JACN
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Klohe-Lehman, D. M.
Right arrow Articles by Bohman, T. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Klohe-Lehman, D. M.
Right arrow Articles by Bohman, T. M.
Journal of the American College of Nutrition, Vol. 26, No. 3, 196-208 (2007)
Published by the American College of Nutrition

Low-Income, Overweight and Obese Mothers as Agents of Change to Improve Food Choices, Fat Habits, and Physical Activity in their 1-to-3-Year-Old Children

Deborah M. Klohe-Lehman, PhD, RD, Jeanne Freeland-Graves, PhD, RD, Kristine K. Clarke, PhD, MPH, RD, Guowen Cai, PhD, V. Saroja Voruganti, PhD, Tracey J. Milani, PhD, Henry J. Nuss, PhD, J. Michael Proffitt, PhD and Thomas M. Bohman, PhD

Division of Nutritional Sciences (D.M.K.-L., J.F.-G., K.K.C., G.C., S.V., T.J.M., H.J.N., J.M.P.)
Addiction Research Institute, Center for Social Work Research (T.M.B.), University of Texas at Austin, Austin, Texas

Address reprint requests to: Jeanne Freeland-Graves, PhD, RD, The Bess Heflin Centennial Professor, Division of Nutritional Sciences, 1 University Station, A2700, The University of Texas at Austin, Austin, TX 78712. E-mail: jfg{at}mail.utexas.edu


   ABSTRACT
TOP
 FOOTNOTES
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Objective: To examine the effects of a weight loss program for mothers on the diet and activity of mothers and their 1–3 year old children.

Design: Overweight and obese mothers participated in an 8-week weight loss intervention encompassing diet, physical activity, and behavioral modification. Anthropometrics, demographic, dietary, and physical activity questionnaires were administered at weeks 0 and 8; anthropometrics were re-evaluated at week 24.

Subjects: Mothers (N=91) of a 1–3 year old child; body mass index (BMI) ≥ 25 kg/m2; non-breastfeeding; age 18–45 years; income < 200% of federal poverty index; Hispanic, African American, or white; and English-speaking were recruited from Special Supplemental Program for Women Infants and Children (WIC) and public health clinics.

Intervention Measures of Outcome: Weight loss in mothers and improvements in diet (reduction in calories, fat, snacks/desserts, sweetened beverages, and increases in fruit, vegetables) and activity in mothers and children.

Results: Weight loss in mothers was modest (–2.7 kg, p < 0.001) and sustained at week 24 (–2.8 kg, p < 0.001), and children gained in height and weight as expected for normal growth (p < 0.001). Initial energy intakes of children exceeded Estimated Energy Requirements (123%) and were reduced to acceptable levels post-intervention (102%, p < 0.001); additional beneficial changes in children's diets were decreased total (47.7 to 39.9 g/day) and saturated fat (19.2 to 16.6 g/day), high-fat snacks/desserts (1.6 to 0.9 servings/day), added fats (81.8 to 40.9% using), sweetened beverages (0.8 to 0.4 servings/day), and fast food consumption (11.6 to 6.6% of meals), and increased home-prepared meals (63.2 to 71.6% of meals) (p < 0.01 for all). Physical activity scores improved by 7% in children (p < 0.05). Comparable changes in food choices and activity also were seen in mothers.

Conclusion: Offering weight loss classes was a successful method of enticing low-income women to participate in an educational intervention that benefited their children. Overweight and obese mothers who modified their food choices and fat habits made comparable changes for their child.

Key words: mothers, children, obesity, prevention, intervention, low-income


   INTRODUCTION
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Pediatric obesity is paralleling the epidemic of obesity in adults. Of particular concern is the prevalence of overweight among infants (11%) and overweight/at risk in 2–5 year olds (22%) [1,2]. These rates are disproportionately higher in 0–23 month old African American [2] and 2–5 year old Hispanic [1] children. Obesity is often more pronounced in low socioeconomic populations [3,4], and the increase in overweight has become a major nutritional problem in low-income, preschool children [5,6]. The main concern over child obesity is its associated co-morbidities, including hypertension, insulin resistance, and type 2 diabetes [7,8], as well as adverse social consequences [9,10].

Interventions should be initiated early in life, as food habits are formed at a young age [11] and excess weight becomes more difficult to treat as one becomes older [12]. Mothers should be the focus of interventions for childhood obesity, as they are the primary providers of food. Also, maternal body mass index (BMI) is a significant predictor of pediatric BMI in low-income, preschool children [13–15]. Thus, interventions in families with overweight and obese mothers are critical for preventing obesity in the child. Among all ethnicities, women of low-socioeconomic status are 50% more likely to be overweight [16] than those from higher incomes; however, the majority of weight loss programs are not designed for low-income mothers. Consequently, a great need exists for interventions tailored to this population.

Two studies have been conducted that involved weight loss in parents for the prevention of obesity in children [17,18]. The study by Epstein and colleagues [17] included 30 at-risk, non-obese 6–11 year olds with an obese parent. The 6-month intervention was delivered to both parents and children who were assigned to the following groups: (1) increase fruit and vegetables or (2) decrease high-fat/high-sugar group. At 1-year, anthropometric and dietary changes were more pronounced in the parents than the children. High-fat/high-sugar foods decreased for all groups; but the increase in fruits and vegetables was only significant in mothers in group 1. It appears that positive messages were more effective for improving diet and weight.

In 2003 Harvey-Berino and Rourke [18] pilot-tested the effectiveness of a 16-week obesity prevention program in overweight Native American parents of children 9-months to 3-years old (N = 40) who were participating in WIC. Parents were divided into two instructional groups: (1) parenting support or (2) obesity prevention plus parenting support. The "obesity prevention" component emphasized skills for improving eating and exercise behaviors in children. Parents in both groups slightly decreased their weight, but not significantly. Weight-for-height z-scores and energy intake of the children in the obesity prevention plus parenting support group declined, as compared to a slight increase in the parenting support alone group (p=0.06).

Numerous other studies have targeted parents for weight loss and role modeling, in combination with obesity treatments in older children [19–26]. Golan and colleagues [19,20] conducted an obesity treatment program among 60 obese 6–11 year olds who had at least one obese parent. Child weight loss was greater when parents were educated exclusively than when the child was treated alone. It was concluded that parents could act as agents of change to foster healthful behaviors in their children. A conceptual model for the familial approach to child obesity treatment was presented by Golan and colleagues [21]. In a study of 142 obese 8- to 12-year-old children and their parents participating in a family-based weight control program, parents with the greatest z-BMI change had children with greater z-BMI changes as compared to children with parents who lost less weight [22]. Similar results have been reported by other researchers who provided family-based obesity treatments [23–26]. The results from these studies indicate that when parents role model healthful behaviors their children are more likely to engage in similar behaviors. However, these programs differed from ours as the children in the present intervention were not undergoing obesity treatment.

