 2007).


A number of factors including genetics, environment, culture, and socioeconomic status contribute to body weight and these factors are thought to interact and influence energy balance, or imbalance resulting in obesity (Centers for Disease Control and Prevention, 2009). The feeding context during early childhood is critical to the establishment of lifelong healthy eating habits (Nicklas et al., 2001b). However, dietary patterns of early childhood often do not follow recommended guidelines (Fox et al., 2010; Kranz et al., 2008). Increases in childhood body weights have largely coincided with changes in diet and consumption patterns, such as increases in portion sizes and energy intake (Nelson et al., 2006). While childhood obesity has been increasing, preschoolers' consumption of fruits, vegetables, and other nutrient-dense foods has decreased resulting in excessive intakes of fat, sodium, and calories in many children's diets (Fox et al., 2010). Reduction and prevention of childhood obesity are national health priorities, and many researchers agree that primary prevention of obesity in childhood is a key strategy for reducing the development of chronic disease and adult obesity (American Academy of Pediatrics, 2003, Dehghan et al., 2005).


Focus on Parenting Risk Factors. While children learn eating behaviors from adults and peers (Jansen et al., 2003), the crucial role of the family in shaping and supporting behaviors leading to healthy weight and preventing child overweight and obesity has been increasingly supported by research investigations since the dearth of such studies was identified in 2000 (IOM, 2000). Since 2000, research has increasingly focused on three aspects of parenting that contribute to children's weight status: general parenting styles, feeding practices, and feeding styles. Parenting style refers to the emotional climate (Darling & Steinberg, 1993) of parent-child interactions that both underlies and transcends specific parenting behaviors (Henry & Hubbs-Tait, 2011). Authoritative (high in responsiveness and high in limits, expectations, and standards), authoritarian (low in warmth and high in parental control), permissive (high in warmth and low in limits), and uninvolved (low in warmth and low in limits and control) parenting styles as well as blends of these styles (Baumrind, Larzelere, & Owens, 2010) are studied in the developmental sciences. Four recent U.S. studies have identified parenting style as a significant predictor of child weight status during the preschool or elementary school years. Two classified children into parenting style categories; two used continuous measures of parenting style. In a sample of 872 children who participated in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development with parenting styles measured in preschool and with child weight measured in first grade, Rhee et al. (2006) found that children of authoritative parents had significantly lower odds of obesity (BMI > 95th percentile) than children of authoritarian, permissive, or neglectful parents, with children of authoritarian parents having the highest odds of obesity. Olvera and Power (2010) found that among 69 Mexican-American 4- to 8-year-old children, those whose mothers were classified as indulgent (i.e., permissive) in parenting style were more likely to have become overweight BMI > 85th percentile and < 95th percentile) 4 years later than their peers whose mothers were authoritarian or authoritative. Chen and Kennedy (2005) reported that continuous parenting style scores that ranged from democratic (permissive) to authoritarian were inversely correlated with continuous BMI in 68 8- to 10-year-old Chinese-American children with lower scores (higher democratic/permissive) associated with higher BMI. Topham et al. (2010) found that 176 mothers' continuous permissive parenting style scores were associated with greater odds of obesity in their first-grade children if the mothers were also depressed or were of higher socio-economic status (i.e., had more economic resources with which to purchase foods). It is important to note that although these four studies of U.S. preschool or elementary school children identified significant links between children's weight status or BMI, three other studies did not (Agras et al., 2004; Gable & Lutz, 2000; Hennessey et al., 2010); two of these studies employed continuous measures of parenting style and one (Hennessey et al.) employed a categorical measure, underscoring the importance of further research, particularly meta-analytic reviews. It is also important to note that of the seven U.S. studies of children in the preschool and elementary school years, the two that focused on obesity (BMI > 95th percentile) found parenting styles to be significantly related to increased odds of obesity either directly (Rhee et al., 2006) or in interaction with other parent or family variables (Topham et al., 2010).


Hughes and her colleagues developed a classification system for parental feeding styles: authoritative, authoritarian, and two permissive feeding styles (indulgent and neglectful) corresponding to general parenting styles (Hughes, Power, Fisher, Mueller, & Nicklas, 2005; Patrick, Nicklas, Hughes, & Morales, 2005). Recent studies of the link of feeding styles to child weight status suggest that the indulgent style is related to higher BMI among preschool (Hughes, Shewchuk, Baskin, Nicklas, & Qu, 2008) and elementary school (Hennessey et al., 2010) children, with the most recent findings replicating these findings among Hispanic preschool boys in Head Start (Hughes et al., 2011).


