Maternal responsiveness and toddler body mass index z-score: Prospective analysis of maternal and child mealtime interactions.

Responsive feeding, where parents are guided by children's hunger and satiation cues and provide appropriate structure and support for eating, is believed to promote healthier weight status. However, few studies have assessed prospective associations between observed parental feeding and toddler growth. We characterized toddler growth from 18 to 36 months and, in a subset of families, examined whether observed maternal responsiveness to toddler satiation cues and encouraging prompts to eat at 18 and 24 months were associated with toddler body mass index z-score (BMIz) from 18 to 36 months. Participants included 163 toddlers and their mothers with overweight/obesity who had participated in a lifestyle intervention during pregnancy. Anthropometrics were measured at 18, 24, and 36 months. In a subsample, mealtime interactions were recorded in families' homes at 18 (n = 77) and 24 (n = 75) months. On average, toddler BMIz remained stable from 18 to 36 months with 31.3% (n = 51) categorized with a healthy weight, 56.4% (n = 92) with at risk for overweight and 12.3% (n = 20) with overweight. Fewer maternal prompts to eat at 18 months was associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p = .002). Higher child weight status at 12 months was also associated with both higher probability of having at risk for overweight/overweight (p < .05), and higher child 36-month BMIz (p < .001). Neither 24-month maternal prompts nor 18 or 24 month responsiveness to satiation cues were associated with toddler BMIz. In this diverse sample, weight status was relatively stable from 18 to 36 months. Maternal prompts to eat measured earlier in toddlerhood and prior child weight status were associated with toddler BMIz.

Successful weight loss initiation and maintenance among adolescents with overweight and obesity: does age matter?

Treatments for adolescents with overweight/obesity demonstrate mixed success, which may be due to a lack of consideration for developmental changes during this period. Potential developmental differences in weight loss motivations, weight maintenance behaviours and the role of parents in these efforts were examined in a sample of successful adolescent weight losers. Participants enrolled in the Adolescent Weight Control Registry (n = 49) self-reported demographic information and weight history, reasons for weight loss and weight control, weight loss approach and weight maintenance strategies, and perceived parental involvement with weight loss. Associations between age at weight loss initiation and the aforementioned factors were examined using linear and generalized regressions, controlling for highest z-BMI and sex. Adolescents who were older (≥16 years) at their weight loss initiation were more likely to report losing weight on their own (37.5% vs. 75%, P = 0.01) and reported greater responsibility for their weight loss and weight loss maintenance (P < 0.001) compared to younger adolescents. Younger age at weight loss initiation was associated with greater parental involvement (P = 0.005), whereas older age was associated with greater adolescent responsibility for the decision to lose weight (P = 0.002), the weight loss approach (P = 0.007) and food choices (P < 0.001). Findings suggest the importance of considering developmental differences in responsibility for weight loss and maintenance among adolescents with overweight/obesity.

Effect of experimental change in children's sleep duration on television viewing and physical activity.

BACKGROUND: Paediatric observational studies demonstrate associations between sleep, television viewing and potential changes in daytime activity levels. OBJECTIVE(S): To determine whether experimental changes in sleep lead to changes in children's sedentary and physical activities. METHODS: Using a within-subject counterbalanced design, 37 children 8-11 years old completed a 3-week study. Children slept their typical amount during a baseline week and were then randomized to increase or decrease mean time in bed by 1.5 h/night for 1 week; the alternate schedule was completed the final week. Children wore actigraphs on their non-dominant wrist and completed 3-d physical activity recalls each week. RESULTS: Children reported watching more television (p < 0.001) and demonstrated lower daytime actigraph-measured activity counts per epoch (p = 0.03) when sleep was decreased (compared with increased). However, total actigraph-measured activity counts accrued throughout the entire waking period were higher when sleep was decreased (and children were awake for longer) than when it was increased (p < 0.001). CONCLUSION(S): Short sleep during childhood may lead to increased television viewing and decreased mean activity levels. Although additional time awake may help to counteract negative effects of short sleep, increases in reported sedentary activities could contribute to weight gain over time.

Relationship between dietary energy density and dietary quality in overweight young children: a cross-sectional analysis.

