2. Public Perceptions of Causes of Childhood Obesity Parental responsibility Modern technology and media Over-consumption of unhealthy foods Children’s lack of knowledge and motivation Physical activity environment Lack of healthy food Lack of physical activity Genes International Journal of Obesity, Hardus, 2003 Individual Responsibility … Environment

3. Individual Choice/Environment Time7:00 am10:00 am Noon2:00 pm4:00 pm5:00 pm6:30 pm MealBreak- fast RewardLunchB-day Party MD Check up DinnerFund- raiser Food/ Drink waffles syrup Juice candythrew out sandwich; juice drink & twix bar Cup- cake; juice drink lollipopMcDs ¼ pounder cheese, md fries lg coke Cookies Sugar grams 60242848128620 Fat grams 78880522 Recommended Sugar Max = 45g Recommended Fat Max = 60g 278 g 85 g

4. SocioEcological Web and Childhood Obesity Individual Interpersonal Factors Institutional Factors Community Factors Public Policy Factors Restaurants Dynamic links School School foods Supermarkets PA opportunities Families FDA-labels advertising

5. SocioEcological Web Influencing Childhood Obesity Individual (individual choice & responsibility) Dietary intake, physical activity, sedentary behavior Influenced by knowledge,attitudes, beliefs, skills Interpersonal Families, friends, peers Provide social identity, support and role definition Institutional Schools, local sporting institutions Rules, regulations, policies that constrain or encourage particular behaviors

6. SocioEcological Web Influencing Childhood Obesity Community Formal or informal local networks and norms Resources that encourage or discourage healthy eating and physical activity Public Policy Local, state and federal policies or laws that regulate or effect eating practices and exercise habits Families

7. Powerful and complex fields of influence embedded in a multi-layered environment Characteristics Foods available at home Food/meal routines – feeding styles Family members’ weight status and diet Attitudes towards weight individuals’ weight status Encouragement of physical activity Rules regarding TV use

8. Families, continued Changes in home environment Increased use of fast foods and home replacement meals (1987-2.6 billion sales; 1992 –5.7 billion sales) 1965 – 30% of food $ spent away from home; 1998 increased to 47% (Bowers, D.E., Food Review January-April 2000:23-29, Jekanowski, M.D. Food Review January-April 1999:32-34, Jekanowksi, M.D., Food Review January-April 1999:11-16)

9. Parent-Child Eating Styles Parents shape children’s eating style Foods available Parent feeding styles restriction of intake (restrict child’s access to unhealthy foods) pressure to eat (pressure child to eat more food, typically healthy foods) Mothers report > use of restrictive practices With increased mothers’ own weight/eating concerns With increased perception of daughters’ risk for weight problem Mothers report > use of pressure to eat With increased perception of daughter as underweight Francis, Appetite, 2001

10. Potential Adverse Effects Result is to focus child away from internal cues regarding hunger and satiety Parent assumes responsibility of initiating or terminating eating Potential to compromise child internal awareness of hunger/fullness and appropriate responses Limitations – white well educated sample of mothers and 5 yo daughters (n=196 Francis, Appetite, 2001

11. Long Term Effects of Parental Restrictive Feeding Styles Assessment of 5-7 yo girls intake of palatable foods after a standardized lunch Girls with large intakes of snack foods in the absence of hunger were 4.6 times more likely to be overweight at 5 and 7 years of age For each unit of increase in parents’ reported restrictive feeding styles at 5 y, girls were 2.1 times as likely to eat in absence of hunger at age 7 (even after controlling for BMI and hunger related eating at age 5) About 50% girls reported negative self evaluation after eating; such report linked to perceptions of being restricted from such foods Fisher, American Journal of Clinical Nutrition, 2002

12. Attitudes, Practices & Concerns Re: Child Feeding and Weight Need to tailor interventions based on attitudes, practices and concerns Build on mothers goals to provide good nutrition while balancing convenience, variety and cost Provide strategies to overcome stress associated with providing meals Focus parents on encouraging child-based hunger/fullness cues and appropriate responses Recognize differences in cultural perceptions of overweight and facilitate recognition of unhealthy weights Sherry, JADA, 2004

14. Parent’s Perceptions Re: Children’s Weight 3 focus groups (n=18; 13 black, 5 white); WIC participants Mothers don’t use reported anthropometrics to assess weight, instead use reported teasing and limitations on exercise; if active with good appetite not considered overweight; overweight children described as “thick or solid”; genes considered cause independent of environment; emotionally difficult to deny or limit foods

