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Childhood Overweight: Fostering Healthful Behaviors

Part 3: Engaging Children in the Process

Volume 8, Number 2 - February/March, 2004

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health, Stephen D. Green, PH.D., Associate Professor and Extension Child Development Specialist, and Debra B. Reed, Ph.D., RD, LD, Associate Professor and Extension Nutrition Specialist

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Childhood Overweight: Fostering Healthful Behaviors -- Engaging children in the process

Widespread societal changes over the last several decades have affected child rearing, which in turn has affected childhood dietary and physical activity patterns (American Academy of Pediatrics, 2003).

"US culture has experienced profound changes over the last 40 years -- the family structure and maternal employment has changed significantly since the 1960s. In 1960, only 9% of children lived in single-parent households, and by 1998 the number rose to 27%. There has also been substantial growth in maternal employment, with 74% of mothers with children ages 6-17 being employed outside the household. This trend alone has implications on many areas of family life including fewer family meals, less time for meal preparation, and increased demand for convenience and prepared foods (Moag-Stahlberg, et.al., 2003)."

"Food consumption away from home has increased dramatically in the past several decades. Outside food consumption increased from about 55% of food in 1977-1978 to about 68% in 1994. Fast food accounted for only 2% of children's total caloric intake in 1977-1978, but increased to 10% in 1994-1996. Meanwhile, the number of fast food restaurants has increased at an annual rate of 7%, compared to 3% for the restaurant industry as a whole...[and] according to a study by the National Restaurant Association, which collected menus from 66 restaurants in 1988 and again in 1993, the number of menus offering more than one portion size, such as "super" sizes, increased 12%. Further, fast food is aggressively advertised to children (Ritchie, et.al., 2001)."

In addition to these factors, "longer work hours and distances to travel for work coupled with advances in technology can produce overall less physical activity for the family (Moag-Stahlberg, et.al., 2003)." National survey data indicate that 20% of US children ages 8 to 16 reported participating in 2 or fewer bouts of vigorous physical activity per week, and more than 25% watched at least 4 hours of television per day (American Academy of Pediatrics, 2003).

Thus, our goals for this issue of HealthHints, in our continued series on childhood overweight, will be to focus on:

"...Teaching parents ways to improve parent-child interactions around eating, meal time and physical play is a likely area for successful interventions (Ritchie, et.al., 2001)."

These goals are in keeping with our seven principles for guiding Extension programs addressing childhood overweight, which are to:

  1. Gradually increase physical activity through active play for children and adults.
  2. Decrease sedentary activities including "screen time" (TV, computer, video, etc.) at home to 2 hours or less each day.
  3. Improve diet quality by following the Food Guide Pyramid for serving size and number. Discourage "super-sizing" amounts.
  4. Increase fruit and vegetable intake to amounts recommended by the Food Guide Pyramid.
  5. Limit sweetened beverages including soft drinks, sports drinks, imitation fruit juices, sweetened teas, agua frescas, etc.
  6. Increase family meals together to improve nutrition, communication, and family connections.
  7. Encourage "engaged parenting," in which parents provide children with healthy food choices and opportunities for physical activity and act as role models for these behaviors.

Parent = Role Model: Importance of modeling healthful behaviors

As a parent, you are a role model for your children. Though children are influenced by many elements in their environment (e.g., peers, extended family members, child care providers, teachers, media), parents serve as the primary influence in their lives. Parents' contributions to their children's physical, social, emotional, and cognitive development are unparalleled, especially during the early years when their personalities and behavior patterns are taking shape (Green, 2004a).

In a recent study, researchers found that children rated parents most frequently as their role model or person they most admired. This was an open-ended response, and therefore, not limited to a set number of choices. If you are thinking to yourself -- "sure, a 3-year-old looks up to his/her parent, but not a teenager, mine doesn't hear a word I say or notice a thing I do" -- this study indicates otherwise. The sample consisted of children ages 9 to 18. Even among children 13 to 18, parents were selected as the number one role model (Moag-Stahlberg, 2003). This finding contradicts the myth that teens do not admire, respect, or listen to parents (Green, 2004a)."