Still others have developed programs for children without encouraging weight loss in the mother. These include obesity prevention for 3–4 month olds [27], cardiovascular disease risk reduction for 7–36 month olds [28], obesity treatment for 3–6 year olds [29], and fruit and vegetable promotion for 1–5 year olds [30–33]. These studies indicate that education of the parents improved consumption of fruits, vegetables, and low-fat foods; increased physical activity; and reduced television viewing in the children. Collectively, these interventions suggest that mothers can be agents of change for promoting healthy lifestyles in young children.

To date no studies were found in the literature that promoted weight loss in low-income, overweight and obese Hispanic, African American, and white mothers of 1–3 year old children as agents of change for their child. The purpose of this study is to examine the influence of a weight loss program on the diet and activity of these women their children.


   MATERIALS AND METHODS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Design
Low-income, tri-ethnic overweight (BMI ≥ 25 kg/m2) or obese (BMI ≥ 30 kg/m2) mothers (N = 91) participated in an 8-week weight loss intervention. Main outcome measures were weight loss in mothers and improvements in diet (reduction in calories, fat, snacks/desserts, sweetened beverages, and increases in fruit, vegetables) and activity in mothers and children. Subjects were measured for height and weight at weeks 0, 8, and 24 (follow-up). Mothers completed demographic and dietary questionnaires [24-hour recalls, 2-day diet records, and food frequency questionnaires (FFQs)] for themselves and their child at weeks 0 and 8. Activity was assessed in children via a Toddler Behavior Assessment Questionnaire (TBQ). [34] and in mothers with pedometers worn for 3-day intervals at weeks 0 and 8.

Subjects
A convenience sample of mother-child pairs were recruited from WIC and public health clinics. Mothers with a healthy 1–3 year old child, BMI ≥ 25 kg/m2, combined family income < 200% of federal poverty level, age ≥ 18 years old, literate in English, and not breastfeeding significantly (<5 minutes/day) were included in the study. Subjects were informed of the benefits and risks and informed consent was obtained. The Institutional Review Board of The University of Texas at Austin approved the protocol.

Determination of Weight Status
Height and weight in mothers and children were measured using a stadiometer (Perspective Enterprises, Portage, MI) and a calibrated digital scale (Model HS-100-A, Fairbanks Scales, St. Johnsbury, VT). Recumbent length was measured for children < 2 years. The child was placed lying on his/her back on a flat table with a tape measure securely adhered to the surface. Two trained people aided, one to hold the head of the child straight against a headboard, and the second to align the legs and position the feet at a 90° angle to the leg. A mark was placed on the tape measure at the bottom of the heel.

Height and weight (kg/m2) were used to calculate BMI in mothers and children ≥ 2 years. In children ≥ 2 years old, BMI-for-age percentile levels were determined using Centers for Disease Control and Prevention (CDC) growth charts [35]. Weight classifications included: underweight, < 5th percentile; normal weight, ≥ 5th and < 85th; at risk for overweight, ≥ 85th; and overweight/obesity, ≥ 95th. In children < 2 years old, weight-for-length was used, and children < 5th percentile were classified as underweight; 5th–95th, as normal weight; and > 95th, as overweight.

Demographic/Health Status
A 40-item general questionnaire contained information on age, income, education, ethnicity, parity, childbirth, and employment status [36]. Additional questions added specifically for this study included infant birth weight and length, notation of any minor obstetrical complications, Medicaid insurance status, and mother and child health histories.

Nutrient Intakes of Children
Nutrient intakes of the children were calculated using an average of three days of intake (one 24-hour recall and 2-days of diet records) for children as recorded by mothers. A trained registered dietitian administered the 24-hour recalls. Strategies to improve accuracy included the use of measuring utensils and food models to determine portion sizes and provision of detailed instructions for completion of an additional 2 days of food records (one week day and one weekend day). The diet records were reviewed/clarified with the subject to ensure completeness. Data from the recall and records were analyzed using Food Processor 7.71 (ESHA Research, Version 7.81, 2001).

Nutrients were adjusted using Software for Intake Distribution Estimation [37], as recommended by the Institute of Medicine [38]. This program removes within-person variance in nutrient intake to obtain better estimates of long-term, usual intake. Nutrient data does not include that from supplements, as we were interested in the nutrient intake from food sources alone. Also, only 10% of mothers gave their child supplements on a regular basis.

Estimated Energy Requirements (EERs) for children were based on age- and gender-specific equations that provided for energy balance, plus a factor for growth [39]. The proportion above/below the Acceptable Macronutrient Distribution Ranges (AMDRs) for % energy from macronutrients was determined. For nutrients with an Estimated Average Requirement (EAR), the EAR cut-point method identified the proportion with intakes below the EAR [38]. The Adequate Intake (AI) criteria were used for nutrients without an EAR. Vitamin A intakes (RE) were compared to the previous 1989 Recommended Dietary Allowances (RDAs) [40], as retinol activity equivalents (RAEs) from the dietary software were unavailable.

Food Choices of Mothers and Children
Food frequency questionnaires (FFQs) developed and validated for a tri-ethnic population of adults [41] and 1–3 year old children [42] determined servings/day of foods and food groups. Both FFQs were derived from the Health Habits and History Questionnaire [43], but were modified to include ethnic foods, low-fat foods, restaurant/fast foods, and supplements. The child FFQ, completed by the mother, was further modified to include age-appropriate foods and portions. Mean coefficients were 0.73 and 0.69 for reliability, and 0.45 and 0.41 for validity, in the mother [41] and child [42] FFQs, respectively.

Frequency was determined via a nine-point response scale ranging from "never or < once per month" to "2 + servings per day" for food items. Subjects were asked to identify the portion size consumed based on fractions of a medium serving, with a small serving designated as 1/2 the medium; a large, 1 1/2 times the medium; and an extra large, 2 times the medium serving. The FFQs were checked by a registered dietitian to ensure accuracy. Fractions of servings/day from the frequency responses were calculated and multiplied by the serving size (as a multiple of a medium serving). Food items with similar nutrient profiles were summed to determine total food group servings/day.

Physical Activity in Mothers
Mothers wore pedometers at weeks 0 and 8 (Model AE170, Accusplit, San Jose, CA) for 3 days (2 week days and one weekend day) to assess physical activity. The Accusplit AE170 model is the Yamex Digiwalker SW-701 sold with a different manufacturer's label. The Yamex Digiwalker SW-701 has been shown to be accurate [44] and to exhibit validity as evidenced by significant correlations with steps during walking (r = 0.84) and VO2 max (r = 0.75) [45]. These pedometers do not need to be calibrated. Mothers recorded number of steps, calories burned, and time the pedometer was worn. Only the step data will be presented in this paper.

