building the foundations of health for all children

13th Annual Pediatric Specialty Update for the Primary Care Physician

– Pediatric Metabolic Health & Nutrition Summit

Jan. 27-28, 2017

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Building the Foundations of Health for All Children

Promoting nutrition and wellness: birth and beyondSandra G Hassink, MD, MS, FAAP

Director AAP Institute for Healthy Childhood WeightAdjunct Professor of Pediatrics

Center for Child Health and Policy Case Western Reserve Medical School



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Understand the foundations of child health

Understand the impact of obesity and food insecurity on the health of children

Understand ways in which pediatricians can care for children’s nutritional needs in their offices and communities



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When I approach a child, she/he

inspires in me two sentiments;

tenderness for what she/he is, and

respect for what he/she may

become.

Louis Pasteur



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Sound, appropriate nutrition

Health-promoting food intake, eating habits beginning with mother’s pre-conception nutritional status

Stable, responsive environment of relationships

Consistent, nurturing, protective interactions with adults that enhance learning, help develop adaptive capacities that promote well-regulated stress response systems

Safe, supportive physical, chemical and built environments

Provide places for children that are free from toxins, allow active, safe exploration without fear, offer families opportunities to exercise, make social connections

http://developingchild.harvard.edu/developingchild.harvard.edu/files/5012/8706/2947/inbrief-health.gif



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Child

Intrauterine Environment

Family

SES

Parental Health

Community

NutritionGender

Age Race

Parent Lifestyle

Safety

Parenting

Parent education

School nutrition

School physical activity

Social Connections

Early care

Access to medical/dental care

Media

DomesticViolence

Injury prevention

Literacy

Recreational facilities

Access to healthy Nutrition

Cultural/Religious Advertising

Foundations of Child Health Rooted in the Socioecologial Model

School

School Achievement

Genetics



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6

How are the children?



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Diet quality ◦ Children ages 2-17 who meet federal diet quality

standards: 50%

Obesity◦ Children ages 6-17 who have obesity: 18%

Activity limitation ◦ Children 5-17 with activity limitation resulting from

one or more chronic health conditions 9%

Food Insecurity ◦ Children 6-10 living in food insecure homes: 21%



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Emotional behavioral ◦ Children 4-17 (parent report) who have serious

problems with emotions, concentration, behavior, getting along with others 5%

◦ Youth 12-17 with past-year major depressive episode 8%

Early education ◦ Children 3-4 not enrolled in preschool 52%

Poverty◦ Children 0-6 live in low-income households 48%

(11% <50% poverty)

Toxic Stress ◦ Children with at least one adverse childhood

experience 50%



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“an adequate diet for children…one that contains an appropriate density of nutrients, is sufficiently diverse that it supplies adequate but not excessive amounts of nutrition, is palatable and culturally acceptable, affordable and available year round and overall supports normal growth and development.”

Allen L, Causes of Nutrition Related Public Health Problems of Children : Available Diet J Ped Gastr Nutr 2006 43 S8-S12



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"the limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways."

"Very low food security," the most severe level measured by the survey, is characterized by irregular meals and inadequate food intake, as determined by caregivers

U.S. Department of Agriculture

http://www.childtrends.org/?indicators=food-insecurity#sthash.VXI2ws3z.dpuf



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www.ncsl.org/issues-research/health/childhood-obesity-trends-state-rates.apx



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0%

5%

10%

15%

20%

25%

1971-1974

1976-1980

1988-1994

1999-2000

2001-2002

2003-2004

2005-2006

2007-2008

2009-2010

2011-2012

National Health and Nutrition Examination Survey (NHANES)

Age 2-5 Age 6-11 Age 12-19

12Childhood Obesity in Primary Care



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Courtesy Bill Dietz



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Source: Ogden, et al., 2014; Data from National Health and Nutrition Examination Survey, 2011-2102

percent



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States that appeared on the bottom 15 list of for obesity and either food insecurity or poverty

States that appeared on all three lists

States that appeared on the food insecurity and poverty list - but not the obesity list



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Obesity and under nutrition have been seen as separate, sometimes opposing entities

These two conditions coexist globally, nationally, locally ― even within families and individuals

The dual burden of under and over nutrition occurring simultaneously within a population is referred to as the double burden of malnutrition

Chopra, M. From apartheid to globalization: Health and social change in South Africa. HygieaInternationalis, 2004.4(1): 153–174.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.hunger-undernutrition.org/blog/2014/11/our-growing-double-burden-.html&ei=XfJ1Vd7gHoqKyASdo4GgDg&bvm=bv.95039771,d.cGU&psig=AFQjCNFZSaf1hfj1qivShhx_JNQwwo6UsA&ust=1433879462500415

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.hunger-undernutrition.org/blog/2014/11/our-growing-double-burden-.html&ei=XfJ1Vd7gHoqKyASdo4GgDg&bvm=bv.95039771,d.cGU&psig=AFQjCNFZSaf1hfj1qivShhx_JNQwwo6UsA&ust=1433879462500415



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Picture of food insecurity is increasingly a child with overweight or obesity consuming a poor-quality diet

Highest rates of obesity found in people with the lowest incomes◦ Among poor populations, 7 times as many children have

obesity as are underweightColeman-Jensen A, Nord M, Andrews M, Carlson S. Household Food Security in the United States in 2011. Washington, DC: US Dept of Agriculture; September 2012. Economic Research Service report ERR-141. http://www.ers.usda.gov/media/884525/err141.pdf

Challenge for low-income families is not obtaining enough food, but rather having dependable access to high-quality food◦ An estimated 16.7 million youth younger than 18 do

not consistently know when, or how adequate, their next meal will be

Kursmark M, Weitzman M. Recent findings concerning childhood food insecurity. Curr Opin Clin Nutr Metab Care. 2009;12(3):310-316

http://www.ers.usda.gov/media/884525/err141.pdf



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Paradigm of a disease embedded in the socioecological framework

Indicator of failure of the wider system to support child health

Need for a multifactorial solution across all sectors

Part of the shift from acute to non communicable disease

Calls for a population health approach



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frac_brief_understanding_the_connections.pdf



