Managing Early Childhood Obesity in the Primary Care Setting: A Behavior Modification Approach

Samantha H. Drohan


Pediatr Nurs. 2002;28(6) 

In This Article

Development of Eating Behaviors in Early Childhood

Children are equipped with an innate preference for sweet and salty tastes. Most likely due to an adaptive function, infants and children are also biased to reject new foods. With the exception of sweet and salt, the rest of our food preferences are learned (Birch, 1998). Children learn to like or prefer foods that are familiar to them. Foods that are familiar are those that are presented in their environment and are eaten by parents, siblings, and peers. The food environment that parents provide undoubtedly helps shape young children's food preference and subsequent selection patterns (Birch & Fisher, 1998).

The social context in which foods are presented is extremely important in the formation of young children's food preferences. Birch, Zimmerman, and Hind (1980) conducted a study to investigate the effects of several social contexts on the formation of preschool children's food preferences. They found that when a neutral food (both sweet and non-sweet) was presented as a reward or accompanied by adult attention, the preference for that food was enhanced. On the other hand, no increase in preference was found for foods presented in a nonsocial or snack-time routine contexts. These effects on preference were not transitory and were still reflected in the post-assessment preference data obtained 6 weeks after the conclusion of the experiment. The use of sweet foods as rewards or pacifiers is pervasive in our culture and may contribute greatly to young children's preference for such foods. It is no great surprise that children often show preference for sweet or high fat foods, since these are the typical foods provided as treats for good behavior or served at holidays and special occasions. Since the enhanced preferences documented in the reward and adult attention contexts were noted for both sweet and non-sweet foods, it is possible to increase preference for non-sweet foods as well. Though it is generally discouraged to use food as a reward, positive contexts could be used to increase preference for foods that are not initially highly preferred but are nutritionally desirable.

A study by Newman and Taylor (1992) investigated the effect of using one food as a means of obtaining another food (means-end contingency) on preschool-aged children's food preferences. After selecting two snacks of equally medium appeal, the children were assigned either to a means-end condition group (where one snack was eaten as a means of gaining the other), a temporal order control group (where one snack was presented and eaten before the other), or a mere exposure control group (where the children chose the order in which they ate the two snacks). Results showed that children in the control groups did not express any change in food preference at the completion of the study. In the means-end group, however, the first snack (means) was less preferred and the second snack (end or reward) was more preferred after the treatment. After the experiment, these children consistently ranked the snack used as a reward higher than the snack used as a means to obtain the reward - despite the fact that the children had preferred the two snacks equally prior to the study. The decreased preference for the snack that functioned as the means, however, was much more significant than the increased preference for the snack presented as the reward. Parents frequently use dessert to reward young children for eating more nutritious foods. Though the reward is offered in an attempt to increase the likelihood that the child will eat the more nutritious food, this tactic may actually cause the child to prefer the dessert more and to prefer the nutritious food much less than before the reward was presented. The more control exerted by a parent in presenting the reward and the more value placed on the reward, the greater the anticipated devaluation of the nutritious food used as the means to the reward. Newman and Taylor (1992, p. 215) suggest that presenting a sequence in temporal order (e.g., "eat your vegetables and then your dessert") rather than in a means-end contingency (e.g., "eat your vegetables so that you can have dessert"), may avoid creating an increased preference for the reward. If healthy food choices are always presented as a means for obtaining sweets instead of in a positive context, children will not learn to prefer nutritious foods.

In addition to environmental and social contexts, parental feeding practices significantly influence young children's ability to choose a healthy diet. Many parents, in a well-intentioned effort to improve children's eating patterns, will utilize power-assertive and coercive child-feeding strategies. According to Satter (1986, 1995), a child's innate ability to self-regulate may be diminished by such a high degree of parental control over feeding practices. Satter recommends a division of responsibility in feeding children. In this scenario, the parent is responsible only for providing safe and appropriate foods in a positive and supportive context. The child is then responsible for deciding what and how much to eat. Children have a remarkable ability to adjust their intake according to energy needs, an ability that is exhibited as early as infancy. Infants are capable of being responsive to the energy density of formula and adjusting intake accord-ingly. Maternal control, however, can override a child's regulatory ability (Birch & Fisher, 1998). If children are not given the opportunity to experience, interpret, and trust their own satiety and hunger cues, then they may lose their ability to self-regulate. Consistently overruling or denying cues coming from children, therefore, will have a detrimental effect. Child feeding practices that overly encourage or restrict children's consumption of foods may decrease the extent to which children use internal signals of hunger and satiety as a basis for adjusting energy intake (Satter, 1986).

External cues, such as the time of day or amount of food left on a plate, also tend to diminish internal cues of hunger and fullness. Johnson (2000) conducted an investigation to determine whether preschool children could be taught to focus on internal cues of satiety rather than on external cues and, consequently, improve their self-regulation of energy intake. At baseline, there was large individual variability in children's ability to self-regulate. Children with greater adiposity initially showed less evidence of self-regulation. During the 6-week intervention, children took part in activities designed to help them recognize internal cues. They were introduced to the concepts of hunger and satiety via video and role play. Concrete, developmentally-appropriate definitions for hunger and fullness were presented and instruction on how to link those concepts to their internal feelings of hunger and satiety provided. The majority of self-regulation scores rose after the intervention, despite whether the children were initially over or undercompensating. Furthermore, posttest data showed that adiposity no longer significantly related to children's regulation scores after the intervention. These findings lend support to Satter's belief that young children are capable of controlling the amount of the food they consume if their internal cues are encouraged by parents or caregivers.

Mothers often misinterpret children's cues. Qualitative research about low-income mothers' feeding practices suggest that crying in infancy is almost always interpreted as a hunger cue. Night crying, in particular, is frequently cited by mothers as an indication that the infant did not get enough to eat during the day. This belief is the impetus for many mothers to initiate early introduction of solids and table foods. This same group of mothers also reported feeding their infants and toddlers based on their own hunger cues, instead of relying on the cues from their children. "Picky eaters" were of particular concern, since mothers believed that a child should be hungry when their parents are hungry and should want to eat what their parents are eating. In preschool aged children, the mothers reported frequently using food to reinforce, promote, or bribe good behavior, rather than using food to satisfy the child's hunger (Baughcum, Burklow, Deeks, Powers, & Whitaker, 1998). This pattern of using food to soothe children or to shape behavior instead of to alleviate hunger will likely interfere with the development of a child's internal self-regulation abilities, particularly for those children with a genetic predisposition for obesity.

Another obstacle for promoting healthy feeding practices, particularly for low-income mothers, is the differing perceptions between mother and PCP about the definition, etiology, and meaning of being overweight. A qualitative study investigating mothers' perceptions about their over-weight preschoolers showed that mothers did not define overweight or obesity according to height and weight measurements on standard growth charts (Jain et al., 2001). For this group of mothers, a bigger child was considered a healthy, well-fed child and indicative of effective parenting. Another dominant belief was that a child's size and growth pattern was fixed or predestined, suggesting that a child would follow their genetically fixed growth curve no matter what types or quantity of food is consumed . Furthermore, the study participants described a lack of control over their preschooler's eating and voiced a powerlessness to remedy the situation. Just as excessive control in child feeding practices may exert a negative influence, perhaps a general lack of structure and control may have a similar effect. The above-mentioned qualitative studies suggest that for low-income mothers a lack of general parenting skills may be contributing to childhood obesity.


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