Feeding practices refer to a wide variety of parental behaviors at snack times or family meals, in purchasing foods, and in eating outside the home. As an illustration of the complexity of current findings we focus first on one feeding practice, restriction. In samples of U.S. preschool and elementary school children, findings on the links between the maternal feeding practice of restriction and children's weight status are varied. Francis, Hofer, and Birch (2001) reported that in a sample of 196 non-Hispanic 5-year old girls and their mothers (104 with BMI > 25), daughters' BMI was positively correlated with mothers' restriction. Similar results were reported by Musher-Eizenman, Lauzon-Guillan, Holub, Leporc, and Charles (2009) for the 59 U.S. mothers of 4 to 7 year old children in this study of both U.S. and French families and for the high-risk for obesity portion of the Infant Growth Study (Faith, Berkowitz, Stallings, Kern, Storey, & Stunkard, 2004). In contrast, no significant association between maternal restriction and child BMI, weight status, or total fat mass was reported in a study of 108 Mexican-American 5th grade children and their mothers (Matheson, Robinson, Varady, & Killen, 2006), in a study of 967 low-income preschool children (May et al., 2007), or in the low-risk-for-obesity portion of the sample of the Infant Growth Study (Faith et al., 2004). Similar to a recent study in the United Kingdom (Webber, Hill, Cooke, Carnell, & Wardle, 2010), a U.S. study that included children ranging in age from 7 to 17 found that parental concern about child weight mediated the link between children's BMI-Z scores and parental restriction with no direct link between parental restriction and child BMI-Z (Gray, Janicke, Wistedt, & Dumont-Driscoll, 2010). These two recent U.S. and U.K. studies suggest that restriction may be a response to concern about child weight status; however, additional research is needed to evaluate whether such a response is effective at preventing child overweight and obesity or promoting healthy child weight.


Other parental feeding practices and more general parenting behaviors are implicated as important in child obesity prevention (Ventura & Birch, 2008). Parents, particularly mothers, are key to developing a home environment that fosters healthful eating among children via several feeding behaviors (Patrick & Nicklas, 2005; Ritchie et al., 2005). Studies have shown relationships between children's food choices and various home environmental factors, such as the influence of television viewing (Coon et al., 2001; Robinson, 2001), the impact of parental feeding practices (Birch & Fisher, 1998), the role of parental modeling (Birch & Marlin, 1982), the effect of food availability and accessibility at home (Baranowski et al., 1998; Baranowski et al., 1999), and the role of family meals (Gillman et al., 2000). Thus a focus on home food environment and parent's role in feeding children provides an important context for developing healthy eating habits and consequently prevention of overweight in children.


In W1005 (2006-2012) we approached childhood obesity prevention in the family context using the concept of resiliency, a characteristic that exists only in a condition of adversity. This concept was applied to families-those living in an environment that promotes obesity, but with children who are not overweight or obese and therefore resilient. We proposed to develop a framework (objective 5) informed by: what is currently being done by practitioners with a concurrent exploration into more useable physical screening tools as well as studies of families with children between the ages of 4-10 years old to distinguish parental behaviors that override the obesogenic environment from those that do not (objectives 1-3). Tools to distinguish between resilient and non-resilient families were to assist in the development of this framework (objective 4). The project team determined that tools exist to identify risk and protective factors for childhood obesity but not to identify resilient families, therefore, resiliency will not be pursued in this proposal. Rather, results from objectives 1-3, along with progress completed on objectives 4 and 5 (focused on parenting that protects from or increases risk of child obesity) will be applied in the new proposal.


Our greatest challenge will be to help the children and adolescents move in to adulthood without carrying the undue burden of obesity and its associated chronic diseases. We do not live in isolation. Children live in families, spend hours in childcare and schools and live and play in communities. How can we train Cooperative Extension specialists and County Agents about the role of parenting related to energy balance? How do parents model good diet and physical activity behaviors as part of a family lifestyle and environment that will help maintain a healthy weight for them and their children?


Integration of Energy Balance and Parenting. Currently, we teach energy balance using a static approach, without understanding the dynamic interplay that occurs between energy intake and expenditure (Hall et al., 2011). Numerous biological and behavioral factors regulate and influence body weight (Galgani & Ravussin, 2008; Hall, et al., 2011; Murphy & Bloom, 2006; Woods & D'Alessio, 2008). Approximately two-thirds of body size is genetically determined, thus, we can only impact the one-third attributed to lifestyle and the environment (Galgani & Ravussin, 2008). Understandably, most education and programming efforts are targeted to the latter. However, to be effective in facilitating sustainable behavior changes, the former must be better understood and appreciated by educators. Further, numerous government programs are aimed at educating about nutrition and/or diet to children and adults, but few have integrated in a meaningful way, the important message of both diet and physical activity. We must identify the most impactful lifestyle and environmental changes that will be most successful in helping children and families manage energy balance and tip the scale toward healthier weights.