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Lack of full service grocery stores and farmer’s markets ◦ Reliance on corner/convenience stores

Greater density of fast food Larson N et al Neighborhood environments, disparities in

access to healthy foods in the US 2009 Am J Prev Med 36(1) 74-81

Cost differential between healthy (nutrient dense) and unhealthy food (energy dense/nutrient poor)

Poorer quality healthy food Andreyeva T et al Availability and prices of foods across

neighborhoods The case of New Haven CN 2008 Health Affairs 27(5) 1381-1388



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Fewer parks, green spaces, bike paths, and recreational facilitates

Gordon-Larson P, et al Inequalities in the built environment underlies key health disparities in physical activity and obesity 2006 Pediatrics 117(2) 417-424

Crime, traffic and unsafe play spaces Gordon-Larson P et al Barriers to physical activity, qualitative data on caregivers

perspective and practice Am J Prev Med 27(3) 218-223

Expense and transportation to participate in sports

Duke J et al Physical activity levels among children 9-13 years United States 2002 MMWR 52(33) 785-788

Low income students spend less time being active in PE and have less recess

Barros R et al School recess and group classroom behavior 2009 Pediatrics 123(2) 431-436



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Metabolic consequences of cycles of over and under consumption

Alaimo K et al Low family income and food insufficiency in relation to overweight in U S Children is there a paradox? 2001 Arch Ped Adol Med 155(10)1161-1167

Dietz W Does hunger cause obesity? Pediatric 95(5) 766-767

Maternal food restriction leading to obesity McIntyre L et al Do Low income mothers compromise their nutrition to

feed their children? 2003 Canadian Med Assoc J 168. 686-691



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Financial and emotional stress◦ Food insecurity, low wage work, difficulty paying

bills, inadequate and long distance transportation, neighborhood violence

Block JP et al Psychological stress and change in weight among US adults 2009 Am J Epid 170 (2) 181-192



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Fast food, sugary beverages, television shows, video games

Kumanyika S et al Targeting interventions for low income and ethnic populations 2006 Future of Children 16(1) 187-207



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Obesity-related co morbidities

◦ Type 2 diabetes◦ Hypertension◦ Nonalcoholic fatty liver

disease ◦ Dyslipidemia◦ Upper Airway Obstruction ◦ Sleep Apnea Syndrome◦ Blount’s Disease◦ Polycystic ovary

syndrome ◦ Obesity related

emergencies ◦ Depression/anxiety



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Children with obesity encounter more behavioral problems in school than children without obesity ◦ Internalizing problems (e.g., low self-esteem,

sadness, acting withdrawn)◦ Externalizing problems (e.g., arguing, fighting,

disobedience)◦ School discipline problems (e.g., detentions and

suspensions) ◦ Problems increasing significantly with increased

weight status Datar A, Sturm R: Childhood overweight and parent- and teacherreported behavior problems: evidence

from a prospective study of kindergartners. Arch Pediatr Adolesc Med 2004, 158(8):804-810. 7.

Halfon N, Larson K, Slusser W: Associations between obesity and comorbid mental health, developmental, and physical health conditions in a nationally representative sample of US children aged 10 to 17. Acad Pediatr 2013, 13(1):6-13.

Shore SM, Sachs ML, Lidicker JR, Brett SN, Wright AR, Libonati JR: Decreased scholastic achievement in overweight middle school students. Obesity (Silver Spring) 2008, 16(7):1535-1538.

Young-Hyman D, Schlundt DG, Herman-Wenderoth L, Bozylinski K: Obesity, appearance, and psychosocial adaptation in young African American children. J Pediatr Psychol 2003, 28(7):463-472.



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School problems increased with child’s BMI. ◦ Repeating a grade

◦ Low school engagement

◦ Increased school absence

Carey FR, Singh GK, Brown III HS, Wilkinson AV. Educational outcomes associated with childhood obesity in the United States: cross-sectional results from the 2011–2012 National Survey of Children’s Health. The International Journal of Behavioral Nutrition and Physical Activity. 2015;12(Suppl 1):S3. doi:10.1186/1479-5868-12-S1-S3.

Exposure to bullying and teasing



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Parent-reported poorer health and developmental risk More frequent stomach aches, headaches, colds, hospitalizations, anemia and chronic conditions More anxiety, depression, school difficulties

Nord M, Food insecurity in households with children: Prevalence, severity, and household characteristics.2009 USDA, Economic Research Service www.ers.usda.gov/Pulbications/EIB56/

More difficulty with interpersonal skills, self control, attentiveness, flexibility and persistence

Howard LL, Does food insecurity at home affect non cognitive performance at school? A longitudinal analysis of elementary school classroom behavior. 2010 Economics of Education Review 20, 157-176

Infants more likely to have insecure attachments and perform more poorly on cognitive assessments

Zaslow M et al Food security during infancy; Implications for attachment and mental proficiency in toddlerhood. 2009 Maternal and Child Health Journal 13(1) 66-80

Lower levels of physical activity To QG, Frongillo EA, Gallegos D, Moore JB.Household food insecurity is associated withless physical activity among children and adults

in the U.S. population. J Nutr. 2014; 144(11):1797–802

http://www.ers.usda.gov/Pulbications/EIB56/



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School age children are aware and distressed

May develop their own strategies for reducing food intake including choosing to eat less that they want

Fram MS, Frongillo EA, Jones SJ. Et al. Children are aware of food insecurity and take responsibility for managing food resources. J Nutr 2011;141(6) 114-119.

Teens express worry, anxiety or sadness, shame or fear of being labeled poor, feeling of having no choice

Connell CL, Lofton KL, Yadrick K, Rehner TA. Children’s experiences of food insecurity can assist in understand its effect on their wellbeing. J Nutr 2005;135(7)1684-1690

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Children who experienced hunger more likely to have poorer health

Repeated episodes of hunger are particularly toxic

Multiple episodes of hunger associated with a higher likelihood of chronic conditions and of asthma

The number of episodes of hunger that children experience is related to their health as they grow older

Kirkpatrick SI, McIntyre L, Potestio ML. Child hunger and long-term adverse consequences for health. Arch Pediatr Adolesc Med 2010;164:754-62.