BACKGROUND: Observational research has found that lower energy density (ED) diets are related to reduced intake of fat and greater intake of fruits and vegetables. No study has examined the relationship between dietary ED and dietary quality, as determined by the Healthy Eating Index-2005 (HEI), in children who are overweight and obese. OBJECTIVE: Examine the relationship between dietary ED and HEI, determined from 3-d food records, in 156 children, aged 4-9 years, who had ≥85th percentile body mass index presenting for family-based obesity treatment. METHOD: Dietary ED, in kcal/g, was calculated using two methods: food and all beverages consumed (food+bev) and food only consumed (food). For calculation of HEI, all components of the HEI were included except oils. RESULTS: Participants were classified as consuming a low-ED, medium-ED or high-ED diet using tertile cut-off points with ED calculated using food and beverages(food+bev) or food only(food) . After controlling for group difference in child sex and race and parent sex, LOW(food+bev) and LOWfood had significantly (P < 0.05) higher total HEI scores, and total fruit, total vegetable and saturated fat HEI scores than HIGH(food+bev) and HIGHfood , with higher scores indicating greater quality. CONCLUSIONS: Lower dietary ED is associated with higher dietary quality in children presenting for obesity treatment. Additional research investigating an ED prescription on dietary quality in children who are overweight or obese is needed to better understand this relationship.

18-month outcomes of a community-based treatment for childhood obesity.

BACKGROUND: Few studies have evaluated community-based interventions for childhood obesity and even fewer provide efficacy data 1 year later. OBJECTIVES: This study assessed changes in relative weight 1 year after a 6-month treatment for childhood obesity. METHODS: Participants were 155 overweight/obese children/adolescents and their caregivers. The primary outcome was change in child percent over body mass index (BMI) from 6 to 18 months. The primary outcome was also assessed from 0 to 18 months and changes in secondary outcomes (BMI z-score, guardian weight, health-related quality of life [HRQoL]) were examined from 6-18 to 0-18 months. RESULTS: From 6 to 18 months, there were no significant changes in any outcome. From 0 to 18 months, there were improvements in BMI z-score (P < 0.001), HRQoL (P < 0.001) and guardian weight (P = 0.02). CONCLUSIONS: Changes in relative weight and HRQoL observed after 6 months persisted 1 year later. The programme produced reductions in BMI z-score and obesity prevalence but not in percent over BMI from 0 to 18 months.

Efficacy of U.S. paediatric obesity primary care guidelines: two randomized trials.

OBJECTIVE: The objective of this study was to examine the efficacy of U.S. primary care paediatric obesity treatment recommendations, within two randomized trials. METHODS: Between November 2005 to September 2007, 182 families (children aged 4-9 years, body mass index [BMI] ≥85th percentile) were recruited for two separate trials and randomized within trial to a 6-month intervention. Each trial had one intervention that increased child growth-monitoring frequency and feedback to families (GROWTH MONITORING). Each trial also had two interventions, combining GROWTH MONITORING with an eight-session, behavioural, parent-only intervention targeting two energy-balance behaviours (Trial 1: reducing snack foods and sugar-sweetened beverages [DECREASE], and increasing fruits, vegetables and low-fat dairy [INCREASE]; Trial 2: decreasing sugar-sweetened beverages and increasing physical activity [TRADITIONAL] and increasing low-fat milk consumption and reducing television watching [SUBSTITUTES]). Child standardized BMI (ZBMI) and energy intake were assessed at 0, 6 and 12 months. RESULTS: In both trials, main effects of time were found for ZBMI, which decreased at 6 and 12 months (P < 0.01). In Trial 1, ZBMI reduced from 0 to 6 months, which was maintained from 6 to 12 months (ΔZBMI 0 to 12 months = -0.12 ± 0.22). In Trial 2, ZBMI reduced from 0 to 6 and from 6 to 12 months (ΔZBMI 0-12 months = -0.16 ± 0.31). For energy intake, main effects of time were found in both trials and intake reduced from 0 to 6 months (P < 0.05), with Trial 1 reducing intake from 0 to 12 months (P < 0.05). CONCLUSIONS: All interventions improved weight status. Future research should examine effectiveness and translatability of these approaches into primary care settings.

The association of maternal food intake and infants' and toddlers' food intake.