Physical Activity in Children
The activity scale of the Toddler Behavior Assessment Questionnaire (TBAQ) was used to determine activity in the children and was completed by the mother [34]. The full questionnaire (108 items) consists of several temperament scales, one of which is the 7-item activity scale used in this study. Cronbach's {alpha} for the activity scale was 0.71, and this scale has been validated in parents of toddlers [34]. The definition of activity level used in the TBAQ was "limb, trunk, or locomotor movement during a variety of daily situations, including free play, confinement, or quiet activities." The 7-point response options had values ranging from 1 (never) to 7 (always observed the behavior during the last two weeks), with a "does not apply" option available. Item values were summed and divided by total number of items with responses for a total score. Higher numbers designate greater activity.

Weight Loss Program
Registered dietitians taught eight weekly two hour classes that included a 15 minute weigh-in, 1 1/4 hour discussion and activities, and 30 minutes of low- to moderate-intensity exercise. The program promoted nutritious food choices and lifestyle changes for good health and weight loss in mothers, with additional components of behavioral modification and physical activity. Child care was available at the classes but transportation to/from the sessions was not. Classes ranged in size from two to 10 mothers.

Design for the weight loss program was grounded in basic concepts of the Social Cognitive Theory (SCT) (Fig. 1). Its premise is that an individual's health behavior can be attributed to an interaction of his/her cognitions, behaviors, and environment, and modification of any of these components will alter the individual's behavior [46]. Objectives of the interventions can be divided into two major categories: change in mother's cognitions and behaviors. Enhanced knowledge of general health, nutrition, and parenting skills should enable the mother to make behavior changes that affect the home environment to positively influence the child's diet and activity behaviors.


Figure 1
View larger version (48K):
[in this window]
[in a new window]

  		Fig. 1. Conceptual model for the prevention of child obesity using mothers as agents of change.

 
Cognitive-behavioral strategies used included self-monitoring, stimulus control, and contingency management. Self-monitoring techniques consisted of diet records and pedometers to measure steps/calories expended in activities. Participants identified triggers and alternatives to unhealthy eating (stimulus control). Prizes were given for obtaining goals and participants were encouraged to reward themselves for achievements (contingency management). Additional techniques included goal-setting, individualized feedback, parenting and coping skills, and relapse prevention.

The dietary component utilized well-balanced eating plans, discussion of health benefits of foods and nutrients, and development of culturally-sensitive meal planning skills. Interactive components were low-fat cooking demonstrations, modification of recipes, and the sharing of strategies found to be effective for weight loss. The Food Guide Pyramid and serving sizes for adults and children were taught with colorful handouts [47,48].

The relationship of physical activity to weight and methods to increase frequency ype were incorporated into most classes. In class physical activities included 30 minutes of walking, stair-climbing, exercise videos, and resistance exercises with light weights. Activities to share with their children also were discussed.

Prior to administration of the program, a focus group was conducted with 10 low-income, tri-ethnic mothers of young children. Mothers provided feedback on the proposed class topics and weight loss techniques.

Program Evaluation
A 23-item program evaluation form was administered at week 8. The form was developed specifically for use following this intervention and contained 18 questions to evaluate the usefulness of the class topics and techniques to promote weight loss. Response options were based on a 5-point scale, ranging from 1 ("strongly agree" or "very useful") to 5 ("strongly disagree" or "not useful/did not use"). Five additional open-ended questions were included for participants to describe aspects of the program and/or instructor's teaching that they liked most/least, as well as recommendations for improvement of the program or instructor's teaching effectiveness.

Statistical Analysis
Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS 11.5, Chicago, IL, 2003). Frequencies, medians, and means were computed for descriptive purposes, and data examined for outliers and normality. Analysis of variance determined significant differences in continuous variables (i.e. age, BMI) by categorical variables (i.e. ethnicity, weight status). Paired-sample t-tests measured significant differences pre-post for continuous variables (i.e. nutrients, food items, food groups, and activity scores). Spearman correlations examined the relationship between mother and child change variables. Pearson correlations identified associations between consumption of select food groups (i.e. high fat foods, fast foods, sweetened beverages) and nutrient intakes or child's weight.

Additional analyses were conducted to examine the effects of demographic covariates (ethnicity, family income, mother's education level, mother's history of employment, mother living with spouse or partner, and age of mother and child) on the main outcome measures. Pre-post change variables (post minus pretest score) were computed for each outcome measure. Relationships between the outcome change variables and potential covariates were evaluated using univariate analysis of variance. The majority of outcome change variables were not affected by the covariates. Outcomes that were significantly related to a covariate are presented in the text.


   RESULTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Of the 235 mothers completing the first class, 106 finished the 8-week intervention (attended at least 7 of 8 classes and both pre- and post-study visits). An additional 15 subjects were excluded from the final analyses due to breastfeeding (n = 10) or failure to return all questionnaires (n = 5). Thus, the final sample size was 91. Factors influencing attrition in this program included lack of transportation, time, childcare, and family support; illness or death; work and family responsibilities; holidays; and stress. Drop-outs did not differ from intervention subjects in anthropometrics or demographics, but were more likely to be single (p < 0.05) and to have never worked (p < 0.01).

The 91 participants were tri-ethnic (62.6% Hispanic, 22.0% African American, and 15.4% white), obese (75.8%) and overweight (24.2%) mothers of 1–3 year olds. The most frequently reported income and education levels were $15,000–$29,999 (51.6%) and partial college (35.2%), respectively. Only 17.6% exclusively breastfed their child during infancy; 29.7% fed formula and 52.7% provided a combination. The mean age of the children was 2.1 years, with approximately equal numbers of boys and girls. According to CDC growth charts, 24% of 1-year olds were overweight, and 19.5% of 2–3 year olds were overweight (7.3%) or at risk (12.2%).

Following the 8-week intervention, mean weight loss in mothers was –2.7 ± 2.8 kg (p < 0.001), and mean BMI was reduced from 34.9 kg/m2 to 33.9 kg/m2 by week 8 (p < 0.001). This weight loss was sustained at week 24 (mean = –2.8 ± 4.9 kg, p < 0.001; mean BMI = 34.1 kg/m2). As expected for normal growth, the children gained slightly in height (p < 0.001) and weight (p < 0.001) during this study. Mean weight-for-height percentile levels for 1-year olds were 66, 66, and 74th percentiles at weeks 0, 8, and 24, respectively. The increase by week 24 was not significant (p = 0.366). Mean BMI-for-age percentile levels for 2–3 year olds were 56, 60, and 69th percentiles at weeks 0, 8, and 24, respectively. The increase by week 24 was significant (p < 0.001). Mothers with less than a high school education were more likely to have a child whose BMI-for-age percentile decreased (x = –12.4th percentile) than mothers with partial college (x = 11.2th percentile, p < 0.01) or college education (x = 8.0th percentile, p < 0.05), whose children experienced increases in BMI-for-age percentiles from week 0 to week 8.