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Short-term hunger can adversely affect attention and interest

Levinger B. Nutrition, health and education for all. Education and Development Centre. Newton MA: Education and Development Center, Inc, 1996.

Overnight and morning fasting (e.g. skipping breakfast) has been shown to adversely affect performance on cognitive tasks, particularly for children who are nutritionally at risk

Pollitt E. Does breakfast make a difference in school?. Journal of the American Dietetic Association 1995;95(10):1134.



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Children who live in food insecure households ◦ Worse performance in math and reading◦ Loss of school days because of illness ◦ Repeated grades◦ Lower engagement in school◦ Lower academic achievement scores in reading,

math, and science

Jyoti DF, Frongillo EA, Jones SJ. Food insecurity affects school children’s academic performance, weight gain, and social skills. J Nutr. 2005;135(12):2831–9.

Alaimo K, Olson CM, Frongillo EA Jr. Food insufficiency and American school-aged children’s cognitive, academic, and psychosocial development. Pediatrics. 2001;108(1):44– 53.

Murphy JM, Wehler CA, Pagano ME, Little M, Kleinman RE, Jellinek MS. Relationship between hunger and psychosocial functioning in lowincome American children. J Am Acad Child Adolesc Psychiatry. 1998; 37(2):163–70

Ashiabi G. Household food insecurity and children’s school engagement. J Child Poverty. 2005;11(1): 3–17

Tolbert Kimbro and Justin T. DenneyTransitions Into Food Insecurity Associated With Behavioral Problems And Worse Health Affairs, 34, no.11 (2015):1949-1955



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Higher rates of externalizing behaviors, such as aggression

Internalizing behaviors, such as depression and anxiety

Hyperactivity and inattention problems. Teachers reported generally worse scores for

interpersonal skills and self-control

Murphy JM, Wehler CA, Pagano ME, Little M, Kleinman RE, Jellinek MS. Relationship between hunger and psychosocial functioning in lowincome American children. J Am Acad Child Adolesc Psychiatry. 1998; 37(2):163–70.

Kleinman RE, Murphy JM, Little M, Pagano M, Wehler CA, Regal K, et al. Hunger in children in the United States: potential behavioral and emotional correlates. Pediatrics. 1998;101(1):E3.

Whitaker RC, Phillips SM, Orzol SM. Food insecurity and the risks of depression and anxiety in mothers and behavior problems in their preschool-aged children. Pediatrics. 2006;118(3):e859–68.

Alaimo K, Olson CM, Frongillo EA. Family food insufficiency, but not low family income, is positively associated with dysthymia and suicide symptoms in adolescents. J Nutr. 2002;132(4):719–25

Tolbert Kimbro and Justin T. DenneyTransitions Into Food Insecurity Associated With Behavioral Problems And Worse Health Affairs, 34, no.11 (2015):1949-1955



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Child hunger predictor of depression and suicidal ideation during late adolescence and young adulthood

Food insecurity linked with higher rates of adolescent mood, behavior and substance abuse disorders

Food insecurity early in life can weaken infants’ attachments to parents, which may negatively affect children’s mental health later in life

McIntyre L, Williams JVA, Lavorato DH, Patten S. Depression and suicide ideation in late adolescence and early adulthood are an outcome of child hunger. J Affect Disord 2013;150:123-9

McLaughlin KA, Green JG, Alegría M, et al. Food insecurity and mental disorders in a national sample of U.S. adolescents. J Am Acad Child Adolesc Psychiatry 2012;51:1293-303

Zaslow M, Bronte-Tinkew J, Capps R, et al. Food security during infancy: Implications for attachment and mental proficiency in toddlerhood. Mat Child Health J 2009;13:66-80.



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In 2010, more than one third of children and adolescents had overweight or obesity.

Childhood obesity has more than doubled in children and tripled in adolescents in the past 30 years.

Increased risk factors for comorbidities such as cardiovascular disease and diabetes.

Annual hospital costs related to obesity and comorbidities such as hypertension, type 2 diabetes, liver disease, and sleep apnea.

$127 million

One in five children lives in a food insecure home.

The US is falling short of meeting child food security targets.

Children with food insecurity are in poorer health

$167.5 billionCost of hunger charity, chronic illness, psychosocial dysfunction, diminished learning and economic productivity.



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31 well-child visits during the first 21years of life.

20 of the visits are during the critical first 5 years of a child’s life.



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FOOD INSECURITY INPEDIATRIC PRACTICE

• Screen for food insecurity― “Within the past 12 months we

worried whether our food would run out before we got money to buy more”

― “Within the past 12 months the food we bought just didn’t last and we didn't have money to get more.”

• Be familiar with and refer positive screens to community resources that address food insecurity (WIC, SNAP, school meals, summer feeding sites, food pantries, etc.)

• Advocate to protect and expand access to and funding for these programs at all levels of government

http://pediatrics.aappublications.org/content/136/5/e1431



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The Keeping Infants Nourished and Developing (KIND) program ◦ Collaboration between the primary care network and the foodbank

◦ The goal was to address FI in households with infants via provision of supplemental infant formula, tailored education, and connection to clinic and community resources or public benefit programs

An on-site physician, social worker, and dietician collaborated to define KIND eligibility criteria.

Families receiving KIND were significantly more likely to report risks relating to parental mental health, housing, benefits, and domestic violence, (highest-risk patients).

