08 5562 lindsay-etal.qxp 1/22/2006 12:54 PM Page 169 The Role of Parents in Preventing Childhood Obesity Ana C. Lindsay, Katarina M. Sussner, Juhee Kim, and Steven Gortmaker Summary As researchers continue to analyze the role of parenting both in the development of childhood overweight and in obesity prevention, studies of child nutrition and growth are detailing the ways in which parents affect their children’s development of food- and activity-related behav- iors. Ana Lindsay, Katarina Sussner, Juhee Kim, and Steven Gortmaker argue that interven- tions aimed at preventing childhood overweight and obesity should involve parents as impor- tant forces for change in their children’s behaviors. The authors begin by reviewing evidence on how parents can help their children develop and maintain healthful eating and physical activity habits, thereby ultimately helping prevent child- hood overweight and obesity. They show how important it is for parents to understand how their roles in preventing obesity change as their children move through critical developmental peri- ods, from before birth and through adolescence. They point out that researchers, policymakers, and practitioners should also make use of such information to develop more effective interven- tions and educational programs that address childhood obesity right where it starts—at home. The authors review research evaluating school-based obesity-prevention interventions that in- clude components targeted at parents. Although much research has been done on how parents shape their children’s eating and physical activity habits, surprisingly few high-quality data exist on the effectiveness of such programs. The authors call for more programs and cost-effective- ness studies aimed at improving parents’ ability to shape healthful eating and physical activity behaviors in their children. The authors conclude that preventing and controlling childhood obesity will require multifaceted and community-wide programs and policies, with parents having a critical role to play. Successful intervention efforts, they argue, must involve and work directly with parents from the earliest stages of child development to support healthful practices both in and outside of the home. www.futureofchildren.org Ana C. Lindsay is a research scientist in the Department of Nutrition at the Harvard School of Public Health. Katarina M. Sussner is a doc- toral candidate in the Department of Biological Anthropology at the Harvard Graduate School of Arts and Sciences. Juhee Kim is a research fellow in the Department of Nutrition at the Harvard School of Public Health. Steven Gortmaker is a professor of the practice of health so- ciology in the Department of Society, Human Development, and Health at the Harvard School of Public Health. VOL. 16 / NO. 1 / SPRING 2006 169 08 5562 lindsay-etal.qxp 1/22/2006 12:54 PM Page 170 Ana C. Lindsay, Katarina M. Sussner, Juhee Kim, and Steven Gortmaker arents are key to developing a fants, and Children (WIC) public health and home environment that fosters educational program.3 Because research healthful eating and physical ac- shows how the parents’ roles in influencing tivity among children and adoles- the development of overweight and obesity cents. Parents shape their chil- differ at different stages of their children’s Pdren’s dietary practices, physical activity, development, these parenting components sedentary behaviors, and ultimately their will be most effective if they are targeted at weight status in many ways. Parents’ knowl- children in particular age groups. edge of nutrition; their influence over food selection, meal structure, and home eating Parental Roles during patterns; their modeling of healthful eating a Child’s Development practices; their levels of physical activity; and Parenting influences the development of their modeling of sedentary habits including overweight and obesity in various ways at dif- television viewing are all influential in their ferent stages of a child’s development. The children’s development of lifelong habits that following discussion is structured around contribute to normal weight or to overweight three time periods in children’s lives: gesta- and obesity.1 tion and early infancy; early childhood, when children are toddlers or preschoolers; and Because the parents’ roles at home in pro- middle childhood and adolescence, when moting healthful eating practices and levels children are attending school.4 of physical activity—and thus in preventing obesity—are so critical, they should also be Gestation and Infancy central to collective efforts to combat the na- Before an infant is even born, aspects of his tion’s childhood obesity epidemic. L. Epstein mother’s pregnancy can put him at risk of offers three reasons for involving parents in overweight in childhood and later in life.5 An obesity-prevention interventions. First, obe- unfavorable intrauterine environment, for sity runs in families, and it may be unrealistic example, can increase a fetus’s future risk of to intervene with one member of a family developing adult metabolic abnormalities, while other family