15. Parent’s Perceptions Re: Children’s Weight Cross sectional survey of 622 WIC participants with children 2-5 years 45% low education (30% moms obese; 19% children overweight) 55% high education (17% moms obese; 14% children overweight) 79% of mothers failed to perceive overweight children as overweight; almost all accurately perceive their own weight Among 99 moms with overweight children, low maternal education associated with misperception after controlling for income, maternal obesity, age, smoking and child’s age, race and gender Baughcum, Pediatrics, 2000

16. Media – Influences Families Conflicting messages Healthy-weight children shown in advertisements negative stereotypes of overweight children among many segments of the population – including health care professionals Unhealthy, academically unsuccessful, socially inept, unhygienic and lazy (Hill, Int J Obesity 1995, Teachman, Int J Obesity 2001) Promotion/Advertisement of energy dense foods in all venues (TV, schools, community sites, Internet

22. Calories 110 Fat 2 g Sugar 1 g Fiber 3 g Calories 110 Fat 1 g Sugar 6 g Fiber 3 g Calories 120 Fat 1 g Sugar 14 g Fiber 0 g Are Cocoa Puffs really part of a healthy breakfast?

23. Media Literacy Activities 35 parents with children participating in Head Start programs; 4 week media literacy program (compared to 4 week food safety educational placebo to control for “attention”); pre-post evaluation 4 week curriculum: advertising techniques, children’s perceptions of ads, comparing food label information to claims, role playing dealing with children’s requests Improved parents’ understanding of TV advertising (p 001), self-efficacy (p<.001), TV mediation behaviors (p<.001), and ability to read food labels (p<.001) Hindin, JADA, 2004

24. Family-Based Interventions Goals Build parental/family support Create supportive home environment Epstein’s review of randomised controlled family-based interventions: “most pediatric obesity interventions are marked by small changes in relative weight or adiposity and substantial relapse”. Example: program with dietary counseling, encouragement to exercise, and family tx for 14-18 months resulted in smaller increase in BMI than no tx controls (1.1 vs 2.8 kg/m 2 @ 1 yr fu); drop out substantial Epstein, Pediatrics, 1998; Isreal, J Ped Psy, 1994

25. Family-Based Interventions Continue to research family-based interventions AND Implement in the context of the socioecological model Saturate communities with multidisciplinary teams Ex: Heart Links Project Quality (research based) Quanity based on internal hunger/fullness

27. SocioEcological Framework for Interventions Individual Interpersonal Factors Institutional Factors Community Factors Public Policy Factors Community campaigns School environment School foods & fundraising PA opportunities Family-based interventions Government regs & recommendations Advertising regulations

29. Year Pounds per Person A 30% Increase www.cspinet.org

30. Sugar Content of Popular Foods FOODTSP“% Daily Value” Snickers bar, 2.1 oz.5¾58 TastyKake Honey Bun, 3¼ oz.660 Lowfat fruit-flavored yogurt, 8 oz.770 Pepsi, 12 oz.10¼103 Pancake syrup, ¼ cup10¼103 Hostess Lemon Fruit Pie, 4½ oz.11½115 Strawberry Passion Awareness Fruitopia, 20 oz.17¾178 Sources: Manufacturers, USDA, CSPI analyses and/or estimates. Center for Science in the Public Interest, August, 1999

31. Obesity and Mortality Tobacco UsePoor Diet and Physical Inactivity 1990200019902000 % of all deaths 19%18.1%14%16.6% # deaths400,000435,000300,000400,000 If this trend continues, obesity will become the leading cause of death by 2005, killing 500,000 people per year. CDC 3/04

36. Yoplait Go-Gurt Cherry & Strawberry Assorted Yogurt Nutrition Facts Serv. Size 1 tube (64g;about 2 oz) Servings 8 Amount Per Serving Calories 70 Calories From Fat 15 % Daily Value * Total Fat 2g 3% Saturated Fat 1g 5% Cholesterol 5mg 2% Sodium 40mg 2% Potassium 125mg 3% Total Carbohydrate 11g 4% Dietary Fiber 0g 0% Sugars 10g Protein 2g

37. Yoplait Go-Gurt Cherry & Strawberry Assorted Yogurt Nutrition Facts Serv. Size 1 container (227g; 6 oz) Servings 1 Amount Per Serving Calories 160 Calories From Fat 0 % Daily Value * Total Fat 0g 0% Saturated Fat 0g 0% Cholesterol 0mg 0% Sodium 130mg 5% Potassium 125mg 3% Total Carbohydrate 30g 10% Dietary Fiber 1g 3% Sugars 29g Protein 8g