KIND may have served as a “connector” between these high-risk households and primary care ◦ Patients receiving KIND were more likely to have complete preventive services (eg,

lead, developmental screening) and 5+ well-infant visits in the first 14 months. more likely to be linked to interventions poised to address multiple and potentially interrelated concerns (eg, social work)

Forging a Pediatric Primary Care–Community Partnership to Support Food-Insecure Families Andrew F. Beck, Adrienne W. Henize, Robert S. Kahn, Kurt L. Reiber, John J. Young, and Melissa D. KleinPediatrics 2014; 134:2 e564-e571; published ahead of print July 21, 2014, doi:10.1542/peds.2013-3845



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• Calculate and classify BMI

• Screen for obesity related comorbidities

• Focus on stepwise family based change for children with obesity

• Prevention 5210

• Focus on early feedingand activity

• Foster parenting skills

https://ihcw.aap.org/



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Birth to 1 yr 8% >98% weight/length

1-2 yr 14% >98% weight/length

2-3 yr 15% overweight, 12% obesity

3-4 yr 16% overweight, 15% obesity

http://www.cdc.gov/pednss/pednss_tables/pdf/national_table20.pdf



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0

2

4

6

8

10

12

Total Boys Girls

>95% CDC

>97.7% WHO

11.0

Prevalence of Childhood and Adult Obesity in the United States

2011-2012

JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732

8.1 7.1

5.0

3.5

11.4

%



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0

1

2

3

4

5

6

7

8

9

10

White Black Hispanic

>95% CDC

>97.7 % WHO

Prevalence of Childhood and Adult Obesity in the United States

2011-2012

JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732

6.6

5.5

8.4

7.3

9.4

8.8

%



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Families with one or both parents who have obesity are at increased risk for having a child and adolescent with obesity

◦ Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869-73.



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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

1-2 yrs 3-5 yrs 6-9 yrs 10-14 yrs 15-17 yrs

not obese

obese

very obese



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Over 1/3 of women 20-39 yrs have a BMI> 30 ◦ Non-Hispanic white women (31.3%)◦ Non-Hispanic black women (47.2%)◦ Hispanic women (37.6%)

18% women 20-39 yrs have BMI > 35

4.2% women 20-39 yrs have BMI > 40 Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in

obesity among US adults 1999--2008. JAMA 2010; 303:235--41. National Health and Nutrition Examination Survey, 2007--2008.

Improving maternal health before and during pregnancy is a focal point for improving pregnancy outcomes, and reducing childhood obesity

Nohr EA, Timpson NJ, Andersen CS, Davey Smith G, Olsen J, Sørensen TI. Severe obesity in young women and reproductive health: the Danish National birth Cohort. PLoS One. 2009 Dec 24; 4(12):e8444



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Father’s BMI positively associated with child’s BMI z score

Father’s vigorous activity associated with child vigorous activity (no relationship between low-mod intensity activity or sedentary behavior)

Father’s total dietary quality associated with child’s total dietary quality (children ate more dairy, father’s more protein)

Vollmar R, Adamson K, Gorin A, Foster J, Mobely Investigating the Relationship of Body Mass Index Diet Quality and Physical Activity Level Between Fathers and their Preschool Age Children A J Acad Nutr Diet 2015

Father’s who were involved in children’s health care are open to discuss diet, activity and weight often felt left out

Lowenstein LM, Perrin EM, Berry D et al Childhood obesity prevention Fathers’reflections with healthcare providers. Child Obes 2013;9(2):137-143



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Parental obesity Maternal diabetes/gestational diabetes Maternal obesity Maternal smoking Intrauterine growth retardation Family high risk nutrition and activity

behaviors.

Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869-73.

Stettler N, Iotova V. Early growth patterns and long-term obesity risk. Curr Opin Clin Nutr Metab Care. Feb 22 2010.

Oken E, Levitan EB, Gillman MW. Maternal smoking during pregnancy and child overweight: systematic review and meta-analysis. Int J Obes (Lond). Feb 2008;32(2):201-210.



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9 yr old children of mothers who exceeded IOM gestational weight gain recommendations had higher:◦ BMI◦ waist circumference◦ fat mass◦ systolic blood pressure◦ c reactive protein◦ Leptin◦ interleukin-6

And lower ◦ HDL cholesterol◦ Apolipoproteina1 levels

Fraser A, Tilling K, Macdonald-Wallis C, Sattar N, Brion MJ, Benfiedld L, Ness A, Deanfield J, Hingorani A, Nelson SM, Smith GD, Lawlor DA Association of Maternal Weight Gain in Pregnancy With Offspring Obesity and Metabolic and Vascular Traits in Childhood. Medical Research Council Centre for Causal Analyses in Translational Epidemiology, Department of Social Medicine, University of Bristol, Bristol, UK.



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Overweight rates were higher in offspring of mothers who were both overweight and had gestational diabetes (GDM)

Lamb MM, Dabelea D, Yin X, Ogden LG, Klingensmith GJ, Rewers M, Norris JM. Early-life predictors of higher body mass index in healthy children. Ann Nutr Metab. 2010; 56(1):16-22. Epub 2009 Nov 27.

Adequate treatment of GDM during pregnancy may attenuate this risk

Hillier T. A., K. L. Pedula, M. M. Schmidt, J. A. Mullen, M. A. Charles and D. J. Pettitt. 2007. Childhood obesity and metabolic imprinting: the ongoing effects of maternal hyperglycemia. Diabetes Care 30(9): 2287-2292.



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Increased fat mass, body fat, ponderal index (wt/ht3),and insulin resistance compared to newborns of mothers with normal weight

The degree of insulin resistance in an infant correlates with maternal insulin resistance and infant adiposity

Sewell MF, Huston-Presley L, Super DM, Catalano P. Increased neonatal fat mass, not lean body mass is associated with maternal obesity. Am J Obstet Gynecol. 2006 Oct; 195(4):1100-3. Epub 2006 Jul

Dundar NO, Anal O, Dundar B, Ozkan H, Caliskan S, Buyukgebiz A. Longitudinal investigation of the relationship between breast milk leptin levels and growth in breast fed infants. J Pediatr Endocrinol Metab 2005;18920 181-187.



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Breastfeeding intention is a significant predictor of initiation and duration.

Infant Feeding Practices Survey II (2005-2007). Odds of intending to exclusively breastfeed in

the first few weeks postpartum were higher among mothers (non Hispanic white, non Hispanic black, Hispanic) who perceived that the baby's father or the maternal grandmother preferred exclusive breastfeeding (vs. preferred other feeding

Mueffelmann RE, Racine EF, Warren-Findlow J, Coffman MJ.Percieved Infant feeding preferences of significant family members and mother’s intention to exclusively breastfeed J Hum Lact. 2014 Oct 13. pii: 0890334414553941.