members are modeling including obesity, hypertension, and non- and supporting behaviors that run counter to insulin-dependent diabetes mellitus.6 The the intervention’s goals. Second, parents children of mothers who suffer from diabetes serve as models and reinforce and support mellitus, gestational diabetes, and undernu- the acquisition and maintenance of eating trition and overnutrition during pregnancy and exercise behaviors. Finally, to produce are at particular risk for obesity, with the maximal behavior change in children, it may greatest risk factor being gestational dia- be necessary to teach parents to use specific betes.7 A key strategy for obesity prevention behavior-change strategies such as positive at this stage of a child’s development, there- reinforcement.2 Several successful school- fore, is to focus on screening for and prevent- based health-promotion interventions, such ing diabetes during pregnancy. as Planet Health and Eat Well and Keep Moving, already include a component tar- Parents also have an important role to play geted at improving parenting behaviors, as during infancy, when a child is establishing does the well-established Special Supple- the foundation for dietary habits and nutri- mental Nutrition Program for Women, In- tional adequacy over a lifetime.8 Although 170 THE FUTURE OF CHILDREN 08 5562 lindsay-etal.qxp 1/22/2006 12:54 PM Page 171 The Role of Parents in Preventing Childhood Obesity debate over whether breast-feeding can help differences.14 Current data, although limited, prevent obesity later in life continues, many suggest that the way parents feed their chil- researchers believe that breast-feeding in- dren contributes to individual differences in fants does have a protective effect against how well children can regulate their food in- obesity. Several studies, for example, have take and perhaps to the origins of energy im- documented lower rates of overweight balance.15 Especially in the early years of a among children who were breast-fed for child’s life, parents have a direct role in pro- longer durations.9 Their findings, however, viding experiences that encourage the child’s were limited to non-Hispanic whites and did control of food intake. Around preschool age, not apply to other racial or ethnic groups.10 when children particularly dislike new foods, One explanation for the protective effect of it is important for parents to model healthful breast-feeding is that it helps infants better eating habits and to offer a variety of health- regulate their food intake than does bottle- ful foods to their children. When parents feeding. Encouraging an infant to empty a provide early exposure to nutritious foods, bottle and using formulas more concentrated even fruits and vegetables, children like and in energy and nutrients than breast milk may eat more of such foods.16 But parents should make it more difficult for the baby to attend observe a clearly defined role in offering the to his or her own normal feelings of satiety. If foods to their children. As described by W. such experiences occur early in infancy and Dietz and L. Stern, parents “are responsible continue, an infant may not develop reliable for offering a healthful variety of foods,” control over food intake. None of the recent while children themselves “are responsible studies of breast-feeding, however, rules out for deciding what and how much they want to the possibility that the protective effect of eat from what they are offered.”17 breast-feeding on obesity later in life may be due to confounding factors such as parental Although children are predisposed to re- weight status or social and economic status.11 spond to the energy content of foods in con- trolling their intake, they are also responsive Toddlers and Preschool Children to their parents’ control attempts. Research As toddlers and preschoolers develop habits has shown that these attempts can refocus related to eating and physical activity, parents the child away from responsiveness to inter- can shape their early environments in ways nal cues of hunger and satiety and toward that encourage them to be more healthful.12 such external factors as the presence of palat- able foods.18 Parents who control or restrict Parents and Healthful Food Behaviors what their young children eat may believe Children come equipped with a biological set they are doing what is best for their child, but of taste predispositions: they like sweet and recent research challenges this assumption. salty tastes and energy-dense foods, and they Imposing stringent controls can increase dislike bitter and sour tastes.13 But they de- preferences for high-fat, energy-dense foods, velop most of their food habits through expo- perhaps causing children’s normal internal sure and repeated experience. Research sug- cues to self-regulate hunger and satiety to be- gests that individual differences in the come unbalanced.19 physiologic regulation of energy intake ap- pear as early as the preschool years and that Parents should also be aware of the social parents have enormous influence on these contexts in which foods are consumed.