- Promote the consumption of a variety of nutritious foods, and encourage and support breastfeeding during infancy.
- Create a healthy eating environment that is responsive to children’s hunger and fullness cues.
- Ensure access to affordable healthy foods for all children. • Help adults increase children’s healthy eating.
The majority of young children in the United States are not consuming nutritious diets (Fox et al., 2010; Fungwe et al., 2009; Siega-Riz et al., 2010). U.S. children of all ages are consuming diets that are too high in added sugar and fat and too low in fruits and vegetables, whole grains, and low-fat and nonfat dairy products (Reedy and Krebs-Smith, 2010; Williams, 2010). Taking action to ensure that children aged 0–5 have access to a variety of nutritious foods can contribute to healthy growth and a reduction in obesity risk.
A child develops food preferences by responding to what he or she is fed and observing adults; the availability of food in the immediate environment also plays a role. Because food offered to young children is determined by caregivers, they should make every effort to introduce children to healthy foods and lifestyle
habits from the beginning of infancy onward (Skinner et al., 2004). Children who have early experiences with eating healthy foods are more likely to prefer and consume those foods and to have dietary patterns that promote healthy growth and weight (Anzman et al., 2010; Mennella et al., 2008), patterns that may then persist in later childhood (Skinner et al., 2004). Given that more than half of children under the age of 5 receive care in out-of-home settings (HHS, 2011a), parents as well as other caregivers need information and guidance on how to foster the development of healthy eating patterns among young children. This chapter includes recommendations designed to improve nutrition through infancy to the consumption of solid foods.
Recommendation 4-1: Adults who work with infants and their families should promote and support exclusive breastfeeding for 6 months and continuation of breastfeeding in conjunction with complementary foods for 1 year or more.
Potential actions include
- hospitals and other health care delivery settings improving access to and availability of lactation care and support by implementing the steps outlined in the Baby-Friendly Hospital Initiative and following American Academy of Pediatrics policy recommendations;
- hospitals enforcing the World Health Organization’s International Code of Marketing of Breast Milk Substitute (This step includes ensuring that hospitals’ informational materials show no pictures or text that idealizes the use of breast milk substitutes; that health professionals give no samples of formula to mothers [this can be complied with through the Baby-Friendly Hospital Initiative]; and that the Federal Communications Commission, the Department of Health and Human Services, hospital administrators [through the Baby-Friendly Hospital Initiative], health professionals, and grocery and other stores are required to follow Article 5, “The General Public and Mothers,” which states that there should be no advertising or promotion to the general public of products within the scope of the code [i.e., infant formula]);
- the Special Supplemental Nutrition Program for Women, Infants, and Children, the Child and Adult Care Food Program, Early Head Start, other child care settings, and home visitation programs requiring program staff to support breastfeeding; and
- employers reducing the barriers to breastfeeding through the establishment of worksite policies that support lactation when mothers return to work.
A number of systematic reviews on the relationship between breastfeeding and childhood obesity conclude that, while the nature of the study designs makes it difficult to infer causality, there is an association between breastfeeding and a reduction in obesity risk in childhood (Adair, 2009; Arenz et al., 2004; Harder et al., 2005; Monasta et al., 2010; Owen et al., 2005). Thus, in the committee’s judgment, a recommendation on breastfeeding is warranted. The first Institute of Medicine (IOM) report on childhood obesity prevention takes a similar position (IOM, 2005).
There is a window of opportunity after birth during which breastfeeding can be initiated. However, many hospitals and health care providers do not provide information about and support for breastfeeding. The most recent data from the Centers for Disease Control and Prevention (CDC) indicate that 75 percent of women in the United States initiate breastfeeding at birth, and 43 percent are breastfeeding at 6 months after birth; however, only 13 percent of mothers are breastfeeding exclusively at 6 months (CDC, 2010), and only 22.4 percent are breastfeeding at 12 months (HHS, 2011b). The American Academy of Pediatrics (AAP) and many other health organizations recommend exclusive breastfeeding for approximately the first 6 months of life, with the addition of complementary foods at around 6 months and continued breastfeeding through the first year of life and beyond (AAP, 2005; ADA, 2005; WHO, 2001).