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2009, 50% of U.S. infants participated in WIC, and about 25% of pregnant women, postpartum women, and children ages 1–4

Oliveira, Victor; Frazao, Elizabeth. The WIC Program: Background, Trends and Economic Issues, 2009 Edition. USDA Economic Research Service Report. 2009; 73

Jackson MI. Early childhood WIC participation, cognitive development and academic achievement.Soc Sci Med. 2015 Feb;126:145-53. doi: 10.1016/j.socscimed.2014.12.018. Epub 2014 Dec 15

WIC overlaps with critical and sensitive periods of developmental plasticity when intervention is crucial for brain development

Gluckman, Petter; Mark, Hanson. The Developmental Origins of Health and Disease: The Breadth and Importance of the Concept. Advances in Experimental Medicine and Biology. 2006; 573(1):1–7.



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Risk for later obesity ◦ Rapid infant weight gain , defined as being in the

highest quartile of change in weight for age z score between birth and 6 mo • Stettler N, Zemel BS, Kumanyika S, Stallings VA. Infant Weight

Gain and Childhood Overweight Status in a Multicenter, Cohort Study. Pediatrics 2002 ;109(2) 194-199

Associated with reduced risk of rapid Infant weight gain (RIWG) between birth and age 1

Edmunds LS, Sekhobo JP, Dennison BA, Chiasson MA, Stratton HH, Davison KK. Association of prenatal particpation in a public health nutrition program with healthy infant weight gain Am J Public Health. 2014 Feb;104 Suppl 1:S35-42. doi: 10.2105/AJPH.2013.301793. Epub 2013 Dec 19



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Study of children with and without WIC participation and early cognitive development and success in school.

Age 2 Bayley Short Form-Research Edition (BSF-R)

Age 11 Woodcock-Johnson Revised reading and math achievement tests

Could account for +/- prenatal WIC but couldn’t tell if all children with prenatal WIC had early childhood WIC although evidence suggests most of them do participate in early childhood.

Jackson MI, Early Childhood WIC Participation, Cognitive Development and Academic Achievement.Soc Sci Med. 2015 February ; 126: 145–153. doi:10.1016/j.socscimed.2014.12.018



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Need to return to work one of the most commonly cited reasons for women of low income to stop breastfeeding

Alexander, A., Dowling D., Furman, L. What do pregnant low income women say about breastfeeding? Breastfeeding Medicine, 2010, 5(1)17-23

Infant feeding choices more about how women were able to fit feeding into the daily context of their lives than commitment to breast or bottle feeding

Reeves EA, Woods-Giscombé CL. Infant feeding practices among African American women: Social-Ecological Analysis and Implications for Practice J Transcult Nurs. 2014 May 8



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Face to face more effective than phone

Offered before and after birth

More effective when high base rates of breast feeding initiation

Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. Support for healthy breastfeeding mother with healthy term babies. Cochrane Database Syst Reve 2012, (5) CDOO1141



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Evidence from multiple studies shows a relationship between duration of breastfeeding and reduced risk of obesity

Arenz S, Rückerl R, Koletzko B, von Kries R. Breast-feeding and childhood obesity—a systematic review. International Journal of Obesity. 2004;28(10):1247–1256

Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics. 2005;115(5):1367–1377.

Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. American Journal of Epidemiology. 2005;162(5):397–403.

Baby-Friendly designated hospitals in the United States have elevated rates of breastfeeding initiation and exclusivity

Elevated rates persist regardless of demographic factors that are traditionally linked with low breastfeeding rates

Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H.Breastfeeding rates in US Baby-Friendly hospitals; results of a national survey Pediatrics. 2005 Sep;116(3):628-34



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Association in early infancy between short sleep duration and increased weight gain

Tikotzky L, DE Marcas G, Har-Toov J, Dollberg S, Bar-Haim Y, Sadeh A Sleep and physical growth in infants during the first 6 months. J Sleep Res. 2010 Mar;19(1 Pt 1):103-10. Epub 2009 Oct 14.PMID: 198402

The risk of overweight increases as more risk factors are added, such as maternal smoking during pregnancy, increased gestational weight gain, shortened breastfeeding duration, and decreased infant sleep duration

Gillman MW, Rifas-Shiman SL, Kleinman K, Oken E, Rich-Edwards JW, Taveras EM Developmental ortiings of chldhood overweight; potential public health impact. Obesity (Silver Spring). 2008 Jul;16(7):1651-6. Epub 2008 May 1.



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Feeding to schedule has also been linked to early weight gain and feeding patterns of formula fed infants tend to have higher volume/feeding and higher daily volume, lower frequency of feeds and a longer interval between feeding.

Sievers E, Oldigs HD, Santer R, Schaub J: Feeding patterns in breast-fed and formula-fed infants. Ann Nutr Metab 2002, 46(6):243-248. Mathew OP, Bhatia J: Sucking and breathing patterns during breast-and bottle-feeding in term neonates. Effects of nutrient delivery and composition. Am J Dis Child 1989, 143(5):588-592.

Mihrshahi S, Battistutta D, Magarey A, Daniels LA. Determinants of rapid weight gain during infancy: baseline results from the NOURISH randomised controlled trial. BMC Pediatr. 2011 Nov 7;11:99. doi: 10.1186/1471-2431-11-99



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2X obesity prevalence at 6 years in children who consumed SSBs during infancy as among non-SSB consumers (17.0% vs 8.6%).

Adjusted odds of obesity at 6 years ◦ 71% higher for any SSB intake ◦ 92% higher for SSB introduction before 6 months compared with no SSB

intake during infancy .

2X odds of obesity in children who consumed SSBs ≥3 times per week during ages 10 to 12 months vs. those who consumed no SSBs in this period.

Among children who consumed SSBs, odds of obesity at 6 years did not differ by age at SSB introduction during infancy or by mean weekly SSB intake during ages 10 to 12 months.