Table 1 displays changes in macronutrient intake of children following the intervention in their mothers. At week 0, energy intakes were above the Estimated Energy Requirements and decreased significantly by week 8. Total fat intake declined; however, the reduction in saturated fat was significant only in 2–3 year olds. For other macronutrients, the majority of the sample was within the Acceptable Macronutrient Distribution Ranges. Mean fiber intake was less than the Adequate Intake.


View this table:
[in this window]
[in a new window]

  		Table 1. Macronutrient Intake of Children Pre- (Week 0) and Post- (Week 8) Weight Loss Intervention in Mothers as Determined by 24-Hour Recall and 2-Day Diets

 
The percentage of children meeting the Estimated Average Requirements (EARs) for select nutrients pre- and post-weight loss intervention in mothers is shown in Fig. 2. The percentage of children below the EARs at baseline was considerable for vitamins E (74.7%) and A (29.7%) and folate (22%). The percentage of children below the EAR at post-intervention did not change significantly for any nutrient. Vitamin D was less than the AI (~95%) and calcium was above (~151%) at both pre- and post-intervention. Nutrient data of the mothers are presented in a manuscript by Clarke and colleagues [Clarke KK, Freeland-Graves JH, Klohe-Lehman DM, Cai G, Voruganti VS, Proffitt JM, Hanss-Nuss H, Milani TJ, Bohman TM. A weight loss program for low-income mothers impacts their nutrition attitudes and dietary intakes. Manuscript submitted for publication.].


Figure 2
View larger version (61K):
[in this window]
[in a new window]

  		Fig. 2. Percentage of children meeting the Estimated Average Requirements (EARs) for select nutrients pre- (week 0) and post- (week 8) weight loss intervention in mothers.

 
Table 2 displays food group servings/day from the FFQs. Following the weight loss intervention in mothers, intakes of breads, fruits/fruit juices, meats, snacks/desserts, and sweetened beverages declined in children. Vegetable and grain consumption were below Food Guide Pyramid recommendations (~58% and 45%, respectively). Although there was a significant decrease in vegetables post-intervention, this decline was negated when fried potatoes were excluded from the analysis. Mother's age was related significantly to change in child's vegetable intake. Younger mothers were more likely to have children who increased their consumption of vegetables, excluding fried potatoes (r = –0.23, p < 0.05). In addition, mothers who had never been employed had children with greater increases in fruit servings than those who had been, or were currently, employed (0.3 servings/day versus –0.6 servings/day, p < 0.05). Younger children also were more likely to increase fruit intake at week 8 than older children (r = –0.34, p < 0.01). Servings of snacks/desserts and sweetened beverages decreased by approximately half at post-intervention.


View this table:
[in this window]
[in a new window]

  		Table 2. Servings Per Day of Food Groups Pre- (Week 0) and Post- (Week 8) Intervention and Correlations as Determined by the Food Frequency Questionnairea

 
Changes in food group servings of children were similar to those in their mothers’ diets, with the exception of low-fat dairy, fruit juices, and high-fat snacks/desserts (Table 2). These relationships remained when controlled for demographic covariates. Fig. 3 illustrates the significant changes in individual foods in the mother's and child's diets.


Figure 3
View larger version (53K):
[in this window]
[in a new window]

  		Fig. 3. Pre (week 0) - post (week 8) changes in mother and child consumption of select food items. ***p < 0.001, **p < 0.01, *p < 0.05 for significant differences at week 8.

 
At post-intervention, mothers used more non-fat cooking spray (from 19.7% to 68.2% using, p < 0.001), or low-fat/monounsaturated fats in cooking foods for their child (from 28.8% to 63.6% using, p < 0.01), and less other fats (from 81.8% to 40.9% using, p < 0.001). Mothers and children also were less likely to eat from fast food restaurants (from 13.9% to 7.7% of meals, p < 0.001) and more likely to prepare meals at home (from 60.9% to 71.8% of meals, p < 0.01). Fast food consumption by children was related positively to energy (r = 0.21, p < 0.05) and sodium (r = 0.24, p < 0.05), and inversely to calcium (r = –0.24, p < 0.05) and vitamin D (r = –0.33, p < 0.01); however, fast foods were not associated with child weight (r = –0.12, p = 0.254).

The activity level of both mothers and children increased at post-intervention (Table 3). Overall activity was not related within mother-child pairs. By week 8, boys were more active than girls, and 1-year-olds and overweight/at risk children enhanced their activity level significantly.


View this table:
[in this window]
[in a new window]

  		Table 3. Physical Activity Pre- (Week 0) and Post- (Week 8) Intervention in Mothers and Children

 
The weight loss program was rated favorably by the participants. All mothers (100%) "strongly agreed" or "agreed" that the classes were well-organized and taught at an appropriate level; the instructors communicated information effectively; and they learned a great deal. Weekly weigh-ins, in-class exercise, and wearing the pedometers were given the highest scores, with 99%, 98%, and 96%, respectively, of participants rating each of these as "useful" or "very useful." Maintaining food records and following menus or meal plans were slightly less useful, with 89%, 86%, and 82% ratings, respectively. Mothers identified as "useful" all class topics. When asked what they liked most via open-ended questions, responses included: the group support and discussion, weigh-ins, in-class exercise, and cooking demonstrations. Specific recommendations to improve the program included: lengthen program duration and offer additional child care.


   DISCUSSION
 
This study suggests that mothers can act as positive agents of change to improve dietary behaviors in their 1–3 year olds. Mothers who modified their food choices and fat habits made comparable changes for their child. In this study the child's diet improved, in terms of reduced calories, fat, sweetened beverages and fast food consumption, and increased home-prepared meals. Others have reported correspondence between mother and child for nutrient intakes [49,50] and food preferences [51–54]. Although activity levels of both mother and child increased overall, they were not related, indicating mothers may not serve as agents of change for their child's activity at this young age.

In a similar pilot study of obesity prevention in Native American preschool children [18], calorie consumption also decreased. In their obesity prevention program, energy intakes of children's diets diminished by 26%, as compared to declines of 16% and 9% in our overweight/at risk and healthy weight children, respectively. Reduced energy intakes among children in this study were warranted, as 22% were overweight/at risk, and the final caloric intakes remained at, or slightly above, the Estimated Energy Requirements.

Total/saturated fat diminished post-intervention, but total fat remained within the recommendation of 30–40% of energy for children, presumably due to substitution of high-fat snacks/desserts, fast foods, and added fats with lower-fat choices. The problem with consumption of high-fat foods early in life is that it may lead to a learned preference [55] and contribute to cardiovascular disease risk and obesity. Several investigators have reported a positive relationship between total/percent energy from fat and child fatness in preschool [56–59]. Thus, interventions should promote moderation of total fat to 30–40% of energy and balance of high- and low-fat foods in diets of children.