Although breastfeeding rates have improved over time, disparities exist by race and ethnicity and by socioeconomic status. Only 58 percent of black infants are ever breastfed, compared with 76 percent of white and 80.6 percent of Latino infants. Fully 88 percent of the infants of college graduates are ever breastfed, compared with only 66 percent of infants of high school graduates. These differences continue for breastfeeding at 6 and 12 months. The Surgeon General’s Call to Action to Support Breastfeeding points out a number of barriers to breastfeeding in the United States, including lack of knowledge, social norms, poor family and social support, embarrassment, lactation problems, employment, child care,
and health services and health professionals that fail to promote or support the practice (HHS, 2011b).
The rapid attrition seen among mothers who breastfeed indicates that support, education, and public policy are inadequate to ensure that all women who want to breastfeed can do so. Support for breastfeeding initiation and maintenance needs to begin during prenatal care and continue at the hospital or other place of childbirth and into child care settings and workplaces.
Institutional support within hospitals is critical to help mothers learn to breastfeed. Hospitals have the potential to influence, educate, and support virtually all new mothers, especially those who have been shown to be less likely to ever breastfeed or sustain breastfeeding up to 6 months or a year. The Baby-Friendly Hospital Initiative is a global program designed to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding (see Box 4-1). The initiative increases the duration of breastfeeding and the initiation of exclusive breastfeeding (Fairbank et al., 2000; Kramer et al., 2001). Mothers in the United States were 13 times more likely to stop breastfeeding before 6 weeks if they delivered in a hospital where none of the 10 steps of the Baby-Friendly Hospital Initiative were followed as compared with mothers who delivered at hospitals where at least 6 of the 10 steps were followed (DiGirolamo et al., 2008). Furthermore, following the steps decreased the disparities in initiation and duration rates of breastfeeding seen across different income, ethnic, and racial groups (Merewood et al., 2005). Although more than 18,000 hospitals worldwide are designated as Baby-Friendly, only 3 percent of maternity hospitals in the United States are so designated (Baby-Friendly USA, 2011; CDC, 2008).
Although employment outside the home is one of the biggest reasons for discontinuing breastfeeding (Mandal et al., 2010) workplace lactation programs can increase the duration of breastfeeding (Abdulwadud and Snow, 2007). Not only do workplace lactation programs increase breastfeeding duration, but they also confer advantages on the employer, such as decreased absenteeism (Cohen and Mrtek, 1994; Mills, 2009; Wyatt, 2002). Twenty-four states have laws related to breastfeeding at the workplace, and the Patient Protection and Affordable Care Act of 2010 and the Reconciliation Act of 2010, which amends the Fair Labor Standards Act of 1938 (29 U.S. Code 207), require an employer to provide reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth (National Conference of State Legislatures, 2011). However, many women still
Baby-Friendly Hospital Initiative
The Baby-Friendly Hospital Initiative (BFHI) is a global program sponsored by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding. The BFHI assists hospitals in helping mothers initiate and continue breastfeeding, and gives special recognition to hospitals that have done so. The BFHI promotes breastfeeding through the Ten Steps to Successful Breastfeeding for Hospitals. The steps for the United States are:
- Have a written breastfeeding policy that is routinely communicated to all health care staff.
- Train all health care staff in skills necessary to implement this policy.
- Inform all pregnant women about the benefits and management of breastfeeding.
- Help mothers initiate breastfeeding within one hour of birth.
- Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
- Give newborn infants no food or drink other than breastmilk, unless medically indicated.
- Practice “rooming in”—allow mothers and infants to remain together 24 hours a day.
- Encourage breastfeeding on demand.
- Give no pacifiers or artificial nipples to breastfeeding infants.
- Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
struggle to breastfeed when they go back to work because of a lack of enforcement of the law (74 percent of employers do not offer lactation rooms or accommodations for breastfeeding, and some employers see little value to breastfeeding in the workplace) (Grummer-Strawn and Shealy, 2009; Libbus and Bullock, 2002).
In addition to workplace lactation programs, breastfeeding duration is affected by the degree of control a woman has over her job, including the flexibility she is allowed; whether she works full time; and the length of maternity leave (Abdulwadud and Snow, 2007; Hawkins et al., 2007; Mandal et al., 2010). These factors are highly relevant for breastfeeding mothers, because the Family and Medical Leave Act covers only 56 percent of women with children younger than 18 months of age (Mandal et al., 2010).