Pan L, Li R, Park S, Galuska DA, Sherry B, Freedman DS. A longitudinal analysis of sugar sweetened beverage intake in infancy and obesity at 6 years Pediatrics. 2014 Sep;134 Suppl 1:S29-35. doi: 10.1542/peds.2014-0646F.



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Timing of solid food introduction has been linked to type of feeding, with early introduction of solids among formula fed infants associated with higher BMI at age 3

Timing of solid food introduction and risk of obesity in preschool-aged children.Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW.Pediatrics. 2011 Mar;127(3):e544-51. doi: 10.1542/peds.2010-0740. Epub 2011 Feb 7

Mixed breast and formula feeding is associated with higher weight and length for age Z scores at 3–6 months, 6–9 months, and 9–12 months

Kramer MS, Guo T, Platt RW, Vanilovich I, Sevkovskaya Z, Dzikovisch, I, Michaelsen KF, Dewey K; Promotion of Breastfeeding Intervention Trials Study Group J Pediatr 2004;145(50 600-605).

Weaning in first 6 mo of life Taveras EM, Gillman MW, Kleinman KP, Rich-Edwards JW, Rifas-Shiman

SL. Reducing racial/ethnic disparities in childhood obesity: the role of early life risk factorsJAMA Pediatr. 2013 Aug 1;167(8):731-8. doi: 10.1001/jamapediatrics.2013.85



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Infants frequently bottle fed in early infancy were more likely to empty the milk from a bottle or cup in late infancy, indicating a possible effect on feeding self-regulation.

Li R, Fein SB, Grummer-Strawn LM Do infnats fed from bottles lack self-regulation of milk intake compared with directly breastfed infants.? . Pediatrics. 2010 Jun;125(6):e1386-93. Epub 2010 May 107

Total energy intake and sucking behavior during a test meal rather than energy expenditure influence body weight of infants over the first 2 years of life

Stunkard AJ, Berkowitz RI, Scholeller D, Maislin G, Stallings VA. Predictors of body size in the first 2 y of life; a high risk study of human obesity. In J Obes Relat Metab Disord 2004;2894 503-13.



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Rate of weight gain during infancy

Breastfeeding

Introduction of complimentary foods

Diet quantity and quality

Parent feeding practices

TV viewing time

Physical Activity

Sleep Routine

Family Meals

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Breastfeeding ( Initiation and Duration) Improved feeding practices for infants:◦ Understanding hunger and satiety cues◦ Safe and appropriate bottle feeding◦ Appropriate introduction of complimentary food and

drink Wait until 6 months to introduce solid foods Expose infants to a variety of foods and textures consistently Water, breast milk or formula are preferred beverage choice

Foster self-feeding and responsive eating◦ Encourage feeding self with finger and utensils◦ Allow child to determine when they are “all done”

Encourage movement and activity



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• Uncomplicated pregnancy

• Normal birth weight

• Breast fed until age 7 mo

• Mother BMI 31.2

• Grandparents with hypertension, hyperlipidemia, diabetes

• History from Pediatrician“mother doing everything I ask her”

• Normal physical exam

• Does not walk, excellent fine motor skills



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Feeding (bottle) at 6:30 4 oz formula

Feeding 9:15 2 oz

Plays

Feeding 10:15 2 oz

Feeding 11:30 2 oz

Feeding 2pm mother feeds him a bowl of rice and water

Naps 2 hours

Feeding 5:30 4 oz

Feeding 7 pm 2 oz

Feeding 8:15 pm 2 oz

Feeding 10:30 2 oz and rice

Mother became increasingly worried about his weight after an episode of diarrhea

Mother reports at times using more than recommended powder, packing the cup.

Does not self feed

At home not enrolled in early childcare/education



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INFANT

Genetics

Gestational diabetes

Excess gestational weight gain

Maternal Smoking during pregnancy

Rapid early weight gain

Birth weight

Decreased sleep

FAMILY

Bottle feeding

Formula feeding

Feeding in response to crying

Early introductionof solids

Early cessation of breast feeding

COMMUNITY

SSB consumption

Breastfeeding peer counseling

Lack of workplace support for breastfeeding

Baby friendly hospital

Early weaningPrenatal WIC

Breastfeeding

Short sleep duration

Sucking behavior

Feeding to schedule

Family support of breastfeeding

Parental Obesity

Key:Evidence Based Risk Factors for Infant Obesity



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Structured meal time

Eat while sitting in high chair

Cup not bottle

Decrease milk, add cereal and vegetables

20 minutes on floor after each feeding

Lost 0.5 kg over first 3 weeks



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Rapidly growing proportion of the childhood obesity population

Maximal access to pediatric visits

Important period for establishing lifelong nutrition and activity behaviors

Need for parenting information and skills

Opportunity to for prevention and early intervention

Cumulative prevention



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5:30 am wakes up 6 am Arrives at family day care 7am Breakfast at family day care 8 am Breakfast at pre school 10 am Snack, cookies and juice at pre school 12 noon Lunch at pre school 1 pm outside time 2 pm Snack, crackers and juice at pre school 3 pm Snack at family ay care 4:30 pm Snack at home, cheese curls 5:30 pm Dinner at home 8 pm Bedtime snack (cookies/juice) at home 9 pm goes to sleep/TV in room



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Review diet and activity targeting high risk nutrition and activity behavior◦ 5210 to start

◦ Schedule meals and snacks

Help parents create appropriate nutrition and activity environment

Give age specific parenting advice

◦ Portion sizes

◦ Developmentally appropriate activity

◦ Limit setting

◦ Temper tantrums



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0

2

4

6

8

10

12

14

16

18

20

Boys Girls

Caucasian

African American

Mexican

American

Obesity Prevalence US Children 2-5 yrs old

Ogden et al JAMA 2010 NHANES

%



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http://www.cdc.gov/obesity/childhood/data.html



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Insufficient sleep<12 hrs from 6mo-2yr (9)

Any intake of sugar sweetened beverages (soda, flavored milk, fruit drinks) at age 2 yr

Blum RE, Wei EK, Rockett HR et al Validation of a food frequency questionnaire in Native American and Caucasian children 1 to 5 years of age Maternal Child Health J 1999.3(3)167-172

Any intake of fast food at age 3 yr Pereira MA, Kartashov AI, Ebbeling CB et al. Fast-food habits, weight

gain and insulin resistance the CARDIA study). 15 yr prospective analysis Lancet.2005;365(9453);36-42.