BACKGROUND: Young children's first experiences with food may influence development of food preferences and lifelong eating habits. However, little is known about what factors are associated with the development of eating behaviours in infants and toddlers. Studies with older children and adolescents suggest that parental food intake is associated with children's food intake. The purpose of the present paper is to determine whether this association starts even earlier during infancy and toddlerhood. METHODS: A convenience sample of n= 98 primarily African American mothers of children 6-18 months old completed questionnaires, including questions on their own and their young child's food intake. Mothers completed questions while waiting to be seen by their child's primary care provider. RESULTS: Per maternal report, children consumed fruit 2.45 (1.79) times, vegetables 1.63 (1.51) times and snack foods 2.22 (2.49) times each day. Infants' and toddlers' fruit (r= 0.54, P < 0.001), vegetable (r= 0.42, P < 0.001) and snack food (r= 0.37, P < 0.001) intake were significantly associated with maternal intake of each of these foods, respectively. These significant associations remained even after controlling for additional study variables. CONCLUSION: Even at very young ages, maternal food intake is an important correlate of children's food intake. Taken together with findings documenting significant snack food consumption in this age group, findings suggest that development of prevention and intervention programmes to enhance healthy eating behaviours need to start very early, perhaps just prior to children being introduced to complementary foods.

'Adventure therapy' combined with cognitive-behavioral treatment for overweight adolescents.

OBJECTIVE: Since peers have such an important influence on adolescents, we evaluated the efficacy of adding peer-based 'adventure therapy' to a standard cognitive-behavioral weight control program for overweight adolescents. METHODS: Adolescents (N = 76) aged 13-16 years and 20 to 80% overweight (M = 60.56%, s.d.=15.17%), were randomly assigned to one of two treatment conditions: cognitive-behavioral group treatment with 'adventure therapy' similar to Outward Bound (cognitive-behavioral treatment with peer-enhanced adventure therapy (CBT + PEAT)) or cognitive-behavioral group treatment with aerobic exercise (CBT+EXER). Anthropometric and psychosocial measures were obtained at baseline, at the end of the 16-week intervention, and at 10 months following randomization. RESULTS: Adolescents assigned to both treatment conditions demonstrated significant weight loss over time, F = 29.06, df = 2, 53, P < 0.01. Average weight loss did not differ significantly between groups (-5.31 kg for CBT + PEAT and -3.20 kg for CBT + EXER) at the end of treatment. There was a significant difference in the percentage of participants maintaining a minimum 4.5 kg (10 pounds) weight loss (35% in the CBT + PEAT condition vs 12% in the CBT+EXER condition, P = 0.042) 10 months from randomization. We also observed a significant age by treatment group interaction, such that older adolescents randomized to CBT + PEAT demonstrated more than four times the weight loss of older adolescents assigned to CBT + EXER (M = -7.86 kg vs M = -1.72 kg) at the end of treatment. CONCLUSIONS: Peer-based 'adventure therapy' is a promising adjunct to standard cognitive-behavioral weight control intervention for adolescents, and may be most effective for older adolescents.

Adolescent motor vehicle crashes: the relationship between behavioral factors and self-reported injury.

PURPOSE: To examine the relative importance of demographic and behavioral factors, as well as alcohol use, in motor vehicle crash (MVC)-related injuries in an adolescent sample. METHODS: Data were collected from two samples of adolescents. In Study 1, a total of 1576 9th through 12th graders from three different high schools provided information on risk-taking behavior and injuries experienced during the previous six months. Study 2 involved a more fine-grained analysis of behavioral factors related to MVC-related injuries. A sample of 573 adolescent males from an all-boys parochial high school completed questionnaires assessing risk-taking, attention and behavior problems, alcohol use, driving behavior, and self-reported injury. RESULTS: Rates of self-reported MVC-related injuries for a 6-month period were consistent across the two studies, ranging from 10% in the mixed-gender sample to 16% in the all-male sample. Consistent with previous findings, males reported more frequent MVC-related injuries and higher rates of risk-taking behavior. In Study 1, age and risk-taking behaviors were predictive of injuries while riding or driving in a car. In the all-male sample, risk-taking behavior and conduct problems were significant predictors of MVC-related injuries. CONCLUSIONS: Risk-taking is a consistent predictor of both general and MVC-related injuries. Intervention efforts with adolescents may be targeted at increasing safe driving strategies as well as decreasing risk-taking behaviors.