Our program was successful at curtailing the intake of sweetened beverages. Excessive amounts of these beverages have been linked to obesity in school-age children and adults [60–62], but there was no association to obesity in our sample of 1–3 year olds or in a study of 2–5 year olds by Newby and colleagues [63]. This lack of association may be due to the young age, as intakes of sweetened beverages may be limited. For example, frequency of sweetened beverages was lower in this investigation (2.4 oz/day) and that by Newby and colleagues [63] (3.1 oz/day), both of which used FFQs, as compared to Rampersaud and colleagues [64] who utilized 24-hour recalls (5.7 oz/day). Although the link to obesity at this age may not be apparent, sodas/fruit drinks/ades could displace more nutritious beverages [65,66].

One behavioral change observed was consumption of more home-prepared meals, with fewer visits to fast food restaurants, in both mother and child. These modifications should improve nutritional adequacy of diets, a fast foods are associated with excess calories and fat, and less milk, fruit, and vegetables [67,68]. Also, home-prepared meals have been reported to be more nutritious [69,70].

The most frequently eaten foods by our children were analogous to other studies of 1–2 year olds in the Feeding Infants and Toddlers Study [71] and 1–3 year olds in the Continuing Survey of Food Intakes by Individuals [72]. Thus, the types of foods selected by toddlers do not appear to differ by socioeconomic status.

The small change in BMI of the mothers following the intervention is not surprising as others have reported similar weight loss among minority populations, including Sullivan and Carter [73] (0.2 kg), Mayer-Davis and colleagues [74] (1.2 kg), Domel and colleagues [75] (1.4 kg), Kumanyika and Charleston [76] (2.7 kg), and Kanders and colleagues [77] (2.9 kg). It was not the intent of this intervention to provide weight management for 1–3 year old children, but rather to measure child dietary and physical activity changes following a weight loss program in mothers. The children in this study remained within the same growth channel (50–75th percentile level), which is considered normal [78], and the percent of children overweight or at risk for overweight did not change significantly from week 0 to week 24. Our weight-for-height and BMI-for-age percentile changes are difficult to compare to the literature, as only one other obesity prevention study was found that measured percentile changes following an intervention in a similar age group [18]. In their study, weight-for-height z-scores decreased non-significantly in the obesity prevention plus parenting support group and increased non-significantly in the parenting support group at post-intervention. Although changes in weight-for-height, BMI-for-age, and percent overweight are common outcome measures in obesity prevention and treatment programs with older children [17,19,22–24], studies with preschool age children are more likely to target dietary improvements as main outcome measures instead [18,29,33].

It is interesting to note that mothers in the current study with lower education levels were more likely to have 2–3 year old children with BMI-for-age percentile decreases by week 24 than mothers with higher education levels, even though there were no significant differences in their initial BMI-for-age percentiles. Thus, mothers with the least education benefited most from the intervention as measured by decreases in their child's BMI-for-age.

Previous studies suggest that physical activity may protect against adiposity at a young age. For example, in a longitudinal study of 180 children, Crawford and Shapiro [79] found that physical inactivity was related to obesity as early as 6-months of age, and the association remained throughout childhood. Klesges and colleagues [58] documented that initial aerobic activity and increases in leisure exercises correlated negatively with BMI in a 3-year longitudinal investigation of 146 preschool children. As a consequence of our program, activity scores improved, particularly among overweight children, even after controlling for age-related developmental increases. In contrast, the intervention study by Harvey-Berino and Rourke [18] that targeted mothers did not find an increase in the activity levels of a similar age group of children. However, an accelerometer was used to assess activity; whereas, we used an activity scale whose limitations are recognized. Nonetheless, we believe that an emphasis on activity should be instituted at a young age to develop early patterns of active lifestyles.

In this study, overall physical activity was not related between mother-child pairs. Mothers who increased their activity did not necessarily have comparable improvements in their child's activity. This finding is similar to that observed in 3–5 years olds [80] and 5-year-old girls [81]. This association was positive only in older children 4–7 [82] and 7–12 years old [83]. Perhaps, parental activity is less influential at younger ages when children's activity levels are typically high.

Quantities of fruits, vegetables, and whole grains in the children's diets were sub-optimal throughout our program, despite intense efforts to encourage greater inclusion. We observed that mothers were more likely to eliminate foods deemed unhealthy, rather than to incorporate more nutritious choices. Presumably, the lack of improvement in vegetable intake of children was related to similar inadequacy in the mothers. Vegetable intakes have been reported to fall below Food Guide Pyramid recommendations in another study of ethnically diverse, low-income mothers [84]. Similarly, Epstein and colleagues [17] did not find an increase in fruits and vegetables in 6–11 year old, non-obese children with obese parents participating in a 6-month intervention to improve eating behaviors. In contrast, Koblinsky and colleagues [33] did document a rise in fruits and vegetables in 1–5 year old children following a nutrition education program for Head Start parents. Thus, immediate enhancement of fruit and vegetable consumption in children with mothers as role models may be challenging.

The large proportion of children with intakes of folate and vitamin E below the EARs may be attributed, in part, to inadequacies in the nutrient database for folate and vitamin E fortified foods. However, observation of the diet records revealed that the 1–3 year old children in this sample were not eating good sources of folate (i.e. spinach, broccoli, legumes, oranges) and vitamin E (i.e. vegetable oils, seeds, and nuts). In addition, the inadequacy of these nutrients from dietary sources was not ameliorated by supplements, as only 10% of the mothers gave their child vitamins/mineral pills on a regular basis. Quantities of these nutrients were comparable to, or slightly lower than, data reported by others [72,85–87].

The strengths of this study include a novel and timely approach to prevent obesity in 1–3 year olds by using mothers as agents of change; multiple measures of food intake and activity; and a theoretically-based intervention. Limitations of the study are the short intervention and short follow-up and use of subjects as their own controls. A longer-term follow-up and re-evaluation of eating habits and anthropometrics is needed to examine the sustainability of the behavioral changes. In addition, it is conceivable that mothers may have biased their report of beneficial behavioral changes in their child at post-intervention; this possibility remains a challenge for studies relying on self-report data. These strengths and limitations should be considered when developing future studies of weight loss using low-income mothers as agents of change.


   CONCLUSION
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
ACKNOWLEDGMENTS
 REFERENCES
 
Targeting mothers as agents of change to improve dietary behaviors of their young children appears to be effective. Overweight and obese mothers who modify their food choices and fat habits will most likely make comparable alterations for their child.

The offer of a free weight loss class was a successful method of enticing low-income women to participate in an educational intervention that benefited their children. In the program evaluation, the most highly rated aspects were the interactive learning components (i.e., wearing pedometers, cooking demonstrations) and group support. Thus, obesity interventions should emphasize an abundance of hands-on activities, rather than just knowledge dissemination.

Effective strategies for the implementation of these weight loss interventions in public health settings are needed. Peer educators could be a feasible, cost-effective means for delivery of these programs in the community [88]. Provision of transportation and chid care could also improve retention.

One problem encountered was that some mothers focused more on eliminating foods considered to be unhealthy, rather than increasing more nutritious foods. Thus, emphasis should be placed on positive messages that stress inclusion of all foods in moderation, without labeling items as "good" and "bad" [89].


