Childhood Eating Behaviors: Developmental and Sociocultural Considerations

Patricia L. B. Lockyear, PsyD

Disclosures

February 02, 2004

The attention devoted to obesity and eating habits in the popular press and the scientific community has increased significantly in the past decade, as has the increase in obesity in children of developed countries.[1] Americans in particular seem obsessed with diets and weight loss, as evidenced by the phenomenal popularity of diet books: Currently, 2 of The New York Times best-sellers are diet books. The singular focus on weight loss loses sight of the multiple factors influencing how we eat. This column, "Nutrition, Culture, and Women's Health," will examine the impact of sociocultural and developmental aspects on eating habits, health, and nutritional status of women at different life stages. This first essay focuses on childhood eating habits.

The development of eating behaviors is a complex process influenced by social, cultural, biological, ecological, and personal factors.[2,3] From a developmental perspective, societal influence increases as the child ages and parental influence remains important throughout childhood. In developed countries, major changes in global societal trends have contributed to changes in the way we eat.[4] An overabundance of food in developed countries has led to a shift in the perceived value of food as a consumer good with little connection to the source of food items. The way food is eaten in developed countries has changed remarkably, with increasing numbers of children eating alone or while watching TV. In developing countries, poor quality of food,[5] limited dietary diversity,[6] and household structure and economic conditions[7] contribute to poor nutritional status of young children.

During infancy, biological influences predominate with a preference for sweet over bitter or sour, which helps to ensure nutritional adequacy through the consumption of breast milk or formula.[4] As infants mature and begin to eat solid food, parental influence and societal factors take on increasing importance. A recent study of infant diets in the United States identified the change from infancy to toddlerhood (9-18 months) as a critical period.[8] Infants from low-income, urban families were found to have inadequate intakes of vitamin D, zinc, and iron. This study focused on these nutrients because low levels of zinc, calcium, and iron increase the susceptibility to lead absorption and storage. The study examined diets of children from infancy to 24 months and found sufficient calories but excessive amounts of protein. As the children matured, the diets became less nutritionally sound and protein consumption increased significantly. These results reflect larger, nationwide surveys of infant diets in the United States and emphasize the importance of parental influence on a child's nutritional status and the development of food preferences. Repeated exposure to certain foods influences a child's preference for that food[4] and can shape eating behavior later in life.

A recent review of childhood diets in sub-Saharan Africa illustrated how limited variety in a young child's diet significantly reduces nutritional status and contributes to retarded growth.[6] Poor-quality diets lacking variety and palatability can influence appetite, leading to meager consumption patterns in young children and diminished growth.[5,6] In Pan American countries, one quarter of food offered is left uneaten by growth-retarded infants and children.[5] Increased risk of infection, higher mortality rates, and poorer cognitive functioning have been linked to poor nutritional status in early childhood.[9] The availability of high-quality food and the ability of the parent to provide such food play a significant role in children's eating behavior and subsequent nutritional status.

Socioeconomic status influences nutritional status and the variety of food available for children aged 5 years or younger.[6] In the Caribbean, biological, married parents devote greater resources to their children's diet than do nonbiological caregivers, single parents, or cohabitating parents.[7] In Latin America, South Africa, and the United States, biological mothers provide greater resources for their children than do adoptive, foster, or stepparents. The socioeconomic status of families, the relationship of the caregiver to the child, and the quality of available foods affect the eating behaviors of children in developing countries. Furthermore, the effects of poor nutrition over time result in declining nutritional status as the child ages.[7] This decline in nutritional status is also seen in developed countries, although for different reasons.