TV set in the room where child sleeps at age 4 yr

Taveras EM, Gillman MW, Kleinman KP, Rich-Edwards JW, Rifas-Shiman SL. Reducing racial/ethnic disparities in childhood obesity the role of early life risk factors. JAMA Pediatr. 2013 Aug 1;167(8):731-8. doi: 10.1001/jamapediatrics.2013.85



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In a large nationally representative sample of 4 year olds, 3 household routines were associated with a reduction in the risk of obesity. ◦ Eating the evening meal (dinner) as a family 6-7

times/week

◦ Obtaining >10.5 hours of nighttime sleep;>10.5 hours

◦ Limiting screen viewing time (television/video/DVD) to 2 hours or less/day.

In children with all 3 routines the prevalence of obesity was 14.3% compared with 24.5% in children with none of these routines.

Anderson SE, Whitaker RC. Household routines and obesity in US preschool aged children Pediatrics 2010 Mar ;125(3) 420-8



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In preschool children, increased rate of obesity in children who slept less than 11 hours/night

Risk of obesity increased as sleep time decreased.

Children who got less than 9 hours of sleep had 1.5 times the risk of having obesity as those with >11 hours/night.

Sekine M, Yamagami T, Hamanishi S, Handa K, Saito T, Nanri S, Kawaminami K, Tokui N,

Yoshida K, Kagamimori S.Parental obesity, lifestyle factors and obesity in preschool children: results of the Toyama Birth Cohort study. J Epidemiol 2002;12:33–39

Young children with persistent tantrums over food and highly emotional temperament were at increased risk for overweight.

Agras WS, Hammer LD, McNicholas F, Kraemer HC. Risk factors for child-hood overweight: a prospective study from birth to 9.5 years. J Pediatr. 2004;145:20–25



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Maternal full time employment associated with higher child BMI◦ Mediated via fewer hours of sleep but not by

other daily routines ◦ Maternal employment status predicted child BMI

one year later May have to wake child earlier and put them to bed later

Each extra hour of sleep was associated with a decrease of BMI percentage by 6.4% a year later

Spier K, Leichty J, Wu C, et al. Sleep but not other daily routines mediates the association between maternal employment and BMI for preschool children (2014) Sleep Medicine 15;1590-1593



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School age children ◦ Breakfast 18% daily calories

◦ Lunch 24% daily calories

◦ Snacks 27% daily calories

◦ Dinner 31% daily calories Robin L, Childhood obesity, food, nutrient and eating habit

trends and influences Applied Physiology, Nutrition and Metabolism 32(4) 635-645.



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BMI positively associated with number of food related events in scripts◦ Play date, movie, sports event

◦ 73% of children + food at movie script

◦ 54% of children + food sports event and play date Muscher-Eisenman D, Marxx J, Taylor M It’s always snack

time: an investigation of event scripts in young children Appetite (2015) 66-69.



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Evidence-based Desired Behaviors

• Breastfeeding• Appropriate bottle feeding• Introduction of solids• Hunger and satiety cues• Foster self-feeding and responsive feeding• Establish routines• Limit/eliminate juice and SSBs• Limit TV and avoid TVs in the bedroom• Encourage active play for all ages• Role modeling



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Across the focus groups parents’ thoughts, ideas and feelings regarding early obesity prevention most often fell into three categories:

Open doors—where parents discussed ideas and expressed a need for additional support and action strategies

Windows—where parents experienced disconnect from recommendations but were open to discussions about early obesity prevention themes and expressed a desire to know the “why”

Closed doors—where parents’ personal experience negated expert guidance and evidence



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Parents think obesity is a serious problem.

However, it is not perceived as a problem in their family.

Parents are receiving mixed messages about obesity.



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Being a parent is an important job◦ Parents across all focus groups regardless of

socioeconomic status, gender, ethnicity, number of children or region felt the most important message developed by the AAP regarding early obesity prevention was:

Individualized attention ◦ Parents viewed early obesity prevention guidance as

more meaningful and actionable when it was perceived to be specifically about their child as opposed to generalized guidance.



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Active Play ◦ Parents welcomed discussions about fun active play. ◦ Parents wanted guidance about safe suggestions for active

play for their child and family across all seasons in their community.

Guidance for other caregivers ◦ Parents expressed concerns, frustrations, and welcomed

ideas on how to approach extended family to support their healthy eating decisions.

Breastfeeding Support◦ Parents across the groups supported breastfeeding and

agreed that some breastfeeding no matter the duration was better than not breastfeeding.

◦ However, parents felt that the decision had to work for their family and barriers had to be overcome to continue to breastfeed successfully.



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When does obesity start?◦ The majority of parents felt obesity prevention starts

“when a baby starts eating solid foods.”◦ Many parents expressed a lack of concern regarding

obesity prevention while the child was consuming only breast milk and/ or formula.

Transitioning to solids ◦ Many parents had followed the 4-6 month solid food

introduction guidance of their pediatrician but more so out of food allergy or choking fears rather than a concern about obesity prevention.

◦ In general, parents did not a find the link between earlier feeding and later weight issues credible, again stating what a parent feeds a child is more important than the timing of solid introduction.



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Juice – why limit? ◦ Parents struggled with how to decipher juice

recommendations.

◦ Many parents had discussed with various health care professionals the need to limit their child’s juice intake but still struggled with understanding if juice was nutritive especially, 100% fruit juice.



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Sleep◦ Parents often discussed sleep, both their own sleep

and their child’s sleep, as a motivation for not adhering to obesity prevention and media use recommendations for young children

The value of TV◦ Parents across all groups were uniformly disinterested

in limiting young children’s TV viewing and only a few parents reported maintaining no TV watching while their children were under the age of 2.