   ACKNOWLEDGMENTS
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
REFERENCES
 
This research was supported by grant UTA#00-377 from the Texas Higher Education Coordinating Board.


   FOOTNOTES
TOP
 FOOTNOTES
ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 
There have been no financial arrangements, organizational affiliations, or other relationships that may constitute a conflict of interest regarding the subject matter of the manuscript.

Received May 16, 2005. Accepted May 16, 2006.


   REFERENCES
TOP
 FOOTNOTES
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 CONCLUSION
 ACKNOWLEDGMENTS
 REFERENCES
 

  1. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM: Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002.JAMA291 :2847 –2850,2004 .[Abstract/Free Full Text]
  2. Ogden CL, Flegal KM, Carroll MD, Johnson CL: Prevalence and trends in overweight among US children and adolescents, 1999–2000.J Am Med Assoc288 :1728 –1732,2002 .[Abstract/Free Full Text]
  3. Drewnowski A, Darmon N: The economics of obesity: dietary energy density and energy cost.Amer J Clin Nutr82 (Suppl 1) :265S –273S,2005 .
  4. Zhang Q, Wang Y: Trends in the association between obesity and socioeconomic status in U.S. adults: 1971 to 2000.Obes Res12 :1622 –1632,2004 .[Medline]
  5. Sherry B, Mei Z, Scanlon KS, Mokdad AH, Grummer-Strawn LM: Trends in state-specific prevalence of overweight and underweight in 2- through 4-year-old children from low-income families from 1989 through 2000.Arch Pediatr Adolesc Med158 :1116 –1124,2004 .[Abstract/Free Full Text]
  6. Chamberlin LA, Sherman SN, Jain A, Powers SW, Whitaker RC: The challenge of preventing and treating obesity in low-income preschool children: perceptions of WIC health care professionals.Arch Pediatr Adolesc Med156 :662 –668,2002 .[Abstract/Free Full Text]
  7. Berenson GS, Srinivasan SR, Bao W, Newman WP, Tracy RE, Wattigney WA: Association between multiple cardiovascular risk factors and atherosclerosis in children and in young adults.New Eng J Med338 :1650 –1656,1998 .[Abstract/Free Full Text]
  8. Mahoney LT, Burns TL, Stanford W: Coronary risk factors measured in childhood and young adult life are associated with coronary artery calcification in young adults: the Muscatine Study.J Am Coll Cardiol27 :277 –281,1996 .[Abstract]
  9. Freidlander SL, Larkin EK, Rosen CL, Palermo TM, Redline S: Decreased quality of life associated with obesity in school-aged children.Arch Pediatr Adolesc Med157 :1206 –1211,2003 .[Abstract/Free Full Text]
  10. Morgan CM, Yanovski SZ, Nguyen TT, McDuffie J, Sebring NG, Jorge MR, Keil M, Yanovski JA: Loss of control over eating, adiposity, and psychopathology in overweight children.Int J Eat Disord31 :430 –441,2002 .[Medline]
  11. Birch LL: Development of food acceptance patterns in the first years of life.Proc Nutr Soc57 :617 –624,1998 .[Medline]
  12. Dietz W: How to tackle the problem early? The role of education in the prevention of obesity.Int J Obes23 :S7 –S9,1999 .
  13. Gyovai V, Gonzales J, Ferran K, Wolff C: Family dietary and activity behaviors associated with overweight risk among low-income preschool age children.Calif J Health Promot1 :66 –77,2003 .
  14. Melgar-Quinonez HR, Kaiser LL: Relationship of child-feeding practices to overweight in low-income Mexican-American preschool-aged children.J Am Diet Assoc104 :1110 –1119,2004 .[Medline]
  15. Whitaker RC: Predicting preschooler obesity at birth: the role of maternal obesity in early pregnancy.Pediatrics114 :e29 –e36,2004 .[Abstract/Free Full Text]
  16. U.S. Department of Health and Human Services: The Surgeon General's call to action to prevent and decrease overweight and obesity 2001. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General,2001 . Available at: http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_glance.htm
  17. Epstein LH, Gordy CC, Raynor HA, Beddome M, Kilanowski CK, Paluch R: Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity.Obes Res9 :171 –178,2001 .[Medline]
  18. Harvey-Berino J, Rourke J: Obesity prevention in preschool Native-American children: a pilot study using home visiting.Obes Res11 :606 –611,2003 .[Medline]
  19. Golan M, Weizman A, Apter A, Fainaru M: Parents as the exclusive agents of change in the treatment of childhood obesity.Am J Clin Nutr67 :1130 –1135,1998 .[Abstract]
  20. Golan M, Fainaru M, Weizman A: Role of behavior modification in the treatment of childhood obesity with parents as the exclusive agents of change.Int J Obes22 :1217 –1224,1998 .[Medline]
  21. Golan M, Weizman A: Familial approach to the treatment of childhood obesity: a conceptual model.J Nutr Educ33 :102 –107,2001 .[Medline]
  22. Wrotniak BH, Epstein LH, Paluch RA, Roemmich JN: Parent weight change as a predictor of child weight change in family-based behavioral obesity treatment.Arch Pediatr Adolesc Med158 :342 –347,2004 .[Abstract/Free Full Text]
  23. Epstein LH, Wing RR, Koeske R, Andrasik F, Ossip DJ: Child and parent weight loss in family-based behavior modification programs.J Consult Clin Psychol49 :674 –685,1981 .[Medline]
  24. Epstein LH, Wing RR, Koeske R, Valoski A: Effects of diet plus exercise on weight change in parents and children.J Consult Clin Psychol52 :429 –437,1984 .[Medline]
  25. Kirschenbaum DS, Harris ES, Tomarken AJ: Effects of parental involvement in behavioral weight loss therapy for preadolescents.Behav Ther15 :485 –500,1984 .
  26. Raynor HA, Kilanowski CK, Esterlis I, Epstein LH: A cost-analysis of adopting a healthful diet in a family-based obesity treatment program.J Am Diet Assoc102 :645 –650,2002 .[Medline]
  27. Pisacano JC, Lichter H, Ritter J, Siegal AP: An attempt at prevention of obesity in infancy.Pediatrics61 :360 –364,1978 .[Abstract]
  28. Simell O, Niinikowski H, Rönnemaa T, Lapinleimu H, Routi T, Lagström H, Salo P, Jokinen E, Viikari J: Special Turku Coronary Risk Factor Intervention Project for Babies (STRIP).Am J Clin Nutr72 (Suppl) :1316S –1331S,2000 .[Abstract/Free Full Text]
  29. Ray R, Lim LH, Ling SL: Obesity in preschool children: an intervention program in primary health care in Singapore.Ann Acad Med23 :335 –341,1994 .