Adolescent risk taking and self-reported injuries associated with substance use.

OBJECTIVE: To examine the incidence of adolescent substance use at the time of injury and its relation to risk-taking behavior. METHOD: A total of 643 male and 782 female 9th through 12th grade students at three high schools anonymously completed surveys on any injuries that had occurred in the prior 6 months associated with substance use and risk-taking behavior. RESULTS: Males reported a higher incidence of injuries related to alcohol or other drugs than females (17.3% vs. 13%). The 17 year olds reported more injuries related to substance use than 14 or 15 year olds (20.2% vs. 14.4% and 15%, respectively). A logistic regression analysis revealed that the odds of a substance use-related injury increased approximately sixfold when adolescents reported engaging in risk-taking behavior. CONCLUSION: A significant portion of adolescents (approximately 15%) reported injuries associated with substance use. Adolescents who reported a history of risk-taking behaviors were much more likely to report substance use-related injuries.

Parent and child mealtime behavior in families of children with cystic fibrosis.

OBJECTIVES: We investigated the hypothesis that children with cystic fibrosis (CF) and their parents would show more maladaptive behaviors during dinner than children without CF and their parents. STUDY DESIGN: Children with CF (n = 32) and their parents were compared with 29 children without CF and their parents on the rate and frequency of parent-child behaviors during a typical dinner in the families' homes by using multivariate analyses of variance. RESULTS: When the rate of behavior, controlling for meal length, was examined, no differences were found between groups. However, parents of children with CF were found to differ from parents of control subjects in the frequency of direct and indirect commands (P <.05), coaxes (P <.01), physical prompts (P <.01), and feeding their child (P <.05). Children with CF were found to engage in more talk, spend more time away from the table, refuse food, and exhibit more noncompliance toward commands to eat than control children (P <.05 for all child variables). When behaviors were examined as a function of meal phase, parents of children with and without CF both showed an increase in commands (P <.01), coaxes (P <.05), feeds (P <.01), and physical prompts (P <.01) in the second half of the meal as compared with the first. Children with CF and the control children showed an increase in behaviors incompatible with eating during the second half of the meal compared with the first (P <.01). When faster eaters were compared with slower eaters, faster eaters consumed a higher percentage of the recommended daily allowance of energy (P <.01) than slower eaters and showed a trend to be at higher weight percentiles for age and sex (P =.08) regardless of group (CF or control). CONCLUSIONS: Children with CF and their parents do not differ from children without CF and their parents in the rate of behaviors exhibited or types of strategies used to encourage eating. However, children with CF and their parents engage in these behaviors more frequently. Our data do not support typical parenting behaviors as effective in meeting the CF dietary requirements. Additional support in the form of child behavior management training may be needed to assist parents in meeting their child's caloric requirements.

Empirically supported treatments in pediatric psychology: pediatric obesity.

OBJECTIVE: To review the efficacy of existing interventions for pediatric obesity with reference to the Chambless criteria. METHODS: Chambless criteria for determining treatment efficacy were applied to 42 randomized studies involving nonschool-based programs targeting childhood and adolescent weight loss. RESULTS: We summarize the following dimensions of the pediatric obesity treatment literature: description of participants, diagnostic criteria for study participation, experimental design, treatment protocol, treatment outcome, and follow-up. CONCLUSIONS: There is strong evidence for the short- and long-term efficacy of multicomponential behavioral treatment for decreasing weight among children relative to both placebo and education-only treatments. Conclusions about adolescent obesity treatment programs are more tentative as they have been less frequently examined, less rigorously controlled, and usually have not conducted long-term follow-up. Current research appears to be working to identify more efficacious treatments for pediatric obesity by exploring the specific behavioral strategies that will be most effective in modifying children's eating and physical activity habits.

Nutrition intervention for weight gain in cystic fibrosis: a meta analysis.