◦ In the eyes of focus group parents, TV serves an educational purpose, and allows parents time for themselves or to complete household chores. TV was also viewed as a sleep aide.

◦ Parents truly felt their own experiences simply did not fit with evidence presented about the negative impact of TV for young children and did not connect TV watching with obesity



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Factors that positively contributed to communication and message uptake

• Respect for the parent and his/her expertise

• Explanation of the “why” behind the recommendations

• Actionable strategies for implementation

• Tailored and personalized information



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Factors that interfered with communication and message uptake

• Use of “obesity” language, especially related to infants.

• Guidance focused on future outcomes.

• Limited knowledge of recommendations.

• Disconnect between guidance and personal experience.



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Adolescent obesity has a high probability of continuing in adulthood and increasing risk for obesity in pregnancy. ◦ Risks of obesity in pregnancy can be added

to the many reasons to engage in prevention and treatment of obesity in adolescence To prevent obesity, the expert committee

recommends that BMI, nutrition, and activity counseling take place at all well visits

Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. Dec 2007; 120 Suppl 4:S164-192



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Longitudinal data suggests that in teens high risk health behaviors may be linked ◦ Association between monthly alcohol consumption,

weekly smoking, daily coffee consumption, and unhealthy food consumption .

◦ Counseling aimed at reducing high risk health behaviors can include obesity prevention and risk assessment.

Positive, healthy behaviors such as good oral hygiene, vitamin use, and regular physical activity are also associated with healthy food consumption and can be reinforced at every opportunity

Nutbeam D, Aar L, Catford J. Understanding children's health behaviour: the implications for health promotion for young people. Soc Sci Med 1989; 29(3): 317–325.



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Community/Social/Demographic

Parenting Styles

Child Characteristics

Child’s WeightStatus

gender age

Dietary Intake

DecisionMaking family

genetics

SedentaryBehavior

PhysicalActivity

Schedule

ChildFeedingPractices

Peer/Sibling

InteractionsFoods

AvailableIn House

NutritionalKnowledge

ParentDietaryIntake Parent

FoodPreferences

ParentWeight Status

ParentEncouragement

of Activity

ParentActivityPatterns

Parent Monitoring

of TV

Family TVViewingSchool

Schedule

SchoolLunch

Program

Ethnicity

Work Hours

SchoolEnvironment

Availabilityof Recreational

Activities

Accessibility ofConvenience Foods

& Restaurants

FamilyLeisureTime

CornerStore

SchoolPhysical

EducationPrograms

Crime RatesGeneral

Safety

SocioeconomicStatus

Activities At Home

Environment and Behavior

12 year old girlBMI 90%



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Neighborhoods and regions where children are more likely to be overexposed to unhealthy factors and underexposed to healthy ones

In these communities, resources are minimal, infrastructure is not conducive to physical activity, income is generally low, and economic opportunities may be scarce.

The rates of obesity in communities at risk continue to rise far above those where children have access to healthy foods and places where they can engage in physical activity.



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Food Insecurity Obesity Prevention and Treatment

Education Dietary

modification Food provision Supplementatio

n and fortification

Reduce disparities and provide equitable access to food

Alleviate poverty

Adult and child health education

Family Systems change

Lifestyle modification

Interaction with clinical care

Access to healthy affordable food

Opportunity and access to physical activity



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Correcting Basic Undernutrition Obesity prevention and treatment

Improve transportation to healthy food sources

Decrease unhealthy food options

Lower cost of healthy foods

Alter existing shopping patterns

Sadler et al Int J Env Res Pub Health 2013 Aug 10(8) 3325-2246

Ability to walk to school

Child friendly neighborhoods

Neighborhood culture (active or inactive)

Faith based initiatives Access to health care

providers and services



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Increase income eligibility for food assistance programs

Increase adult full time employment

Increase eligibility for households with disabled adult

Increase high school completion for adults in household ◦ http://www.ers.usda.gov/media/1

120651/eib-113.pdf

Health benefits Wellness programs Healthier work

environments Activity opportunities Marketing of healthier

choices



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Increase participation in school lunch program

Increase breakfast in class

Increase nutritional quality of after school snack

Consider alternate venues for summer feeding programs

Identify infants with undernutrition

Vending machine snacks and beverages

School meals Physical education Fund raising Health education Built environment Time constraints



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State and National policy Healthy Hunger-Free Kids Act

WIC

SNAP

Head Start



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WIC

Healthier Babies and Lower Infant Mortality

Higher Vaccination Rates and Improved Access to Health Care

Breastfeeding Promotion

Improves Children’s Educational Prospects



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Program Number of Children Served in 2014

Supplemental Nutrition Assistance Program (SNAP)

20.5 million

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

6.3 million

Child and Adult Care Food Program (CACFP)

3.6 million

Free or reduced-price school lunch 21.7 million

Free or reduced-price school breakfast

11.5 million

Summer feeding programs 2.7 million



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Coleman-Jensen et al Household Food Security in the United States in 2011ERR-141 USDA Economic Research Service, 9/12.



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Nutrition assistance through free- or reduced-price school lunches reduced the child poverty rate by 1.1% in 2014.

SNAP has lifted about 2.1 million out of poverty. Without SNAP benefits alone child poverty would have increased by 2.8% in 2014.

WIC supports sound nutrition during critical periods of cognitive development to mitigate the detrimental effects of poverty.



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School meals are most effective for those most in need◦ Improvement in school attendance◦ Improvement in concentration with school breakfast ◦ Improvement in pro social playground activities ◦ Breakfast short term improvement on morning

testing

Kristjansson B, Petticrew M, MacDonald B, et al. School feeding for improving the physical and psychosocial health of disadvantaged students (Review). Cochrane Database Syst Rev 2007;(1):CD004676. doi:10.1002/14651858.CD004676.pub2



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The Institute serves as a translational engine for pediatric obesity prevention, assessment, management and treatment; and moves policy and research from theory into practice in American healthcare, communities, and homes.

INSTITUTE FOR HEALTHY CHILDHOOD WEIGHT



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Institute for Healthy Childhood Weight Web site

aap.org/healthyweight

building the foundations of health for all children

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