Differences in maternal and paternal pressure to eat and perception of household responsibilities.

Controlling feeding practices, such as pressure to eat, are associated with a child's disinhibited eating and extremes in bodyweight. We aimed to explore which factors are associated with parent dyads' pressuring feeding practices, including how mothers and fathers perceive the sharing of household tasks such as mealtime and child feeding responsibilities. In this cross-sectional study, parent dyads (mother and father) of healthy preschool-aged children completed an identical questionnaire consisting of measures of picky eating (food fussiness subscale of Child Eating Behavior Questionnaire), parental concern for undereating, and pressure to eat (Child Feeding Questionnaire). We used separate multivariable linear regression models for mothers and fathers to assess correlates associated with pressure to eat subscale score, including slowness of eating and enjoyment of food, child BMI z-score and race/ethnicity, and household income. Separate unadjusted linear regression models for mothers and fathers were used to report the association of pressure to eat with household responsibilities. Parents (N = 88) had similar mean picky eating, concern for undereating, and pressure to eat scores; more fathers had high pressure to eat scores (36% vs 27%). Higher pressure to eat was significantly associated with lower income, non-Hispanic Black or Black race/ethnicity, slow eating, and lower enjoyment of food. Pressure was not associated with household responsibilities. While there were similar maternal and paternal perceptions of child eating behaviors, more fathers reported pressuring their child to eat. Identifying differences in parental feeding practices may assist in intervention development to improve feeding practices.

Eating Family Meals Together at Home.

This JAMA Pediatrics Patient Page describes the benefits of eating family meals together at home.

Examining Full-Time Academic General Pediatric Faculty Compensation by Gender, Race, and Ethnicity: 2020-2021.

OBJECTIVE: In medicine, women have lower lifetime earnings than men. To our knowledge, an in-depth examination of academic general pediatric faculty compensation by gender, race, and ethnicity has not been conducted. We aimed to 1) explore full-time academic general pediatric faculty salary differences by race and ethnicity; 2) explore these differences among all full-time pediatric faculty. METHODS: We performed a cross-sectional study using data on median full-time academic general pediatric faculty compensation for the academic year of 2020-2021 from the Association of American Medical Colleges Medical School Faculty Salary Survey report. Pearson's chi-square tests were used to evaluate the association of faculty rank with gender, race, ethnicity, and degree. We used hierarchical generalize linear models with a log link and a gamma distribution to model to assess the association of median salary with faculty race and ethnicity, adjusting for degree, rank, and gender. RESULTS: Men academic general pediatric faculty consistently had higher median salaries than women faculty even after adjusting for degree, rank, race, and ethnicity. Underrepresented in medicine academic general pediatric faculty had a lower median salary when compared to White faculty, and this was similar when adjusted for degree, rank, race, and ethnicity. CONCLUSIONS: Our results demonstrated broad disparities in general academic pediatric compensation by both gender and race and ethnicity. Academic medical centers must identify, acknowledge, and address inequities in compensation models.

What Parents Should Expect From the New AAP Obesity Guidelines.

This JAMA Pediatrics Patient Page describes pediatric weight management according to the obesity guidelines recently published by the American Academy of Pediatrics (AAP).

Maternal stress and early childhood BMI among US children from the Environmental influences on Child Health Outcomes (ECHO) program.