OBJECTIVES: A meta analysis of the literature on treatment approaches to malnutrition in cystic fibrosis (CF) was conducted to evaluate the effectiveness of oral supplementation, enteral nutrition, parenteral nutrition, and behavioral intervention on weight gain before and after treatment. STUDY DESIGN: Eighteen studies were reviewed: four behavioral, six supplement, five enteral nutrition, and three parenteral nutrition. RESULTS: The weighted effect size for weight gain was large for each intervention: 1.51 behavioral, 1.62 oral, 1.78 enteral, and 2.20 parenteral intervention. All interventions produced a large effect for weight gain in patients with CF. A univariate analysis of variance indicated no significant difference among the four interventions, F(3, 17) = 0.87, p > 0.05. Effect size for calorie intake was also evaluated when data were available (N = 7 studies), yielding a sample size of three behavioral, two enteral, and two oral supplement studies. Analysis of variance indicated a significant effect for treatment, F(2,4) = 13.34, p < 0.05, with post hoc analysis indicating that the behavioral intervention had a greater effect size for calorie intake than oral supplement. CONCLUSIONS: All interventions were effective in producing weight gain in patients with CF. Behavioral intervention appeared to be as effective in improving weight gain in patients with CF as more invasive medical procedures. These findings support continued research on nutrition intervention with patients with CF including controlled clinical trials of the interventions and long-term follow-up on the impact of nutrition on disease progression.

Relationship between substance use and self-reported injuries among adolescents.

High school students (n = 1983), 14-18 years olds, were surveyed regarding the incidence of injury and substance use at the time of the injury in the prior 6 months. Alcohol or other drugs were reported particularly often for falls, cuts, and gun and assault injuries. Alcohol or other drugs were reported to be involved in a substantial proportion of injuries resulting in medical care, most notably for gunshots (70%), pedestrian injuries (42%) and physical fights (38%).

Risk taking, reported injury, and perception of future injury among adolescents.

Investigated the relationships among self-reported injury, risk taking, and perception of injury risk in a sample of 1,426 adolescents, 14 to 18 years old. Both risk taking and injury were higher in males than females across age groups. Having a friend injured the same way was the strongest predictor of injury, accounting for 28% of the variance. Risk taking accounted for 4% of the variance. Sociodemographic variables-gender, age, and race-accounted for only 1% of the variance. Findings underscore the potential role of pediatric psychologists in both understanding and reducing the incidence of adolescent injury.

Descriptive analysis of eating behavior in school-age children with cystic fibrosis and healthy control children.

STUDY OBJECTIVE: To investigate calorie intake, behavioral eating styles, and parent perception of eating behavior of school-age children with cystic fibrosis (CF) compared with healthy peers. DESIGN: A two-group comparison study. SETTING: A clinical sample of 28 school-age children with CF and a community sample of 28 healthy peers matched for age (6 to 12 years) and socioeconomic status. MEASUREMENTS AND MAIN RESULTS: The children with CF consumed more calories per day (2175 cal/d) than the control children (1875 cal/d) and achieved a significantly higher recommended daily allowance (RDA) of energy (128% of the RDA) than the control children (91.61% of the RDA). Fifty-four percent of the CF sample were achieving the CF dietary recommendations of 120% of the RDA. Despite this energy intake, the CF sample was significantly below the control sample on weight (24.56 vs 31.23 kg), height (125.48 vs 133.06 cm), and z score for weight (-0.811 vs 0.528) and height (-0.797 vs 0.371). On measures of behavioral eating style, the CF sample had significantly longer meals (23.90 min) than the control sample (17.34 min) and had a significantly slower pace of eating (43.27% 10-second intervals with bites) than the control sample (51.29% 10-second intervals with bites) but did not differ significantly on the number of calories consumed during dinner. On a measure of parent report of mealtime behaviors, parents of the children with CF rated mealtime behavior problems of "dawdles" and "refuses food" as more intense (mean, 3. 46) than did the parents of control children (mean, 2.67). For the CF sample, a significant correlation was found between the parent intensity ratings of problem behavior in general and meal duration (r = .48), and a significant negative correlation was found between the parent intensity ratings of problem mealtime behaviors and the percentage of intervals with bites (pace of meal) (r = -.533). CONCLUSIONS: Although the school-age children with CF were consuming more calories per day than their healthy peers, and more than 50% of the children in the CF sample were at or above the CF dietary recommendations, the children in the CF sample were significantly below the control children on measures of weight and height. The behavioral data suggest that increased caloric intake is not without cost, because the CF sample spent an additional 7 minutes per day at dinner and ate their meals at a slower pace than their healthy peers. These data were associated with higher intensity ratings of mealtime behaviors by parents of children with CF. These findings point to the need for individualized assessment of energy needs for school-age children with CF and comprehensive programs that teach parents behavioral strategies to motivate their children to meet these higher energy requirements in an adaptive manner.