Knowing that your children pay close attention to your actions, it is important that you set a good example for them. Researchers have discovered that this is especially true when it comes to your eating and exercise habits. Studies show that a child's eating and exercise habits are directly related to their parents (Golan, et.al., 1998). This means that if you model a lifestyle that involves healthy food choices and regular physical activity, your children will likely do the same. Unfortunately, if you model for them a lifestyle that is characterized by unhealthy food choices and very little exercise, they too will tend to adopt a similar lifestyle (Green, 2004b).

French Fries for Breakfast?

Would you serve your child French fries for breakfast? Most parents would answer "no," but at the same time we are allowing even our youngest children to consume french fries and candies in place of healthier choices at other meal times. Though non-traditional choices for breakfast are a great way to get your children to eat breakfast, french fries should be an infrequent choice at any meal time.

"As the eating habits of adults continue to include high-calorie and high fat foods, a new study says those same habits are the food choices of young children too. The study, funded by the Gerber Company, found that a significant number of infants and toddlers, ages 4 months to 2 years old, are eating pizza, French fries, candy and soda. The results of the survey may be a predictor for health problems for future generations. Other key indicators from the study include:

The study points to the need for parents to add nutritious foods to your child's eating plan -- and your own -- to help build healthy bodies and healthy eating habits (American Dietetic Association, 2003)."

Recommendations for Positive Role Modeling: Your best efforts for your children's healthy future

"Think about what is best for you and your children's long-term health. What behaviors would you like for them to adopt as they grow older? Talk about these behaviors with your spouse, your child's caregiver, the child's grandparents, etc. Do your children see you eating a variety of fruits and vegetables? Do they see you eating nutritious snacks between meals? Do your children see you engaged in regular physical activities? Or, in contrast, do your children see you eating unhealthy snacks, oversized portions, and engaged in prolonged sedentary activities (e.g., excessive TV viewing) (Green, 2004b)?"

The following recommendations (adapted from Parents as Role Models for Healthy Living: Recommendations for Improving Your Child's Nutritional and Physical Activity Patterns by Stephen D. Green, Ph.D., Associate Professor and Extension Child Development Specialist (see this handout in its entirety at the end of this issue of HealthHints) are intended to help you become a more positive role model for your children, and in turn, help prevent some of the harmful physical and psychosocial health problems that result from unhealthy eating and exercise habits.

Begin modeling healthy eating and exercise habits while your children are young

The early years of a child's life are a critical time for developing certain kinds of knowledge and skills. Every aspect of development (e.g., physical, social, emotional, cognitive, moral) is influenced by the quality of care parents and caregivers provide for young children. What happens during the early years can impact children for the rest of their lives. This includes eating and exercise habits. Researchers have found that when excess pounds are put on during the toddler years, children are at a much greater risk for becoming overweight as adults. It is difficult to change behavior patterns once they are established. Therefore, as a parent, it is important to start modeling healthy lifestyle choices the day your children are born (if not before).

Eat meals with your children whenever possible

Use meal time as an opportunity to talk with your children about the importance of healthy food choices and regular physical activity. Make it a habit to eat meals together as a family -- not in front of the television. Family meals provide a great opportunity for discussing healthy food choices and regular physical activity, as well as a way to keep connected with your children. When discussing healthy food choices and physical activity, use age-appropriate language, such as talking about how the carrots a child is eating helps his/her eyesight or how physical activity strengthens muscles. Be sure to put your words into practice by regularly modeling these healthful behaviors.

