The Longitudinal Relation between Infant Feeding Styles and Growth Trajectories among Families from Low-Income Households.

BACKGROUND: Parental feeding styles, including the emotional environment parents create to modify a child's eating behaviors, have been associated with measures of adiposity in cross-sectional studies. The longitudinal relation between parental feeding styles in early infancy and adiposity in later infancy/toddlerhood are scant and have shown mixed results, particularly in families from low-income households. OBJECTIVES: This study examined the relation between parental feeding styles and infant BMI z-score trajectories between 6 and 18 mo in families from low-income households. METHODS: Parent-infant dyads were recruited during the infant's 6-, 9-, or 12-mo well-child visit. Feeding styles were assessed using the Infant Feeding Style Questionnaire (IFSQ). Infant anthropometrics from birth through 18 mo were extracted from the electronic medical record. BMI z-score slopes were estimated for each infant between 0-6 mo and 6-18 mo. Associations between feeding styles and BMI z-score slopes were examined using mixed models controlling for demographic, clinical, and feeding covariates. RESULTS: The final analytic sample included 198 dyads (69% Black; median infant age: 9.0 mo; IQR: 6.8-10.3 mo). The predominant parent feeding styles included the following: laissez-faire (30%), restrictive (28%), responsive (23%), and pressuring (19%). In adjusted models, the predominant feeding style at enrollment was associated with the BMI z-score slope between 6 and 18 mo, with the responsive feeding style exhibiting a steeper increase in BMI z-score than other feeding styles. Infant feeding style was not associated with BMI z-score slope between birth and 6 mo of age. Infants of parents who exhibited restrictive feeding styles were more likely to have a BMI ≥85th percentile at their last measurement. CONCLUSIONS: The predominant parent feeding style during infancy in a low-income population was associated with infant BMI z-score between 6 and 18 mo of age, but not earlier. Further studies are needed to better understand how predictive factors collectively contribute to BMI increase in the first 2 y.

Factor structure of the Intuitive Eating Scale-2 among a low-income and racial minority population.

Intuitive eating, where an individual relies on one's own physiologic hunger and satiety cues instead of situational and emotional cues, is associated with healthier lifestyle choices, lower body-mass index (BMI), and positive psychological well-being. Despite the importance of this construct, no assessment measure of intuitive eating has been validated for use in a low-income Black population, who have an elevated risk for poor health outcomes. The aim of this study was to evaluate the factor structure of the Intuitive Eating Scale-2 (IES-2) in a predominately low-income Black population. A confirmatory factor analysis (CFA) followed by an exploratory factor analysis (EFA) were conducted using data from 204 adult participants. A large majority (71%) identified as Black and 89% had public insurance. The relationship between scores on the IES-2, BMI, and body-image dissatisfaction scores were also evaluated. A CFA of the previously used IES-2 structure demonstrated less than optimal fit. An EFA supported a six-factor, twenty-three item measure with the following names set for subscales: Avoiding Forbidden Foods (3 items), Permission to Eat (3 items), Avoiding Emotional Eating (4 items), Avoiding Food-Related Coping Strategies (4 items), Reliance on Hunger and Satiety Cues (6 items), and Body-Food Choice Congruence (3 items). The modified IES-2 scores were negatively associated with BMI and body-image dissatisfaction scores. A modified factor structure of the IES-2 may be a better measure of intuitive eating in low-income Black populations.

Halo or horn? A qualitative study of mothers' experiences with feeding children during the first year following bariatric surgery.

BACKGROUND: Obesity is a chronic condition that has an intergenerational effect. The aims of the study were to better understand the impact of maternal bariatric surgery on obesogenic risks to child offspring in the home via documenting mothers' thoughts, behaviors, and experiences around child feeding, family meals, and the home food environment during her first year postsurgery. METHOD: Utilizing a mixed-method cross-sectional design, 20 mothers (Mage = 39.6 ±â€¯5.7 years, 75% White, MBMI = 33.6 ±â€¯4.3 kg/m2, Mtime = 7.7 ±â€¯3.1 months post-surgery) of children ages 6-12 years completed validated self-report measures and participated in a focus group. Mother and child heights/weights were measured. RESULTS: The majority of children (N = 20; Mage = 9.2 ±â€¯2.3 years, 65% White, 60% female) were overweight (N = 12; BMI≥85th percentile) and were not meeting the American Academy of Pediatrics healthy eating and activity recommendations to treat/reduce obesity risk. As child zBMI increased, mothers expressed significantly more weight concern (r = 0.59, p = 0.01) and lower obesity-specific quality of life (r = -0.56, p = 0.01), yet assumed less responsibility for child eating choices (r = -0.47, p = 0.04). Qualitative data demonstrated disconnects between mothers' changes to achieve her own healthier weight and applying this knowledge to feeding her child/family. CONCLUSIONS: While bariatric surgery and requisite lifestyle change are effective tools for weight loss at the individual level, there is a great need for innovative family-based solutions. Pediatric obesity is preventable or risk-diminished if addressed early. Maternal bariatric surgery may be a unique (yet missed) opportunity to intervene.

Associations Between Age of Onset of Pediatric Overweight/Obesity, a Child's Sociodemographic Characteristics, and Characteristics of a Child's Home Census Tract.

PURPOSE: To identify associations between age of onset of overweight/obesity, a child's sociodemographic characteristics, and characteristics of a child's home census tract. DESIGN: Retrospective electronic health record review of children with overweight/obesity. SETTING: Three primary care centers associated with a free-standing, tertiary-care pediatric institution in Cincinnati. SUBJECTS: Patients born between August 1, 2013 and July 31, 2014, who had a body mass index (BMI) ≥85th percentile before 5 years of age (n = 794). MEASURES: Primary outcome was the patient's age at the first encounter when BMI was ≥85th percentile. Patient-level predictors were sex, age, race/ethnicity, health insurance, and number of moves captured in the health record. Census tract-level predictors were density of bus stops, presence of grocery stores, and a Socioeconomic Deprivation Index. ANALYSIS: Multivariable linear regression models assessed for independent associations between age of onset of overweight/obesity and predictors. RESULTS: Patients were 55.8% female, 73.6% black, and 79.1% publicly insured. Each additional move per year was associated with onset of overweight/obesity occurring 4.05 months earlier (P < .0001). No significant associations between age of onset of overweight/obesity and census tract-level density of bus stops (P = .82), presence of grocery stores (P = .39), and socioeconomic deprivation (P = .53) were demonstrated. CONCLUSION: Public policy efforts toward improving access to grocery stores or public transportation may not be sufficient to prevent childhood obesity. Population-level interventions related to improving housing may also reduce obesity.

Seasonal variability in body mass index change among children enrolled in the Pediatric Obesity Weight Evaluation Registry: A step in the right direction.

BACKGROUND: Research has shown children disproportionately gain excess weight over the summer months (vs. school months), with stronger effects for children with obesity. However, the question has not been investigated among children receiving care in paediatric weight management (PWM) programs. OBJECTIVE: To test for seasonal variability in weight change among youth with obesity in PWM care enrolled in the Pediatric Obesity Weight Evaluation Registry (POWER). METHOD: Longitudinal evaluation of a prospective cohort from 2014 to 2019 among youth in 31 PWM programs. Change in percentage of the 95th percentile for BMI (%BMIp95) was compared by quarter. RESULTS: Participants (N = 6816) were primarily ages 6-11 (48%), female (54%), 40% non-Hispanic White, 26% Hispanic and 17% Black, and 73% had severe obesity. Children were enrolled on average 424.9 ± 401.5 days. Participants reduced their %BMIp95 every season, but compared with Quarter 3 (July-September), reductions were significantly greater in Q1 (Jan-March, b = -0.27, 95%CI -0.46, -0.09), Q2 (April-June, b = -0.21, CI -0.40, -0.03), and Q4 (October-December, b = -0.44, CI -0.63, -0.26). CONCLUSION AND RELEVANCE: Across 31 clinics nationwide, children reduced their %BMIp95 every season, but reductions were significantly smaller during the summer quarter. While PWM successfully mitigated excess weight gain during every period, summer remains a high-priority time.

Telehealth Use in a National Pediatric Weight Management Sample During the COVID-19 Pandemic.

Background: This study aimed to assess the implementation and access to telehealth-delivered pediatric weight management (PWM) during the initial phase of the COVID-19 pandemic at six US PWM programs (PWMP) using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Methods: The COVID-19 period (COVID) was defined in this retrospective, multisite study as the time when each site closed in-person care during 2020. The Pre-COVID period (Pre-COVID) was an equivalent time frame in 2019. Patients were stratified by visit completion status. Patient characteristics for COVID and Pre-COVID were compared to examine potential changes/disparities in access to care. Results: There were 3297 unique patients included across the six sites. On average, telehealth was initiated 4 days after in-person clinic closure. Compared with Pre-COVID, COVID (mean duration: 9 weeks) yielded fewer total completed visits (1300 vs. 2157) and decreased revenue (mean proportion of nonreimbursed visits 33.30% vs. 16.67%). Among the completed visits, COVID included a lower proportion of new visits and fewer patients who were male, non-English speaking, Hispanic, or Asian and more patients who were Black or lived ≥20 miles from the program site (p < 0.05 for all). Among no-show/canceled visits, COVID included more patients who had private insurance, older age, or a longer time since the last follow-up. Conclusion: Rapid implementation of telehealth during COVID facilitated continuity of PWM care. Clinic volume and reimbursement were lower during COVID and differences in the patient population reached by telehealth emerged. Further characterization of barriers to telehealth for PWM is needed.

A Quality Improvement Initiative Addressing Provider Prescription of Weight Management Follow-up in Primary Care.

INTRODUCTION: Few providers routinely comply with the American Academy of Pediatrics recommendations to prescribe weight management follow-up in-between well-child checks for children with obesity/overweight. This quality improvement (QI) project aimed to increase the percentage of patients prescribed weight management follow-up within three months of their well-child check. METHODS: The project took place in 1 outpatient primary care clinic at a large, free-standing children's hospital from May 2018 to April 2019. We grouped interventions in 4 Plan-Do-Study-Act ramps with the following themes: (1) provider education; (2) electronic health record note changes; (3) discharge order modifications; and (4) provider feedback. The primary outcome was the percent of patients ages 2-18 years with body mass index ≥ 85% that had an order placed to schedule a follow-up weight management appointment in primary care. We monitored attendance rates for scheduled follow-up visits as a balancing measure. RESULTS: Mean prescription rates increased from 32% at baseline to 58%, with special cause analysis demonstrating improvement. Of patients prescribed follow-up, 40% returned for a weight management visit, compared to 13% before the QI initiative. The no-show rate was 35%. CONCLUSIONS: The utilization of QI methodology led to an increase in the percentage of patients appropriately prescribed weight management follow-up and a resultant increase in the number of patients seen for follow-up. The next steps include a re-examination of process failures to improve patient buy-in in follow-up prescriptions.

Is Parent Readiness to Change Predictive of Follow-through with Diet and Activity Modifications in Children?

Assessing parental readiness to change their child's lifestyle behaviors can be used as a guide for counseling during well-child appointments. The aim of our study was to determine if parental readiness to change pre-visit was associated with plan adherence post-visit in a predominantly low-income population. Parents (n=178) self-identified readiness to change on a Likert scale and subsequently received counseling. Multivariate logistic regression was used to evaluate associations between readiness to change and plan adherence. There was no association between readiness to change and self-reported follow-through with nutrition plans (AOR at 3 months: 1.5 [0.52; 4.18]; p=.5). The ready-to-change group reported higher, albeit non-significant, follow-through with activity plans at three months (AOR 3.6 [0.82; 15.96]; p=.09). Providers should engage all parent/child dyads in behavior modification for nutrition and activity regardless of parents' pre-visit readiness to change.

Giving "prescriptions" for paediatric weight management follow-up in primary care.

The American Academy of Paediatrics recommends that primary care paediatricians "prescribe" follow-up for weight management between well child checks. We sought to describe rates and predictors of prescribed and actual clinic attendance for weight management in primary care in a predominantly low-income population. A chart review was performed at a large, hospital-based, primary care clinic, where a treatment algorithm for obesity exists. Eligible children were 6 to 12 years of age with a body mass index (BMI) ≥85th percentile and seen for a well child check in 2014. Primary outcomes were the physician prescribing follow-up in primary care and the patient returning for weight management. Multivariable logistic regression was used to identify predictors of prescribing follow-up and predictors of return. Participants included 1339 patients: mean age 9 years (SD: 1.8 years); 53% female; 79% Black; 89% Medicaid-insured; 56% with an obese BMI (vs overweight). Twenty-seven percent of patients were prescribed follow-up in primary care, of which 13% returned (only 4% of the original sample). The odds of the physician prescribing follow-up were greater if the child had obesity (vs overweight), was older, female or non-Medicaid insured. Older and non-Black patients had greater odds of returning. Patients prescribed follow-up within 2 months or less (vs 3-6 months) were also more likely to return (aOR 2.66; CI: 1.34, 5.26). Rates of prescription for weight management in primary care are low and few patients return, even when follow-up is prescribed. Prescribing follow-up at shorter intervals from the index visit (≤ 2 months) may improve patient return.

Maternal Body Dissatisfaction and Accuracy of Infant Weight Perception in Families From Low-Income Backgrounds.

OBJECTIVE: To examine the association between maternal body dissatisfaction and mother's (mis)perception of their infant's weight classification among families from low-income households. METHODS: Mother-infant dyads were recruited during well-child visits from 2 urban primary care clinics. Maternal body dissatisfaction was measured using the Stunkard Figure Rating Scale. Perception of infant weight was assessed using a 5-point Likert scale. Infant weight-for-length percentiles were calculated using World Health Organization growth charts. Associations between maternal body dissatisfaction score and mother's (mis)perception of their infant's weight classification were examined using logistic regression allowing for nonlinear associations via restricted cubic splines. RESULTS: Mothers (n = 180) were 26.6 ± 5.1 years old and 72% Black; infants were 8.8 ± 2.1 months old. Mean infant weight-for-length percentile was 64 ± 26. On average, mothers wanted to be one body figure smaller than their perceived current body size. Most mothers (82%) accurately perceived their infant's weight classification while few overestimated (7%) or underestimated (11%) their child's weight category. The probability of mothers misperceiving their infant's weight classification increased as maternal body dissatisfaction increased in either extreme in unadjusted (P < .05) and adjusted analysis (P = .06). CONCLUSIONS: Increased maternal body dissatisfaction may be associated with mother's misperception of infant weight classification. Future studies should examine this relationship in a heterogeneous population.

Parental intuitive eating behaviors and their association with infant feeding styles among low-income families.

INTRODUCTION: Feeding styles, the attitudes and behaviors parents use to direct their child's eating, shape a child's ability to self-regulate food intake and affects their future risk of obesity. This study examined how parental intuitive eating, where parents follow their own hunger and satiety cues, relates to infant feeding styles in a low-income, predominately Black population. METHODS: Parents of healthy infants aged 5.5-12.5 months were recruited during well-child visits at two urban primary care clinics. Parent's intuitive eating behaviors and infant feeding styles were measured using the Intuitive Eating Scale-2 (IES-2) and the Infant Feeding Style Questionnaire (IFSQ), respectively. Multivariable regression analysis, controlling for maternal and child demographic variables, was conducted to determine the relationship between parent intuitive eating behaviors and five infant feeding styles: restrictive, pressuring, indulgent, laissez-faire, and responsive. RESULTS: 201 parents completed the study, 90% were mothers and 69% were Black. Average infant age was 8.8 ±â€¯2.0 months. Parents who reported relying on their own hunger and satiety cues when eating were more likely to feed their infant in a responsive style (ß 0.10 ±â€¯0.04, p < 0.05). Parents who reported eating unconditionally, not labeling foods as forbidden, were more likely to feed their infant in a laissez-faire (ß 0.16 ±â€¯0.06, p < 0.05) and indulgent (ß 0.09 ±â€¯0.03, p < 0.05) feeding style. CONCLUSIONS: Parental intuitive eating behaviors are associated with both responsive and non-responsive infant feeding styles. Future studies should examine how parental intuitive eating and infant feeding styles affect infant growth trajectories.

Community Healthcare and Technology to Enhance Communication in Pediatric Obesity Care.

Childhood obesity continues to be a critical healthcare issue and a paradigm of a pervasive chronic disease affecting even our youngest children. When considered within the context of the socioecological model, the factors that influence weight status, including the social determinants of health, limit the impact of multidisciplinary care that occurs solely within the medical setting. Coordinated care that incorporates communication between the healthcare and community sectors is necessary to more effectively prevent and treat obesity. In this article, the Expert Exchange authors, with input from providers convened at an international pediatric meeting, provide recommendations to address this critical issue. These recommendations draw upon examples from the management of other chronic conditions that might be applied to the treatment of obesity, such as the use of care plans and health assessment forms to allow weight management specialists and community personnel (e.g., school counselors) to communicate about treatment recommendations and responses. To facilitate communication across the healthcare and community sectors, practical considerations regarding the development and/or evaluation of communication tools are presented. In addition, the use of technology to enhance healthcare-community communication is explored as a means to decrease the barriers to collaboration and to create a web of connection between the community and healthcare providers that promote wellness and a healthy weight status.