Behavioral intervention to improve calorie intake of children with cystic fibrosis: treatment versus wait list control.

Changes in calorie intake and weight gain were evaluated in five children with cystic fibrosis (CF) who received behavioral intervention and four children with CF who served as wait list controls. The behavioral intervention was a 6-week group treatment that provided nutritional education plus management strategies aimed at mealtime behaviors that parents find most problematic. The control group was identified prospectively and was evaluated on all dependent measures at the same points in time pre- and posttreatment as the intervention group. Difference scores on calorie intake and weight gain from pre- to posttreatment were compared between groups using t tests for independent samples. The behavioral intervention group increased their calorie intake by 1,032 calories per day, while the control group's intake increased only 244 calories per day from pre- to posttreatment [t(6) = 2.826, p = 0.03]. The intervention group also gained significantly more weight (1.7 kg) than the control group (0 kg) over the 6 weeks of treatment [t(7) = 2.588, p = 0.03] and demonstrated catchup growth for weight, as indicated by improved weight Z scores (-1.18 to -0.738). The control group showed a decline in weight Z scores over this same time period (-1.715 to -1.76). One month posttreatment, the intervention was replicated with two of the four children from the control group. Improved calorie intake and weight gain pre- to posttreatment were again found in these children. At 3- and 6-month follow-up study of children receiving intervention, maintenance of calorie intake and weight gain was confirmed. No changes were found on pulmonary functioning, resting energy expenditure, or activity level pre- to posttreatment. This form of early intervention appears to be promising in improving nutritional status and needs to be investigated over a longer period of time to evaluate the effects of treatment gains on the disease process.

Eating in preschool children with cystic fibrosis and healthy peers: behavioral analysis.

STUDY OBJECTIVE: To investigate calorie intake, behavioral eating styles, and parent perception of eating behavior of preschool children with cystic fibrosis (CF) compared with healthy peers. DESIGN: A two group comparison study. SETTING: A clinical sample of 32 preschool children with CF (aged 2 to 5 years) and a community sample of 29 healthy peers matched for age and socioeconomic status. MEASUREMENTS AND MAIN RESULTS: The two groups did not differ on the total number of calories consumed per day or the percentage of calories derived form fat. The CF sample achieved a significantly higher percent of the recommended daily allowance (RDA) of energy (95% RDA) than the control group (84% RDA), P < .05, but did not achieve the CF dietary recommendations of 120% RDA. On measures of behavioral eating style, the CF sample had significantly longer meals (24.63 min) than the control group (18.57 min), P < .01, but did not differ on pace of eating or calories consumed per bite. On a measure of parent report of mealtime behavior, parents of the CF sample identified mealtime behaviors of "dawdles" and "refuses food" as more problematic (M = .93) than parents of control children (M = .22), P < .05. CONCLUSIONS: While preschool children with CF consume as much or more than healthy peers, they are not achieving the CF dietary recommendations. Furthermore, there appear to be behavioral differences in eating and parent perception of CF children's eating that may contribute to the failure to achieve dietary recommendations.

Modifying problematic mealtime interactions of children with cystic fibrosis and their parents via behavioral parent training.

Implemented behavioral parent training targeting maladaptive mealtime behavior with two children with cystic fibrosis (CF) and their parents. Treatment was implemented in multiple baseline fashion across the two families. Primary dependent measure was coding of parent and child behaviors from videotaped dinners. Data were also collected on the children's daily calorie intake and weight. During treatment and at the posttreatment follow-ups, parents' attention to disruptive behavior decreased, attention to appropriate eating increased, and parental control at meals increased. The children showed an increase in appropriate behavior and a decrease in disruptive behavior; caloric intake and weight also improved. Results are discussed in terms of the applicability of behavioral intervention with feeding problems in children with CF.