  30. Cox RH, Gonzales-Vigilar MR, Novascone MA, Silva-Barbeau I: Impact of a cancer intervention on diet-related cardiovascular disease risks of White and African-American EFNEP clients.J Nutr Educ28 :209 –218,1996 .
  31. Del Tredici AM, Joy AB, Omelich CL, Laughlin SG: Evaluation study of the California Expanded Food and Nutrition Education Program: 24-hour food recall data.J Am Diet Assoc88 :185 –190,1988 .[Medline]
  32. Havas S, Anliker J, Damron D, Langenberg P, Ballesteros M, Feldman R: Final results of the Maryland WIC 5-A-Day promotion program.Am J Publ Health88 :1161 –1167,1998 .[Abstract/Free Full Text]
  33. Koblinsky SA, Guthrie JF, Lynch L: Evaluation of a nutrition education program for Head Start parents.J Nutr Educ24 :4 –12,1992 .
  34. Goldsmith HH: Studying temperament via construction of the Toddler Behavior Assessment Questionnaire.Child Dev67 :218 –235,1996 .[Medline]
  35. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL: 2000 CDC Growth Charts for the United States: methods and development. National Center for Health Statistics.Vital Health Stat11 :1 –190,2002 .
  36. Walker LO, Freeland-Graves JH, Milani T, Hanss-Nuss H, George G, Sterling BS, Kim M, Timmerman GM, Wilkinson S, Arheart KL, Stuifbergen A: Weight and behavioral and psychosocial factors among ethnically diverse, low income women after childbirth.I. Methods and Context. Women Health40 :1 –17,2004 .
  37. Software for Intake Distribution Estimation for SAS/IML (SIDE), version 1.0, Iowa State University: Assessed at: http://cssm.iastate.edu/software/side.html.
  38. Institute of Medicine: "Dietary Reference Intakes: Applications in Dietary Assessment." Washington, DC: National Academy Press,2000 .
  39. Institute of Medicine, Food and Nutrition Board: "Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids." Washington, D.C.: National Academy Press,2002 .
  40. National Academy of Sciences, Food and Nutrition Board: "Recommended Dietary Allowances," 10th ed. Washington, D.C.: National Academy Press,1989 .
  41. George GC, Milani TJ, Hanss-Nuss H, Kim M, Freeland-Graves JH: Development and validation of a semi-quantitative food frequency questionnaire for young adult women in the Southwestern United States.Nutr Res24 :29 –43,2004 .
  42. Klohe DM, Clarke KK, George GC, Milani TJ, Hanss-Nuss H, Freeland-Graves JH: Relative validity and reliability of a food frequency questionnaire for a tri-ethnic population of 1–3 year old children from low-income families.J Am Diet Assoc105 :727 –734,2005 .[Medline]
  43. Block G, Thompson FE, Hartman AM, Larkin FA, Guire KE: Comparison of two dietary questionnaires validated against multiple dietary records collected during a 1-year period.J Am Diet Assoc92 :686 –693,1992 .[Medline]
  44. Schneider PL, Crouter SE, Bassett DR: Pedometer measures of free-living physical activity: comparison of 13 models.Med Sci Sports Exerc36 :331 –335,2004 .
  45. Hendelman D, Miller K, Baggett C, Debold E, Freedson P: Validity of accelerometry for the assessment of moderate intensity physical activity in the field.Med Sci Sports Exerc32 (Suppl) :S442 –449,2000 .
  46. Bandura A, Adams NE, Beyer J: Cognitive processes mediating behavioral change.J Pers Soc Psychol35 :125 –39,1977 .[Medline]
  47. US Department of Agriculture: Center for Nutrition Policy and Promotion: "The Food Guide Pyramid." Washington, DC: Home and Garden Bulletin No. 252,1996 .
  48. US Department of Agriculture, Center for Nutrition Policy and Promotion: "The Food Guide Pyramid for Young Children." Program Aid 1647, 1999. Available at: http://www.usda.gov/cnpp/KidsPyra/PyrBook.pdf Last accessed October 13,2003 .
  49. Oliveria SA, Ellison RC, Moore LL, Gillman MW, Garrahie EJ, Singer MR: Parent-child relationships in nutrient intake: the Framingham Children's Study.Am J Clin Nutr56 :593 –598,1992 .[Abstract/Free Full Text]
  50. Vauthier J-M, Lluch A, Lecomte E, Artur Y, Herbeth B: Family resemblance in energy and macronutrient intakes: the Stanislas Family Study.Int J Epidemiol25 :1030 –1037,1996 .[Abstract/Free Full Text]
  51. Fisher JO, Mitchell DC, Smiciklas-Wright H, Birch LL: Parental influences on young girls’ fruit and vegetable, micronutrient, and fat intakes.J Am Diet Assoc102 :58 –64,2002 .[Medline]
  52. Lee Y, Birch LL: Diet quality, nutrient intake, weight status, and feeding environments of girls meeting or exceeding the American Academy of Pediatric recommendations for total dietary fat.Minerva Pediatr54 :179 –186,2002 .[Medline]
  53. Skinner J, Carruth BR, Moran III J, Houck K, Schmidhammer J, Reed A, Coletta F, Cotter R, Ott D: Toddlers’ food preferences: concordance with family members’ preferences.J Nutr Educ30 :17 –22,1998 .
  54. Skinner JD, Carruth BR, Bounds W, Ziegler PJ: Children's food preferences: a longitudinal analysis.J Am Diet Assoc102 :1638 –1647,2002 .[Medline]
  55. Ricketts CD: Fat preferences, dietary fat and body composition in children.Eur J Clin Nutr51 :778 –781,1997 .[Medline]
  56. Newby PK, Peterson KE, Berkey CS, Leppert J, Willett WC, Colditz GA: Dietary composition and weight change among low-income preschool children.Arch Pediatr Adolesc Med157 :759 –764,2003 .[Abstract/Free Full Text]
  57. Nguyen VT, Larson DE, Johnson RK, Goran MI: Fat intake and adiposity in children of lean and obese parents.Amer J Clin Nutr63 :507 –513,1996 .[Abstract/Free Full Text]
  58. Klesges RC, Klesges LM, Eck LH, Shelton ML: A longitudinal analysis of accelerated weight gain in preschool children.Pediatrics95 :126 –130,1995 .[Abstract/Free Full Text]
  59. Robertson SM, Cullen KW, Baranowski J, Baranowski T, Hu S, de Moor C: Factors related to adiposity among children aged 3 to 7 years.J Am Diet Assoc99 :938 –943,1999 .[Medline]
  60. Bray GA, Nielsen SJ, Popkin BM: Consumption of high-fructose corn syrup beverages may play a role in the epidemic of obesity.Am J Clin Nutr79 :537 –543,2004 .[Abstract/Free Full Text]
  61. Ludwig DS, Peterson KE, Gortmaker SL: Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis.Lancet357 :505 –508,2001 .[Medline]
  62. Nicklas TA, Yang SJ, Baranowski T, Zakeri I, Berenson G: Eating patterns and obesity in children. The Bogalusa Heart Study.Am J Prev Med25 :9 –16,2003 .[Medline]