Severe Obesity Decreasing in Children in Cincinnati, Ohio.

Childhood obesity rates appear to be leveling off. Studies not looking at severe obesity may be masking a rightward shift in the distribution of body mass indexes. Our objective was to provide current prevalence rates and examine trends in overweight, obesity, class 2 obesity, and class 3 obesity for youth in Cincinnati, Ohio. We performed a retrospective chart review of children 2 to 18 years old seen at Cincinnati Children's Hospital Medical Center between July 1, 2011, and June 30, 2014. Data from 217 037 BMIs were obtained; 35.2% of children were found to have an elevated BMI. Prevalence rates were highest in older, Hispanic, and Medicaid-insured children. The only significant trend over the 3-year period was a downward shift in class 3 obesity ( P = .02), contrary to national findings. Further studies assessing which clinical/community efforts have led to this downward trend will be essential to target future resources and facilitate continued progress.

Are Mealtime Best Practice Guidelines for Child Care Centers Associated with Energy, Vegetable, and Fruit Intake?

BACKGROUND: Mealtime best practices for obesity prevention in child care have been developed from experimental studies and expert opinion. Our objective was to describe adherence to best practices in child care centers and to evaluate the association between mealtime practices and children's dietary intake. METHODS: We conducted an observational study of 349 preschoolers, ages 36 to 72 months, from 30 child care centers in Cincinnati, Ohio (November 2009 to January 2011). Trained observers recorded providers' behaviors related to six mealtime best practice recommendations and documented children's intake (n = 60 group lunches). General linear mixed models were used to evaluate the association between practice use and children's total energy (caloric consumption) and fruit and vegetable consumption. RESULTS: Adherence to individual mealtime best practices was variable (0%-77%). Staff sitting with children at lunch was associated with lower energy intake and higher vegetable intake. Staff eating some of the same foods was associated with higher energy intake and higher vegetable intake. Staff encouraging children to try new/less-favorite foods more than once was associated with lower fruit intake. Staff having general conversations with children (not addressed in recommendations) was associated with lower vegetable intake. Family-style meal service, staff talking about healthy foods, and staff helping children assess hunger before seconds were not significantly associated with intake. CONCLUSIONS: Few mealtime best practices were associated with dietary intake. Given the number of meals children consume in child care and the prevalence of childhood obesity, efforts to identify mealtime practices that improve children's dietary intake are crucial for obesity prevention.

Randomized controlled trial of a Wellness Action Plan to promote healthy diet and activity in pediatric primary care.

INTRODUCTION: Diet and activity counseling is recommended during all well child visits to promote optimal health and prevent childhood obesity. The objective of this study was to determine the effectiveness of a novel Wellness Action Plan aimed at: 1) improving parent recall of diet and activity plans made during routine well child visits 2) increasing adherence with plans, and 3) enhancing parents' identification of their child's weight category. METHODS: Parents of children 2.5 to 14 years (n = 181) seen at a pediatric primary care clinic in Milwaukee, Wisconsin between March and August of 2013 received standard diet and activity counseling from their physician (both control and intervention groups). In addition, parents randomized to the intervention group were asked to complete a Wellness Action Plan, where established diet and activity goals were documented. Parents completed surveys about BMI identification, plan creation, and plan adherence pre visit, post visit, and at 1 and 3 months. RESULTS: Intervention parents were significantly more likely to recall diet (p = 0.003) and activity (p = 0.03) plans at 3 months and were also more likely to report adherence with diet (p = 0.006) and activity (p = 0.08) plans at three months. There was no difference between groups in their ability to correctly identify children's weight categories (p > 0.05). CONCLUSION: The Wellness Action Plan was associated with higher parent diet and activity plan recall and self-reported adherence. The Wellness Action Plan is a potentially important counseling tool that can be used to help parents make lifestyle modifications for their children. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, Identifier NCT02185248.