Avoid the "Do as I say, not as I do" mentality

Our children tend to copy our behavior (Dickey, school lunch..., 2002). Children are more inclined to pay attention to what we do rather than what we say, so it is important to back up our words with practice. Saying one thing, while doing another can establish a negative pattern that can be confusing to children. If you tell your children to eat their fruits and vegetables, make sure you are eating yours, too. If you don't want your children to eat french fries with their fast food meal, it is probably a good idea for you not to order them either. This principle applies to physical activity patterns as well. If you tell your children to get outside and exercise, rather than watching television so much, make sure you are doing the same. Your children look to you as a guide; set a good example and they will likely follow.

Model an enthusiastic attitude toward regular physical activity and healthful food choices

Have you ever noticed yourself complaining about needing to exercise or making a face from the scent of broccoli on your plate? Parents who complain about physical activity or healthy foods they dislike will probably raise children who come to view exercise as a nuisance and/or who avoid specific healthy food choices.

Parents communicate both verbally and non-verbally, so be aware of the messages you convey to your children through words as well as tone of voice, facial expressions, and body movements. You may not come right out and say you don't like spinach, but if you grimace each time you swallow a bite, your dislike may be conveyed to your child. In the same manner, if a child notes disappointment rather than enthusiasm in your voice when you tell him/her it's time to take a walk outside he/she may come to the conclusion that walking is not something you find important or enjoyable. Make physical activity fun through active play and being physically active as a family. For more ideas on physical activity for the family or for when a child is on his/her own see the handouts included in HealthHints vol. 7 no. 9 at http://fcs.tamu.edu/health/Health_Education_Rural_Outreach/Health_Hints/2003/sept-oct/childhood_ overweight.htm.

Model appropriate use of television, computers, and other technology

Research has consistently found a link between the amount of time spent watching television and childhood overweight (Dennison, et. al., 2002). While there is nothing inherently wrong with any of these technology-associated activities, they can take away from time that could be spent in physical activity. The American Academy of Pediatrics recommends that children spend no more than two hours of media time per day (American Academy of Pediatrics, 2003).

As a parent, you are in a unique position to model appropriate use of these media. Demonstrate to your children that technologies can be used in ways that do not impede other healthy activities. Think about the amount of time you spend in front of the television or behind the computer screen. Do these media take precedence over physical activity? Offer your children alternatives, instead of watching television, use that time to take your children outside on a nature hike or go play catch. Physical activities can be both educational and fun. Though children may complain when the television is first turned off, it is remarkable how quickly they can come to enjoy other activities if you offer alternatives with an enthusiastic attitude.

Parents -- You are your child's primary influence -- like it or not -- make a commitment to be a positive role model for their healthy futures (Adapted from Green, 2004b).

Putting the Family Back in Meal Time: Healthy Benefits of family meal time

Whether your family is a "pack of ten" at the table or a "perfect pair" -- you and your child, sitting down together daily for regular family meal times has healthy benefits. Research indicates that adolescents who eat frequent meals together have more healthful dietary intake patterns, including more intake of vegetables, fruits, and dairy products (Neumark-Sztainer, et.al., 2003), less fried food and soda, less saturated and trans fat, and more fiber and micronutrients from food (Gillman, et. al., 2000). Studies indicate that most people, children and teens, as well as older adults and singles, eat more balanced meals when they eat with family or friends (Oregon Dairy Council, 1997). Additionally, research indicates younger children may have higher vocabulary scores when they learn words in the context of family meal times (Beals, 1997).

Children learn important lessons and skills at the dinner table as well. They learn to view food as nourishment for active and healthy bodies; they learn table manners; and, they learn important social skills, such as learning to take turns speaking and listening in polite conversation (American Dietetic Association, 2000a).

Getting together for family meals provides many benefits:

It is important for parents to make family meal times as calm and pleasant as possible. To create a welcoming eating atmosphere and make the most of family meal time, try the following ideas:

(The information in the section above is adapted from American Dietetic Association, 2000a, except where otherwise denoted.)

Sometimes just getting around the family table is not easy. With after school activities, work, and other commitments, any number of obstacles can get in the way of family meal time. Here are some suggestions for overcoming these obstacles:

Emotions and Other "Non-Hunger" Reasons for Eating

As a society, we eat for many reasons -- many unrelated to hunger. Try this activity yourself or with program participants. List three foods you like to eat when you're unhappy, sick or need comforting; three foods you like when you're celebrating a holiday or special event; and three foods you think of as so yucky you can't imagine how anyone could eat them. Once you and/or your participants have done this, consider this....If you were able to list these items in any or each category, you can see that we eat for many reasons, not just hunger or the need to satisfy our bodies' needs for energy and growth (adapted from Berman, et. al., 1991). There are many reasons why children and adults eat (or don't eat) certain foods. Some reasons other than hunger may include stress, visual appeal, culture, habit, peer pressure, cravings, boredom, anger, sleepiness, frustration, etc. (Baylor College of Medicine, 1998; Berman, et. al., 1991). In fact, the American Academy of Pediatrics lists stress management among healthy habits to curb excess weight gain (American Academy of Pediatrics, 2002). Like adults, children will sometimes eat when they are under stress. Unlike adults, however, children have less control over their lives and thus have fewer options with which to respond to emotional peaks and valleys. They may be prone to change the way they eat as their moods change. This may occur when they are stressed, bored, anxious, depressed, or even extremely pleased or happy with things (American Academy of Pediatrics, 2000).

As a parent or care provider, you can help your children to recognize why they eat, and suggest alternatives to automatically reaching for a snack (Baylor College of Medicine, 1998). "Studies have shown that children who make small, progressive modifications in behavior are able to build on their achievements and make permanent changes. These behaviors focus on healthy diet and increased physical activity, and are supported by a combination of emotional and behavioral features (Baylor College of Medicine, 1998)." Don't ignore the effect overweight can have on your child's self-concept. Boosting a child's self-esteem is equally important to diet and exercise (American Academy of Pediatrics, 2000). Just as with adults, when kids feel good about themselves, they're more likely to make healthy changes. Point out your children's unique strengths and abilities, and encourage them to find activities to help them flourish. What can your son or daughter do to make him/her feel valuable? Volunteer at a recycling center? Pick up an elderly neighbor's newspaper? Take an art class? Encourage some physically active ideas. It may take some creativity to help your child try new things, but with family encouragement and support, new habits are within everyone's reach (Baylor College of Medicine, 1998). Remember, love your children and help them love themselves by praising their positive strengths, skills, and unique abilities. Emphasize feeling healthy and strong and de-emphasize weight. Also, remember that during puberty caloric needs increase. So, don't be alarmed if your 10 to 12 year old starts to eat more; these additional calories and nutrients fuel the incredible growth that occurs during adolescence (American Medical Association, 2002). Continue to encourage eating only when hungry, a variety of foods, moderate portion sizes, and physical activity. Use positive reinforcement (such as praise) for healthy behaviors; make healthy eating relaxing and calm; make physical activity fun and rewarding; and, involve the whole family (adapted from American Medical Association, 2000).

Hunger Cues, Portion Control, and Self-Service: Helping your child develop good eating habits

Did you know it takes 15 to 20 minutes for our bodies to register that we are full (Baylor College of Medicine, 1998; Dickey, 2004)? One simple way to help our families control portions is to simply hold off on seconds for a few minutes to allow our bodies to realize we are full or until we know we are really still hungry. Particularly with small children (ages 2 to 6), encourage small first portions, reassuring them that they can have seconds if they are still hungry (Dannon Institute, 2002). Spend a few minutes talking around the table, enjoy each others company -- you'll find you chew your food more slowly, take more time to eat, and realize when you're full (Nemours Foundation, 1995). Then, if you and/or your children are still hungry, serve seconds. For that matter, allow your child to serve themselves. Recent research from the USDA Children's Nutrition Research Center at Baylor College of Medicine found that when preschool aged children were served over-sized portions they tended to eat about 25% more of the entree, and their overall caloric intake at that meal was 15% higher than when they received a normal, appropriate-sized portion. When they were allowed to serve themselves, however, the children tended to eat age-appropriate amounts (Filipic, 2003). "It is recommended that parents be responsible for selecting healthy foods and the manner in which these foods are presented, and children be allowed to select from the food choices and determine the quantity consumed. Similarly, positive promotion of physical activity involves children being given latitude in their choice of type and extent of activity, and involves parental modeling of a physically active lifestyle (Ritchie et. al., 2001)."

Allow your children to be a part of the decision-making process. Don't require your children to "clean their plates;" and, on the other hand, don't push them to eat less. If you always control the amount your children eat, it is hard for them to learn what's enough and to control the amount they eat when they need to do it on their own. Do all you can to build your child's self-efficacy (i.e., his feeling that he is capable). A positive attitude can help your child eat in a normal, healthful way (United States Department of Agriculture, 2003a).

Food Selection and Preparation: Involving your children in the process

"Good kitchen helpers usually make good food tasters. Children learn best by doing, not watching (Oregon Dairy Council, 1997)."

It can often be a challenge to help children eat healthy foods by choice, particularly helping them eat enough vegetables, fruits, and dairy products. One way to encourage their consumption of these foods is to involve them in the food preparation process. Children are more likely to eat foods they have helped prepare (American Dietetic Association, 2000b; Food Standards Agency, 2003). Here are some ideas to help involve your children in the process as they grow:

Allow children to help plan what the family will eat

Encourage your child to design menus, choosing at least one favorite food for each meal (American Medical Association, 1998). Have children make a list of all the foods your family likes to eat. Use the list to help choose foods to serve each week. When planning meals, ask your child to choose the fruit and/or vegetable that will be served (Center on Hunger, Poverty, and Nutrition Policy, 2003b). Encourage children to help look for healthy recipes in cookbooks or on websites (American Dietetic Association, 2000a). List complete meals (entree, vegetable, etc.) on individual index cards. Work up to compiling 30 cards, which would cover one month worth of meals. Let family members take turns selecting cards for the week; then use the cards for that week's grocery list.

Involve children in grocery shopping

Have your child help make the list of foods needed. Have younger children look to see if you have certain ingredients or items in the pantry or refrigerator. Ask your child to count how many eggs, apples, or other items you have left so you can decide how many to buy (Center on Hunger, Poverty, and Nutrition Policy, 2003b). At the store, ask your child to choose a new vegetable or fruit from two or three choices, for a weekly "family try-a-new-food night." Allow your child to help prepare the new food (United States Department of Agriculture, 1999). Teach older children the skill of staying within the budget (American Dietetic Association, 2000a). Teach children about how empty-calorie and non-nutritious foods are often packaged and promoted in stores (American Medical Association, 1998).

Allow children to help prepare meals. Though children younger than age 10 usually cannot safely help out with the cooking, they can help in the kitchen in other ways. Here is a list of age-appropriate ideas:

Keep in mind, children have to be shown and taught how to do these activities, and children learn at different paces (adapted from United States Department of Agriculture, 1999). In time, children develop the skills and confidence to do even more and can build their self esteem. Praise efforts and try not to let spills interrupt your efforts -- use it as an opportunity to teach your child to clean up. Be sure to encourage hand washing and food safety (see "Clean: Wash hands and surfaces often" at http://fightbac.org/clean.cfm and "Basics for Handling Food Safely" at http://fsis.usda.gov/OA/pubs/facts_basics.htm for more information).

Be creative and make food fun and appetizing. Here are some ideas for creative food and fun family tables:

Remember, preparing family meals together benefits your family by increasing the likelihood your child will eat certain foods, increasing your time together, and increasing your child's self-sufficiency in preparing foods (Adapted from United States Department of Agriculture, 2003d).

Eating Away from Home: Carrying habits beyond the home

The way we eat at home affects our children's food choices when eating away from home. Not only do nutritious family meal time habits benefit the way our children eat at home, they also influence the way our children choose to eat when they are not under parent's supervision. Children tend to stick to what they know; so, once in the hot lunch line at school, they tend to eat more of the items they have been introduced to at home (Dickey, 2002).

Offer your children a variety of new and interesting foods at home, so they have a wide variety of healthy choices when eating out. The home and family meal time is also a good place to give your children advice and discuss how to choose healthy foods in restaurants. Encourage children to include salad or other vegetables in their meals when ordering out (American Medical Association, 1998).

What about fast food, you ask? Good question. Fast foods are typically high in fat, calories and sodium; low in fiber, calcium and other nutrients; and short on fruits and vegetables (United States Department of Agriculture, 2003e). Here are some tips for helping you guide your child in the fast food market:

Don't forget to allow your children to enjoy birthday cake, ice cream, chocolate bars, and other foods that are a memorable part of childhood. Simply make sure these foods are eaten in moderation, and balance them with more healthful fare at meal times. And, let a nutritious breakfast be your "insurance policy" for those times when your child may not choose the nutritious items from the hot lunch line... or pack a nutritious brown-bag lunch (see "Packing a healthy, safe lunch" for a few tips) (American Medical Association, 1998). When eating fast food as a family, try this idea -- pick a fast food place with a playground so your children can have some active play after their meal (United States Department of Agriculture, 2003e) -- or take it "to go" and go to a park for a picnic and some healthy, fun physical activity.

Packing a Healthy, Safe Lunch

"If your child is brown bagging it, plan ahead. Last-minute lunches tend to rely on fat-laden prepackaged foods (Dickey, 2002)."

Involve your child in the lunch-packing process. As with other meals, involvement gives your child a sense of ownership with what has been selected and prepared; and, there is less of a chance that your child will be willing to barter the lunch s/he prepared for the cake in the lunch bag across the table (Dickey, 2002).

Here are some healthy, fun lunch ideas:

Snacks and sides are as important as the main entree. Try to stay away from cookies, cakes, and other prepackaged sweets. Try some of these alternatives: pretzels, graham crackers, whole-wheat crackers, sesame breadsticks, naturally sweetened cereal, trail mix (dried fruit, nuts, and seeds), granola bars, applesauce or fruit, mini rice cakes, air-popped popcorn, yogurt, pudding.

For beverages, milk would be the drink of choice for a nutritionally sound lunch. Preferably low-fat milk, but even chocolate milk is okay on occasion to give your child a good source of calcium. Fruit juice is okay occasionally as well, just make sure it is 100% fruit juice and not a high-sugar fruit drink. Be sure to use an ice pack or insulated thermos to keep milk or juice cold.

Keep in mind how important it is to keep your child's food safe from food borne bacteria by keeping hot foods hot and cold foods cold. Let your child choose an insulated lunch box or sack to ensure foods stay at the proper temperature. Use refreezable ice packs for cold foods and a well-insulated thermos for hot ones. Be sure to wash the lunch box or sack with warm soapy water each day to combat bacteria (Adapted from Nemours Foundation, 2001, except where otherwise denoted).

Small Steps...Small Victories

Taking small steps at first can help your family be successful in making healthy changes for a lifetime. Frequently, people make too many changes at first and experience "burn out." Perhaps start increasing physical activity first for your family one or two times a week. Then when this habit is established, slowly add more physical activity. Then change food choices slowly. Choosing to make small and easy changes at first may help your family successfully reach the goal of regular physical activity and healthy food choices without feeling overwhelmed.

Do your best to be a positive role model for your children. It's worth the investment of your time and effort as you can help prevent overweight and its consequences (diabetes, high blood pressure, etc.).

We can choose to spend our time and money on prevention (making healthy food choices and increasing physical activity) or on treatment (taking off work and school to go to doctor's appointments, spending money on medications and other treatments). Make the choice to be a good role model for your children -- it's worth it!

References

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Special Series on Childhood Overweight

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