  63. Newby PK, Peterson KE, Berkey CS, Leppert J, Willett WC, Colditz GA: Beverage consumption is not associated with changes in weight and body mass index among low-income preschool children in North Dakota.J Am Diet Assoc104 :1086 –1094,2004 .[Medline]
  64. Rampersaud GC, Bailey LB, Kauwell GPA: National survey beverage consumption data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages.J Am Diet Assoc103 :97 –100,2003 .[Medline]
  65. Harnack L, Stang J, Story M: Soft drink consumption among US children and adolescents: nutritional consequences.J Am Diet Assoc99 :436 –441,1999 .[Medline]
  66. Skinner JD, Bounds W, Carruth BR, Morris M, Ziegler P: Predictors of children's body mass index: a longitudinal study of diet and growth in children aged 2–8 y.Int J Obes28 :476 –482,2004 .[Medline]
  67. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS: Effects of fast food consumption on energy intake and diet quality among children in a national household survey.Pediatrics113 :112 –118,2004 .[Abstract/Free Full Text]
  68. Paeratakul S, Ferdinand DP, Champagne CM, Ryan DH, Bray GA: Fast-food consumption among US children: dietary and nutrient intake profile.J Am Diet Assoc103 :1332 –1338,2003 .[Medline]
  69. Gillman MW, Rifas-Shiman SL, Frazier L, Rockett HRH, Camargo CA, Field AE, Berkey CS, Colditz GA: Family dinner and diet quality among older children and adolescents.Arch Fam Med9 :235 –240,2000 .[Abstract/Free Full Text]
  70. Neumark-Sztainer D, Hannan PJ, Story M, Croll J, Perry C: Family meal patters: associations with sociodemographic characteristics and improved dietary intake among adolescents.J Am Diet Assoc103 :317 –322,2003 .[Medline]
  71. Fox MK, Pac S, Devaney B, Jankowski L: Feeding Infants and Toddlers Study: What foods are infants and toddlers eating?J Am Diet Assoc104 (Suppl) :S22 –S29,2004 .[Medline]
  72. U.S. Department of Agriculture, Agricultural Research Service: "Food and Nutrient Intakes by Children 1994–96, 1998," 1999. Available at http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm Accessed May 17,2004 .
  73. Sullivan J, Carter JP: A nutrition-physical fitness intervention program for low-income black parents.J Natl Med Assoc77 :39 –43,1985 .[Medline]
  74. Mayer-Davis EJ, D'Antonio A, Martin M, Wandersman A, Parra-Medina D, Schultz R: Pilot study of strategies for effective weight management in type 2 diabetes: Pounds Off with Empowerment (POWER).Fam Community Health24 :27 –35,2001 .[Medline]
  75. Domel SB, Alford BB, Cattlett HN, Gench BE: Weight control for black women.J Am Diet Assoc92 :346 –348,1992 .[Medline]
  76. Kumanyika SK, Charleston JB: Lose weight and win: a church-based weight loss program for blood pressure control among black women.Patient Educ Couns19 :19 –32,1992 .[Medline]
  77. Kanders BS, Ullmann-Joy P, Foreyt JP, Heymsfield SB, Heber D, Elashoff RM, Ashley JM, Reeves RS, Blackburn GL: The black American lifestyle intervention (BALI): the design of a weight loss program for working-class African-American women.J Am Diet Assoc94 :310 –312,1994 .[Medline]
  78. Trahms CM, Pipes PL: "Nutrition in Infancy and Childhood," 6th ed. WCB/McGraw-Hill,1997 .
  79. Crawford PB, Shapiro LR: How obesity develops: a new look at nature and nurture.Obes Health5 :40 –41,1991 .
  80. Trost SG, Sallis JF, Pate RR, Freedson PS, Taylor WC, Dowda M: Evaluating a model of parental influence on youth physical activity.Am J Prev Med25 :277 –282,2003 .[Medline]
  81. Davison KK, Birch LL: Child and parent characteristics as predictors of change in girls’ body mass index.Int J Obes25 :1834 –1842,2001 .[Medline]
  82. Moore LL, Lombardi DA, White MJ, Campbell JL, Oliveria SA, Ellison RC: Influence of parents’ physical activity on activity levels of young children.J Pediatr118 :215 –219,1991 .[Medline]
  83. Fogelholm M, Nuutinen O, Pasanen M, Myohanen E, Saatela T: Parent-child relationship of physical activity patterns and obesity.Int J Obes23 :1262 –1268,1999 .[Medline]
  84. George GC, Milani T, Hanss-Nuss H, Freeland-Graves J: Compliance with dietary guidelines and relationship to psychosocial factors in low-income women in late postpartum.J Am Diet Assoc105 :916 –926,2005 .[Medline]
  85. Alaimo K, McDowell MA, Briefel RR, Bischof AM, Caughman CR, Loria CM, Johnson CL: "Dietary Intake of Vitamins, Minerals, and Fiber of Persons Ages 2 Months and Over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988–91." Advance Data from vital and health statistics; No 258. Hyattsville, MD: National Center for Health Statistics,1994 .
  86. Devaney B, Ziegler P, Pac S, Karwe V, Barr SI: Nutrient intakes of infants and toddlers.J Am Diet Assoc104 (Suppl) :S14 –S21,2004 .[Medline]
  87. Nolan K, Schell LM, Stark AD, Gómez MI: Longitudinal study of energy and nutrient intakes for infants from low-income, urban families.Publ Health Nutr5 :405 –412,2002 .
  88. Auslander W, Haire-Joshu D, Houston C, Rhee CW, Williams JH: A controlled evaluation of staging dietary patterns to reduce the risk of diabetes in African-American women.Diabetes Care25 :809 –814,2002 .[Abstract/Free Full Text]
  89. Freeland-Graves JH, Nitzke S: Position of the American Dietetic Association: total diet approach for communicating food and nutrition information.J Am Diet Assoc102 :100 –108,2002 .[Medline]



This article has been cited by other articles:


Home page
 CLIN PEDIATRHome page
J. A. Groner, T. Skybo, L. Murray-Johnson, P. Schwirian, I. Eneli, A. Sternstein, E. Klein, and G. French
Anticipatory Guidance for Prevention of Childhood Obesity: Design of the MOMS Project
Clinical Pediatrics, June 1, 2009; 48(5): 483 - 492.
[Abstract] [PDF]

Home page
 The ANNALS of the American Academy of Political and Social ScienceHome page
L. DeMattia and S. Lee Denney
Childhood Obesity Prevention: Successful Community-Based Efforts
The ANNALS of the American Academy of Political and Social Science, January 1, 2008; 615(1): 83 - 99.
[Abstract] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Klohe-Lehman, D. M.
Right arrow Articles by Bohman, T. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Klohe-Lehman, D. M.
Right arrow Articles by Bohman, T. M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS