Many efforts targeting obesity focus on school-aged children. But a growing body of research suggests that to have the biggest impact, the work needs to start with even younger children, and their mothers.
“It is very difficult to reverse the [course] of obesity if you wait until kids are in school or school-aged to start doing something about it,” said Rafael Perez-Escamilla, a professor of epidemiology and public health at the Yale School of Public Health and co-author of a new report on preventing childhood obesity, released by the Child Health and Development Institute of Connecticut.
In the past decade, Perez-Escamilla said, there’s been an “explosion” of research linking childhood obesity to factors in early childhood and before birth, including a mother’s excessive weight gain during pregnancy and a child’s nutrition during the first five years of life.
But he and other experts say policy and anti-obesity efforts haven’t yet reflected that knowledge.
“Most of the interventions have been focused…on school-aged children. We just need to shift that earlier, because if the imprint of childhood obesity and the eating patterns are already developed by the time they get to school, it’s just harder to reverse those patterns,” said Katie Martin, a professor of nutrition and public health who directs the public health program at the University of St. Joseph.
A multigenerational cycle
Research cited in the report suggests that a woman’s high body-mass index before pregnancy or excessive weight gain while pregnant can impact her child’s risk of becoming obese and developing associated chronic diseases. And that could mean her female children are more likely to be overweight when they’re old enough to have children.
“It’s a multigenerational problem that’s spiraling and getting worse and worse with every succeeding generation,” said Judith Meyers, the report’s co-author and president and CEO of the Child Health and Development Institute.
Those risk factors could also be compounded by “suboptimal” feeding habits in infancy and early childhood, the report notes.
But often, thinking about obesity risk in infants is at odds with common perceptions about chubby babies being healthy and concerns about labeling young children, Meyers said.
Even the U.S. dietary guidelines released in 2010 don’t include any recommendations for children under 2, noted Perez-Escamilla, who was a member of the advisory committee that helped work on them. He said that’s expected to change — in 2020.
And even if pediatricians and other professionals notice young children are overweight, their parents might not.
“WIC and Head Start staff will tell us they already see the burden of childhood obesity in their kids at very young ages,” Martin said, referring to the Special Supplemental Nutrition Program for Women, Infants and Children, which provides food assistance and nutrition education for pregnant and postpartum women and children under 5.
“I think the challenge is, as parents, we’re much slower to see our kids as being at risk. We see them as being a healthy weight. But if a parent is hearing consistently from their pediatrician, the WIC staff, the Early Head Start that their kid might be on this tough trajectory, I think those perceptions could change,” Martin said.
One in three Connecticut kids
A 2010 and 2011 survey by the Connecticut Department of Public Health found that nearly one in three kindergarteners and third graders were overweight or obese.
Consistent with other surveys, this one found significant racial and ethnic disparities. Among white children, the overweight or obesity rate was 26.8 percent, compared to 40.8 percent among blacks and 43.3 percent among Hispanics.
“Latino and Black children living in the United States are significantly more likely than their white counterparts to be exposed to almost all the known early-life risk factors for becoming overweight or obese early on in life,” Meyers and Perez-Escamilla wrote.
Among the factors: higher maternal body-mass index before pregnancy, a higher likelihood of maternal depression and diabetes during pregnancy, lower rates of exclusive breastfeeding, introduction of solid foods before four months of age, faster weight gain during infancy, and young children’s having a television set in their bedrooms.
The report recommends taking into account cultural, class and race factors when developing messages about obesity-prevention, promoting breastfeeding, increasing enrollment in food assistance programs and other efforts.
What to do
Young children are biologically wired to prefer food and drinks full of calories, sugar and salt, making it especially important that their caregivers try to shift their preference toward healthier foods at an early age, Perez-Escamilla and Meyers wrote.
The authors said research has identified three major techniques for doing so:
- Offering foods many times: Infants, toddlers and preschoolers might react negatively to new foods, but often accept them after being offered them repeatedly.
- Providing a positive context: “Research has shown that children are more likely to consume healthy foods if they receive caring adult attention, including verbalization, during the meal and are not pressured to eat,” Perez-Escamilla and Meyers wrote.
- Modeling good eating: Young children are wired to learn by imitating their caregivers, and their food preferences are influenced by what they see their parents or other caregivers eat.
Policy advice
The report makes several recommendations for Connecticut, including:
- Support evidence-based programs that target early childhood obesity. The authors suggest analyzing existing programs and creating a database with information on each effort’s results and funding so policymakers can see which are most promising.
- Develop a consistent set of messages about preventing obesity for families, childcare providers and others, and develop better ways to measure and report weight in very young children.
- Expand participation in nutrition assistance programs for low-income households. Nationally, more than a third of people eligible for food stamps and 40 percent of those eligible for WIC — the program for young children and mothers — don’t participate, according to the report.
- Help more women to breastfeed longer, including by improving workplace accommodations for breastfeeding mothers.
- Include early-childhood obesity prevention efforts in the health care system overhaul the state is planning.
- Designate an existing umbrella group to coordinate early-childhood obesity prevention efforts, or create a new group if necessary.
Because there are already many efforts aimed at nutrition and obesity, Martin said the state doesn’t need to start from scratch. She pointed to one state-level collaboration between WIC and Early Head Start and Head Start that tries to identify children at risk of becoming overweight, to ensure that they’re enrolled in both programs and that their families receive consistent messages about nutrition.
Perez-Escamilla said the goal of the report isn’t to diminish programs for school-aged children. Efforts to improve school nutrition and physical activity are important, he said.
But, he added, “If we wait to start for them, it’s too late for many children.”