BACKGROUND: We aimed to understand the association between maternal stress in the first year of life and childhood body mass index (BMI) from 2 to 4 years of age in a large, prospective United States-based consortium of cohorts. METHODS: We used data from the Environmental influences on Child Health Outcomes program. The main exposure was maternal stress in the first year of life measured with the Perceived Stress Scale (PSS). The main outcome was the first childhood BMI percentile after age 2 until age 4 years. We used an adjusted linear mixed effects model to examine associations between BMI and PSS quartile. RESULTS: The mean BMI percentile in children was 59.8 (SD 30) measured at 3.0 years (SD 1) on average. In both crude models and models adjusted for maternal BMI, age, race, ethnicity, infant birthweight, and health insurance status, no linear associations were observed between maternal stress and child BMI. CONCLUSIONS: Among 1694 maternal-infant dyads, we found no statistically significant relationships between maternal perceived stress in the first year of life and child BMI after 2 through 4 years. IMPACT: Although existing literature suggests relationships between parental stress and childhood BMI, we found no linear associations between maternal stress in the first year of life and childhood BMI at 2-4 years of age among participants in ECHO cohorts. Higher maternal stress was significantly associated with Hispanic ethnicity, Black race, and public health insurance. Our analysis of a large, nationally representative sample challenges assumptions that maternal stress in the first year of life, as measured by a widely used scale, is associated with offspring BMI.

A Pilot Study Examining the Association of Parental Stress and Household Food Insecurity with Dietary Quality in Pre-School-Aged Children.

Adequate dietary quality is necessary for children's appropriate development and may be influenced by family factors. This study with 24 healthy 3-5-year-old children assessed the associations of parental stress and household food insecurity (HFI) with a child's dietary quality. Parents completed three 24 h dietary recalls, and the Healthy Eating Index was calculated to assess dietary quality. Parents also completed a questionnaire, including The Perceived Stress Scale (assessing overall parental stress) and the Hunger Vital Sign screen (assessing HFI). Children's height/weight were measured, and BMIz was calculated. Separate multivariable linear regression models assessed the association of dietary quality components with HFI and parental stress, adjusting for household income, child sex, and child BMI z-score. In bivariate analyses, children with HFI consumed more added sugars, and parental stress was associated with the child's greens/beans intake. In multivariable analysis, HFI was associated with lower total protein scores and higher added sugar intake, while parental stress was associated with lower greens/beans intake. Higher household income was associated with higher total vegetable and sodium intake, and children with a higher BMIz had a lower total protein intake. Parental stress and HFI can impact a child's dietary quality; providers should counsel families on strategies to improve diet quality.

Examining the effect of parent participation in an adult weight management program on changes in children's weight.

Children of parents participating in weight management programs (WMPs) are more likely to adopt their parents' weight control practices. Little is known about the weight outcomes of children who have a parent participating in a WMP. This study aimed to assess this relationship. Children 2-17 years of age with a parent who participated in a WMP were included in the study. Multilevel linear mixed-effects regression models were used, stratified by child weight status at the time of parental WMP participation (healthy weight, overweight/obesity) to determine change in children's BMIz from before to after parents WMP participation, including covariates of parent BMI and parental feeding practices. Parents (N = 77) were mostly white (76%) and female (84%). Children (N = 114) had a mean age of 10.5 ± 4.6; 47% had overweight or obesity. Children with overweight or obesity prior to their parent's WMP had a decrease in BMIz (-0.68) after the WMP while children with a healthy weight had no significant change. Children with overweight or obesity had a decrease in BMIz from before to after parent's participation in a WMP. Further research is needed to understand changes in family eating practices that occur during and after parent WMP participation.

The association of food insecurity with mental health in preschool-aged children and their parents.

BACKGROUND: Household food insecurity (HFI) is associated with poor general and mental health. Prior studies assessed parent and child mental health separately and did not assess other social risks. OBJECTIVE: To assess the relationship between HFI and both parental and child mental health. METHODS: Parents of 3-5-year-old children completed validated measures of food insecurity and mental health. Separate linear regression models were used for unadjusted analysis for each mental health outcome (parent depression, anxiety, and stress, and child mental health). Multivariable analysis was performed using hierarchical regression to adjust for relevant covariates. RESULTS: Children (n = 335) were racially and socioeconomically diverse. HFI was reported in 10% of participants. HFI was associated with worse parent depression and stress in unadjusted analyses; however, after adjusting for covariates, the associations became insignificant. HFI was significantly associated with worse child mental health in unadjusted and multivariable analysis (aß 2.24, 95% CI 0.59-3.88) compared to those without HFI. CONCLUSION: HFI was not associated with parental mental health outcomes when other social risks were included in the analyses; however, HFI was significantly associated with worse childhood mental health in all analyses. Pediatric providers should screen for and develop interventions to target both HFI and mental health. IMPACT: Household food insecurity was associated with worse parent depression and stress in unadjusted analyses; however, after adjusting for other social risks, the associations became insignificant. Household food insecurity was significantly associated with worse child mental health, even after adjusting for demographics, other social risks, and parent mental health. Social risks are differentially associated with parent and child mental health. Understanding the complexities of family stressors can help better support parents and children struggling with mental health problems and social risks.

Parental concerns about picky eating and undereating, feeding practices, and child's weight.

OBJECTIVE: Parents' concerns about their child's feeding may lead parents to pressure their child to eat, which may lead to a greater risk for obesity. We aimed to assess if parental concerns for picky eating and undereating are associated with pressure to eat and increased child BMI z-score (BMIz). METHODS: We performed a cross-sectional study of 328 parents of healthy preschoolers assessing parent concerns about picky eating (Child Eating Behavior Questionnaire) and child undereating ("Are you concerned …doesn't eat enough?"), parent pressure to eat (Child Feeding Questionnaire), and covariates. Dyads' heights and weights were measured. Structural equation modeling (SEM) was performed to examine the relationships between parental concerns, pressure to eat, and child BMIz. Measurement models were tested and refined, and the structural model was tested. Model fit was determined using multiple goodness-of-fit indices. RESULTS: Dyads were racially and socioeconomically diverse. The SEM model demonstrated good goodness-of-fit. Children who were perceived as not eating enough had significantly higher picky eating scores (ß 0.756; p < 0.001). Parents had higher pressure to eat scores if children were more picky (ß 0.148; p = 0.02) or were perceived as not eating enough (ß 0.654; p < 0.001). Parental pressure to eat was not associated with the child's BMIz. CONCLUSIONS: In a cohort of diverse preschoolers, parent concerns about eating were associated with increased pressure to eat, but pressure to eat was not associated with BMIz. Identifying these relationships is important to develop effective interventions to improve feeding practices in young children.

Association of Food Insecurity with Mental Health Outcomes in Parents and Children.

BACKGROUND: Food insecurity affects 13.7 million US households and is linked to poor mental health. Families shield children from food insecurity by sacrificing their nutritional needs, suggesting parents and children experience food insecurity differentially. OBJECTIVE: To identify the associations of food insecurity and mental health outcomes in parents and children DATA SOURCES: PubMed, Embase, Web of Science, and PsycInfo STUDY ELIGIBILITY CRITERIA: We included original research published in English from January 1990 to June 2020 that examined associations between food insecurity and mental health in children or parents/guardians in the United States. STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers screened studies for inclusion. Data extraction was completed by one reviewer and checked by a second. Bias and confounding were assessed using the Agency for Healthcare Research and Quality RTI Item Bank. Studies were synthesized qualitatively, grouped by mental health outcome, and patterns were assessed. Meta-analyses were not performed due to high variability between studies. RESULTS: We included 108 studies, assessing 250,553 parents and 203,822 children in total. Most studies showed a significant association between food insecurity and parental depression, anxiety, and stress, and between food insecurity and child depression, externalizing/internalizing behaviors, and hyperactivity. LIMITATIONS: Most studies were cross-sectional and many were medium- or high-risk for bias or confounding. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Food insecurity is significantly associated with various mental health outcomes in both parents and children. The rising prevalence of food insecurity and mental health problems make it imperative that effective public health and policy interventions address both problems.

Prevalence of High Weight Status in Children Under 2 Years in NHANES and Statewide Electronic Health Records Data in North Carolina and South Carolina.

OBJECTIVES: We evaluated the prevalence of high weight status in children ages 0 to 24 months (m) using data from electronic health records (EHR) and NHANES. We also examined relationships between weight status during infancy and obesity at 24 months of age. METHODS: EHR data from 4 institutions in North and South Carolina included patients born January 1, 2013-October 10, 2017 (N = 147,290). NHANES data included study waves from 1999 to 2018 (unweighted N = 5121). We calculated weight-for-length (WFL), weight-for-age (WFA), and body mass index (BMI), excluding implausible values, and categorized weight status (<85th, 85th to <95th, or ≥95th percentile), assessing prevalence at birth, 6, 12, 18, and 24 months. Utilizing individual, longitudinal EHR data, we used separate regression models to assess obesity risk at 24 months based on anthropometrics at birth, 6, 12, and 18 months, adjusting for sex, race/ethnicity, insurance, and health system. RESULTS: Prevalence of BMI ≥95th percentile in EHR data at 6, 12, 18, and 24 months were 9.7%, 15.7%, 19.6%, and 20.5%, respectively. With NHANES the prevalence was 11.6%, 15.0%, 16.0%, and 8.4%. For both, the prevalence of high weight status was higher in Hispanic children. In EHR data, high weight status at 6, 12, and 18 months was associated with obesity at 24 months, with stronger associations as BMI category increased and as age increased. CONCLUSIONS: High weight status is common in infants and young children, although lower at 24 months in NHANES than EHR data. In EHR data, high BMI at 6, 12, and 18 months was associated with increased risk of obesity at 24 months.

Growth of Pediatric Refugees after Resettlement to the Southeastern United States.

OBJECTIVE: To compare weight status and body mass index z-scores (BMIz) of refugee children upon arrival to the Southeastern US and after resettlement with age- and sex-matched controls of nonrefugee children. METHODS: We identified refugee children resettled between July 2014 and June 2018 to Forsyth County, NC. Refugees were assigned age- and sex-matched controls (3 controls:1 refugee) who received care at the same health care site, were Medicaid insured, and had height and weight recorded at time of their matched refugee's resettlement plus at least 2 additional visits. BMI and BMIz were calculated. Pearson chi-square test assessed differences in weight status at the time of refugee resettlement and at the last measured time point. Multilevel linear mixed-effects regression models assessed change in BMIz by refugee status, adjusting for sex, race/ethnicity, age, and time since resettlement. RESULTS: This study examined 139 pediatric refugees and 417 nonrefugee controls; 46% were female. At the time of resettlement, refugees had a higher rate of underweight (3.3%  vs 1.9%), higher rate of healthy weight (68.9% vs 48.2%), and lower rate of overweight/obesity (27.8% vs 50%), compared to controls P < .001. At the last available time point, compared to controls, refugees had higher rates of underweight (3.3% vs 3.0%) and healthy weight (69.5% vs 54.2%) and lower rates of overweight/obesity (27.2%  vs 42.7%), P = .005. Refugees had a lower predicted BMIz compared with controls (adjusted ß: -0.78; 95%  confidence interval -0.91, -0.66). CONCLUSIONS: Resettled pediatric refugees were found to have significantly lower predicted BMIz than their age- and sex-matched nonrefugee controls.

Trends in food insecurity rates at an academic primary care clinic: a retrospective cohort study.

BACKGROUND: Healthcare organizations are increasingly screening and addressing food insecurity (FI); yet, limited data exists from clinic-based settings on how FI rates change over time. The objective of this study was to evaluate household FI trends over a two-year period at a clinic that implemented a FI screening and referral program. METHODS: In this retrospective cohort study, data were extracted for all visits at one academic primary care clinic for all children aged 0-18 years whose parents/guardians had been screened for FI at least once between February 1, 2018 to February 28, 2019 (Year 1) and screened at least once between March 1, 2019 to February 28, 2020 (Year 2). Bivariate analyses tested for differences in FI and demographics using chi-square tests. Mixed effects logistic regression was used to assess change in FI between Years 1 and 2 with random intercept for participants controlling for covariates. The interaction between year and all covariates was evaluated to determine differences in FI change by demographics. RESULTS: Of 6182 patients seen in Year 1, 3691 (59.7%) were seen at least once in Year 2 and included in this study. In Year 1, 19.6% of participants reported household FI, compared to 14.1% in Year 2. Of those with FI in Year 1, 40% had FI in Year 2. Of those with food security in Year 1, 92.3% continued with food security in Year 2. Compared to Hispanic/Latinx participants, African American/Black (OR: 3.53, 95% CI: 2.33, 5.34; p < 0.001) and White (OR: 1.88, 95% CI: 1.06, 3.36; p = 0.03) participants had higher odds of reporting FI. African American/Black participants had the largest decrease in FI between Years 1 and 2 (- 7.9, 95% CI: - 11.7, - 4.1%; p < 0.0001). CONCLUSIONS: Because FI is transitional, particularly for racial/ethnic minorities, screening repeatedly can identify families situationally experiencing FI.

Impact of COVID-19 on Pediatric Primary Care Visits at Four Academic Institutions in the Carolinas.

We aimed to determine how COVID-19 affected the number and type of pediatric primary care visits in April 2020, compared to April 2019, and which characteristics were associated with obtaining care in 2020. We performed a retrospective chart review of patients receiving care in April 2019 and April 2020 from four large, academic institutions across two states. The subjects were included if they were aged 0-18 years and were seen in a pediatric clinic in April 2019 or April 2020. We extracted the number of visits, visit type, and visit diagnosis; and the patient characteristics, including age, race/ethnicity, and insurance status. Logistic regression analysis identified characteristics associated with obtaining care in April 2020. We included 120,230 visits. Participants were 50% white and half had Medicaid. In 2020 there were significantly fewer visits for both well and acute visits with 42,670 visits in 2020 compared to 77,560 in 2019; 6616 were telehealth visits in 2020. Visits for chronic conditions were significantly decreased in 2020. Attending a visit in 2020 was more likely if the participant was black or Hispanic, younger, attending an acute visit, or had private insurance. During the COVID-19 pandemic, pediatric primary care decreased substantially for both well visits and follow-up of chronic conditions.

Food insecurity is associated with increased weight loss attempts in children and adolescents.

Household food insecurity (HFI) has been associated with adverse childhood outcomes and shares many common risk factors with obesity. Half of adolescents with overweight or obesity are actively attempting to lose weight. We aim to evaluate whether HFI is associated with weight loss attempts and unhealthy weight loss control practices in children. We examined cross-sectional data of children ages 8 to 15 years old from the National Health and Nutrition Examination Survey. Attempted weight loss was more common among children with very low food security (OR 1.50, 95% CI 1.09, 2.07). Children with a healthy weight with very low food security had increased odds of attempting weight loss (OR 1.51, 95% CI 1.00, 2.26) but there was no association in children with overweight or obesity. Very low food security was also associated with unhealthy weight control practices (OR: 1.42, 95% CI: 1.04, 1.93). Physicians should counsel all children and adolescents on healthy and unhealthy weight loss behaviours, regardless of weight or food security status.

Association of household food insecurity and childhood weight status in a low-income population.

One in seven US households with children are food insecure. The health effects of household food insecurity (HFI) are well documented, but its association with childhood weight status remains unclear. We aimed to assess this association and to describe correlates of HFI in children. We conducted a cross-sectional study of 3019 low-income children aged 2 to 17 years. Data were extracted via chart review. HFI was assessed using the hunger vital sign screener. Body mass index (BMI) was calculated from documented clinical measurements. We used adjusted linear and logistic regression to assess the association of HFI with BMI z-score (BMIz) and weight status. We used logistic regression to examine correlates of HFI including age, race/ethnicity, tobacco exposure, number of parents and siblings living at home, weight status, and census-tract poverty rate and food access. Of participants whose HFI status was documented, 91% were food secure and 9% were food insecure. The mean (SD) BMIz was 0.81 (1.11). Fifty five percentage of children were healthy weight, 18% overweight, and 26% obese. In adjusted analyses, HFI was not associated with BMIz but was associated with decreased odds of obesity (OR 0.56; 95% CI 0.36-0.87). Tobacco exposure (1.63; 1.10-2.44), additional siblings (1.16; 1.04-1.30), and residence census tract with high poverty rate (1.02; 1.01-1.03) were all associated with HFI. We concluded that food-insecure children were less likely to have obesity and had differences in household makeup, exposures, and residential location compared to food-secure children. Clinicians should understand these relationships when counselling families about weight status and food insecurity.

Assessing Parents' Communication of Weight and Weight Management from Clinic to Home.

Background: Family-oriented therapies are the gold standard of childhood obesity treatment, yet little is known about if or how information gathered by one parent from a health care provider is translated to the home. We assessed how families of children and adolescents with overweight and obesity communicate weight-related information received from their provider to family members not present at the visit. Methods: Parents and children (9-18 years old, N = 112) completed the McMaster's Family Assessment Device Communication Subscale (FADc) and investigator-derived questions describing weight-related communication practices with family members. We used descriptive statistics to describe communication practices and separate logistic regression models to assess associations of communication practices with parent-reported FADc, child BMI z-score, child sex, parent BMI, household income, and site. Results: Most parents discuss with other family members: their child's weight (60.4%) or weight management discussions with the child's provider (57.9%). Median parent FADc score was 2.0 (IQR 0.5). The most common facilitator to weight-related conversations was understanding what the provider said (95.1%). Higher FADc score (worse communication) was associated with whether parents ask other family members' opinions about weight information received from their child's provider [odds ratio 0.22 (95% confidence interval 0.05-0.99)]. Higher income was associated with many healthy communication practices. Conclusions: Slightly more than half of parents discuss with family members what their provider said regarding their child's weight. More effort must be placed on aiding parents in relaying information from the provider to other family members in the home to encourage family lifestyle changes and alleviate childhood obesity.

Predictors of Engagement in a Pediatric Weight Management Clinic after Referral.

Background: Little is known about factors that affect a family's ability to engage in pediatric weight management clinics (PWMCs). We aimed at comparing child and family characteristics of patients referred to a PWMC by participants' attendance at orientation, attendance at intake, or completing the program. Methods: We performed a retrospective study of patients ages 2-18 years referred to a PWMC between 2014 and 2017. We extracted data from electronic medical records and clinic databases, including age, sex, race/ethnicity, language, referral year, address, and insurance. We performed t-tests and chi-square tests to examine the association of engagement outcomes with covariates. We used separate multivariate logistic regression models to assess the predictors of engagement outcomes, including significant covariates from bivariate analyses. Results: Participants (N = 2020 referred) had a mean age of 11.5 ± 3.5 years; 72% had Medicaid, and 34% lived in city limits. Participants were 39% white, 30% black, and 27% Hispanic. Of those referred, 41% attended orientation, 14% attended intake, and 9% completed. Significant predictors of attending orientation were age [odds ratio (OR): 0.93, 95% confidence interval (CI): 0.91-0.96], male sex (OR: 0.74, 95% CI: 0.60-0.91), Hispanic ethnicity (OR: 1.69, 95% CI: 1.26-2.26), living in city limits (OR: 1.39, 95% CI: 1.11-1.75), and Medicaid (OR: 0.77, 95% CI: 0.60-0.98). Significant predictors of attending intake were age (OR: 0.93, 95% CI: 0.90-0.96), Medicaid (OR: 0.61, 95% CI: 0.46-0.81), and 2017 referral year (OR: 0.21, 95% CI: 0.12-0.35). Hispanic ethnicity was associated with twice the odds of completion (OR: 2.07, 95% CI: 1.10-3.91). Conclusions: Child and family characteristics more strongly predicted initial engagement with a PWMC than completion. Future research should examine how targeting these predictors (e.g., referring at younger age) can improve PWMC engagement.