Societal trends in developed countries reflect reduced time devoted to food preparation and heavier reliance on prepared foods and fast food. In the United States, increased reliance on fast foods has led to poorer eating habits among school-age children.[1,10] Recently published results of the 1994-1996 and 1998 Continuing Survey of Food Intakes show that the 42% of children who reported consumption of fast food had reduced nutritional status for vitamins A and C, lower consumption of milk, fruits and vegetables and a concomitant increase in saturated fat, sodium and calories.[10] Consumption of fast food or restaurant food increased 300% between 1977 and 1996. [1]

Children between the ages of 6 and 17 years also consume more soft drinks than in previous years, with an increase of 48% since 1977/1978.[11] Not only are more children consuming soft drinks, but the amount consumed has increased from 5 ounces per day to 12 ounces per day. These trends in eating behaviors are accompanied by an increase in childhood obesity. Sixteen percent of 6- to 11-year-olds are above the 95th percentile for body mass index (BMI), and 14.3% are between the 85th and 95th percentile for age-related BMI; approximately 30% of all children are overweight or at risk of becoming overweight.[1]

Overall, the eating patterns of US children reflect poor nutrient intakes, with 16% of children not meeting any of the recommended daily allowances (RDAs) and only 1% meeting all food group recommendations.[12] Approximately 70% of children between the ages of 2 and 19 did not consume the recommended servings of fruit, grain, dairy, or meat products, and 64% did not eat the recommended number of servings for vegetables. A recent study of US children's eating patterns showed that gender and ethnic differences influence eating behaviors.[13] Although none of the children surveyed in the study met the RDAs, African-American children ate diets with more fruit, meat, and vegetables. Girls consumed greater amounts of fat and thus had higher total energy intakes than boys. These are particularly frightening statistics, as obesity and poor nutritional status have been shown to increase the risk of developing diabetes, cardiovascular disease, and certain cancers in adulthood.[14]

The eating habits of European children show similar trends in reliance on convenience foods, an increase in dieting, and poorer eating habits. A study of eating behavior of children in Liverpool showed older children and adolescents regularly skipping breakfast, especially girls.[15] The missed breakfast was replaced by eating convenience food on the way to school. Primary school-age children were more likely to eat fruits and vegetables than secondary school-age children, although only 31% of primary and 21% of secondary-age children included in the Liverpool assessment regularly ate fruits and vegetables.

Age and gender differences in eating habits also were evident in the study conducted in Ireland, with changes appearing at the onset of adolescence.[14] More girls than boys viewed their weight negatively and either were on a diet or believed they should be on a diet, although significant numbers of boys reported self-perception of being overweight (46% of girls and 26% of boys viewed themselves as overweight). Food restriction was related to increased consumption of cigarettes, coffee, and alcohol. Although these findings derive from only 2 studies, they describe large numbers of children (4197 respondents in Liverpool and 8497 children in Ireland) and represent a cross-section of children's eating behaviors in developed countries: behaviors that indicate decreasing quality of food intake, increasing health risk behaviors, and greater reliance on food consumed outside the home. Eating behaviors may deteriorate as the child ages and becomes more independent and more concerned about body image and weight.

Despite increasing independence in food choices as a child ages, parental influence remains high through adolescence. In France, 86% of the 1000 children surveyed (aged 9-11 years) reported relying on their mother's ability to provide nutritious meals, although 31% reported fighting with their mothers about food.[16] In the United States, a study of 282 families in the Seattle area showed the food preparer's preferences and eating habits -- most often the mother's -- significantly influenced the consumption of fruits and vegetables by children 5-17 years of age.[17]

Caregivers provide physicians a prime opportunity to influence children's eating behaviors. They provide most of the food a child consumes, and children depend on them to do so. Parents, especially mothers, rely heavily on what their pediatricians and family physicians recommend. Using anticipatory guidance, physicians can positively affect child health behaviors.[18] Specific, concrete suggestions delivered at times of low stress are most effective in communicating health messages to caregivers.[19] Physicians can provide nutrition information to their patients through brief verbal suggestions, written information, and office posters. Given the rapid increase in obesity among children and the decline in healthful eating behavior among children of all ages, it is imperative for healthcare providers to take a proactive approach in promoting healthier eating habits among children.

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