Presently, there is no systematic approach that combines what we know about nutrition, healthy eating and physical activity related to energy balance into an integrated approach to teach parents about their role in obesity prevention for their children. One desired outcome of this project is to translate the scientific energy balance evidence and parenting styles into practical and appropriate recommendations for training extension health educators that work with parents.


The new proposal seeks to identify childhood obesity prevention strategies as influenced by parenting, (unique to this proposal) and to provide resources for community and health professionals to use this information in practice.

Related, Current and Previous Work

Review of CRIS projects that include energy balance (EB) and childhood obesity (CO) as descriptors with evaluation of the inclusion of W2005's emphasis on parenting is located in Appendix A.


Presently, there are 14 reports in the CRIS database that address energy balance (EB) and childhood obesity (CO). W1005: An Integrated Approach to Prevention of Obesity in High Risk Families was the only study that addressed parenting styles as well as energy balance and childhood obesity. W1005 through Objective 3 developed and administered a uniform research survey protocol to assess feeding styles, parenting styles, and dietary intake in relationship to perceived and actual weights of young children and their mothers. Members collaborated on data collection with low-income mothers and their 3- to 10-year-old children to identify patterns of maternal parenting styles, feeding styles, feeding practices, and modeling of healthy eating and activity linked to child obesity and overweight. Behaviors that were positively linked to overweight and obesity were viewed as risk factors that would not promote resilience of children in low-income families to overweight and obesity. In contrast, behaviors that were negatively linked to overweight and obesity were viewed as protective factors that would promote such resilience. Preliminary analyses reveal the possibility that, as is the case in several other studies (e.g., Rhee et al., 2006), authoritative general parenting style may be one of the protective factors against childhood overweight and obesity in the multistate data set.


The Multistate Research approach is ideal for developing and conducting research that will integrate parenting and energy balance research to stem the increase in rates of childhood obesity. This Multistate Research project will be integrated research, Extension and graduate education. Nitzke et al. (2004) describe the benefits of collaborations where Research and Extension professionals combined their expertise. The research component of the proposal is specified in objective 1 and the Extension component in objective 2 (see below). Graduate students of participating faculty members will be included in the activities pertinent to both objectives in order to integrate graduate education into W2005.


In summary, previous methods to prevent obesity and interventions to promote weight loss/weight control have been unsuccessful at stemming the increase in weight gain among both children and adults. Low income and minority populations are especially vulnerable to obesity but reasons for this are unknown. It is clear that the causes of obesity are multi-factorial involving complex interactions between physiological, behavioral, social and environmental variables.

Objectives

  1. Compare and contrast outcomes from 2006 W1005 objective 1 (field practice perspective) and objective 3 (parent-child interaction) with findings from seminal obesity-prevention research to identify successful child obesity prevention strategies as influenced by parenting.
  2. Using the results of objective 1 (above) develop resources such as translational research articles that community and public health professionals could use in implementing community programs that ultimately could change the trajectory of childhood obesity and overweight.

Methods

A. Objective 1- Compare and contrast outcomes from 2006 W1005 objective 1 (field practice perspective) and objective 3 (parent-child interaction) with findings from seminal obesity-prevention research to identify successful child obesity prevention strategies as influenced by parenting. 1. Develop preliminary list of correlates of childhood obesity that could be modified by parent, family, or community interventions. 2. Review the pertinent literature regarding parent, family, or community obesity- prevention research from the perspective of nutrition, physical activity, and developmental sciences. 3. Arrive at a consensus about the primary correlates of childhood obesity that can be addressed by parent, family, or community obesity prevention programs. 4. Assess the findings from 2006 W1005 objectives 1 and 3 in relation to the determinants identified in the review of literature, highlighting the differences. 5. If sufficient literature on the impact of parenting on child obesity is identified to warrant a meta-analysis, then one will be conducted that includes the results of objectives 1 and 3 from 2006 W1005. 6. If sufficient literature is identified, effect modifiers (moderators) will be explored in the meta-analysis in order to explain the differences identified in step 4 above. 7. These results and recommendations for future research will be published and presented for discussion and comment to provide new directions for prevention of childhood obesity. 8. Participating institutions: KY, OK, MI, NV, , NY, OR, AZ, MS, CT, HI, IL, SC. Laura Hubbs,Oklahoma State University and Madeleine Sigmon-Grant, University of Nevada, will take the lead on this objective. All those participating in this project will be involved in objective 1. Specific assignments will be delineated through conference calls and annual meetings B. Objective 2 - The aim of objective 2 is to translate the outcomes of objective 1 for use by community and public health professionals. Using the results of objective 1 (above) develop resources such as translational research articles that community and public health professionals could use in implementing community programs that ultimately could change the trajectory of childhood obesity and overweight. 1. Develop the protocol for discussion groups at the state, regional, or national level to prioritize and assess the feasibility of objective 1 findings for translation to the community level. 2. Execute the protocol for discussion groups at a variety of venues. 3. Compile and prioritize results from the discussion groups. 4. Develop resources based upon results from step #3. 5. Disseminate via webinars through eXtension, CYFERnet (Children, Youth and Families Education and Research Network), and professional organizations (e.g., National Extension Association of Family and Consumer Sciences, Society for Nutrition Education and Behavior, Priester Conference). All of these webinars will be archived for future use. A second avenue of dissemination will be translational presentations at professional meetings (e.g., National Extension Association of Family and Consumer Sciences, Society for Nutrition Education and Behavior, Priester Conference). 6. Participating institutions: KY, OK, MI, NV, NY, OR, AZ, MS, CT, HI, IL, SC. Melinda Manore, Oregon State University and Janet Kurzynske, University of Kentucky, will take the lead on this objective. All those participating in this project will be involved in objective 1. Specific assignments will be delineated through conference calls and annual meetings

Measurement of Progress and Results

Outputs

  • Manuscript(s) reporting the outcomes of the literature reviews.
  • Manuscript(s) and/or presentation(s) on the findings from 2006 W1005 objectives 1 and 3 in relation to the determinants identified in the review of literature, highlighting the differences.
  • A meta-analysis will be published if sufficient studies on the impact of parenting on child obesity are identified.
  • Translation and dissemination to parents of results of literature review and/or meta-analysis will take place through eXtension Communities of Practice (e.g., Families, Food, and Fitness)
  • Presentations at regional and national meetings to disseminate the discussion group findings. Webinars for eXtension, CYFERnet, and professional associations.

Outcomes or Projected Impacts

  • Advance the science of child obesity prevention, particularly an understanding of parenting, energy dynamics, and lifestyle determinants.
  • More effective programs for children and parents resulting from the educators being focused on those determinants of child obesity prevention, which are most effective in family- and community-based settings.

Milestones

(2013): 1. Develop preliminary list of correlates of childhood obesity that could be modified by parent, family, or community interventions. 2. Develop preliminary list of correlates of childhood obesity that could be modified by parent, family, or community interventions. 3. Review the pertinent literature regarding parent, family, or community obesity- prevention research. 4. Arrive at a consensus about the primary correlates of childhood obesity that can be addressed by parent, family, community obesity prevention programs.

(2014): 1. Assess the findings from 2006 W1005 objective 1 and 3 in relation to the determinants identified in the review of literature, highlighting the differences. 2. If sufficient literature on the impact of parenting on child obesity is identified to warrant a meta-analysis, then one will be conducted that includes the results of objective 2006 W1005. 3. If sufficient literature is identified, effect modifiers (moderators) will be explored in the meta-analysis in order to explain the differences identified above. 4. These results and recommendations for future research will be published and presented for discussion and comment to provide new directions for prevention of childhood obesity. 5. Develop the protocol for discussion groups at the state, regional, or national level to prioritize and assess the feasibility of objective 1 findings for translation to the community level.

(2015): 1.Execute the protocol for discussion groups at a variety of venues. 2. Compile and prioritize

(2016): 1. Develop resources based upon results.

(2017): 1.Disseminate via webinars through eXtension, CYFERnet (Children, Youth and Families Education and Research Network), and professional organizations (e.g., National Extension Association of Family and Consumer Sciences, Society for Nutrition Education and Behavior, Preister Conference). All of these webinars will be archived for future use. A second avenue of dissemination will be translational presentations at professional meetings (e.g., National Extension Association of Family and Consumer Sciences, Society for Nutrition Education and Behavior, Priester Conference).

Projected Participation

View Appendix E: Participation

Outreach Plan

Results will be disseminated through refereed publications, non-refereed but peer reviewed publications and presentations at state, regional, and national professional meetings. In addition, webinars will be conducted and archived on eXtension and CYFERnet. A particular effort will be made to reach Cooperative Extension educators, partners in public health, schools, youth development groups such as 4-H, and government who are trying to address the problem of childhood obesity. More than 50% of participants in W2005 hold Cooperative Extension appointments which will allow state educators across multiple states to disseminate findings to educators.

Organization/Governance

The organizational structure consists of a chair, vice-chair, and secretary nominated and elected annually by the technical committee. The chair will appoint subcommittees to complete specific tasks. Conference calls will be held at minimum quarterly and an annual meeting will take place to address progress on the project. After the initial call for participation, new membership will be determined by technical committee vote either at the annual meeting or by electronic poll. Voting criteria is based upon the project's need for specific expertise. This is to ensure project continuity and focus. It is expected that members will be active participants.

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