Providers in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), child care settings, Early Head Start, and home visitation programs also have many opportunities to support breastfeeding, especially among low-income women (Shealy et al., 2005). The WIC program, for example, serves almost half of the babies born in the United States (IOM, 2006). One-to-one health education and peer counseling in the prenatal and postnatal periods have been found to be highly effective in increasing the initiation and duration of breastfeeding (Fairbank et al., 2000; Gross et al., 2009). Home visitation has been used successfully to provide instruction, guidance, and support to mothers who are learning to breastfeed and continuing to do so throughout the baby’s first year. Moreover, as the current work environment often is not conducive to supporting women who breastfeed, the support of health care providers can be integral in overcoming the isolation and other obstacles mothers often face while balancing work and breastfeeding an infant.
Child care centers that provide lactation rooms or other space for breastfeeding mothers and optimally support working mothers, including their staff, who want to breastfeed their infant could be labeled as Breastfeeding-Friendly (Box 4-2). This label could be similar to the Baby-Friendly Hospital designation, indicating child care centers that follow basic guidelines to support breastfeeding schedules. Breastfeeding-Friendly space would allow women to continue breastfeeding even after returning to work, a key factor in increasing breastfeeding rates. Multiple stakeholders should explore incentives and actions such as these for encouraging and supporting breastfeeding at the worksite, as suggested by the Surgeon General (HHS, 2011b) and by the IOM in Local Government Actions to Prevent Childhood Obesity (IOM and NRC, 2009).
Breastfeeding is the best way to support the growth and development of a young infant. However, the committee realizes that some women will formula feed their infant and not breastfeed, and that many women who breastfeed may use a bottle to feed their infant breast milk or formula on some occasions, often because of one or more of the barriers to breastfeeding described above. These women also need the advice and support of their health care providers, especially because there is a greater risk that a bottle-fed infant can be overfed or encouraged to “finish the bottle,” in turn increasing the risk for obesity. The literature suggests the following guidelines on bottle feeding:
Ten Steps to Breastfeeding-Friendly Child Care Centers
- Designate an individual or group who is responsible for development and implementation of the ten steps.
- Establish a supportive breastfeeding policy and require all staff be aware of and follow the policy.
- Establish a supportive worksite policy for staff members who are breastfeeding.
- Train all staff so that they are able to carry out breastfeeding promotion and support activities.
- Create a culturally appropriate breastfeeding-friendly environment.
- Inform expectant and new families and visitors about your center’s breastfeeding-friendly policies.
- Stimulate participatory learning experiences with the children, related to breastfeeding.
- Provide a comfortable place for mothers to breastfeed or pump their milk in privacy, if desired.
- Educate families and staff that a mother may breastfeed her child wherever they have a legal right to be. Establish and maintain connections with local breastfeeding coalition or community breastfeeding resources.
- Maintain an updated resource file of community breastfeeding services and resources kept in an accessible area for families
SOURCE: Wisconsin Department of Health Services, http://www.dhs.wisconsin.gov/health/physicalactivity/pdf_files/BreastfeedingFriendlyChildCareCenters.pdf.
- Only breast milk or infant formula should go in the bottle (USDA, 2009). Juice, soda, and sweetened or carbonated beverages should not be put in the bottle. Cow’s milk should not be introduced until at least 1 year of age (AAP, 2008).
- Based on the average intake of 2–4 ounces of breast milk or formula by an infant from birth to 4 months of age (Hagan et al., 2008), a 4-ounce bottle should be used to feed an infant. If the infant shows signs of hunger after finishing a 4-ounce bottle, it may be time to transition to a larger bottle size.
- The bottle should be held by an adult caregiver. It should not be propped, which prevents the infant from being able to stop feeding. An adult should feed the infant to watch for cues of satiety (Shelov, 2009).
- Feeding should not be initiated automatically any time the infant cries. Infant hunger cues should be appreciated (see Table 4-1). A bottle should not be used as a quieting device. Alternative soothing strategies, such as
holding or swaddling the infant, should be tried first (AAP, 2008; Hagan et al., 2008; Shelov, 2009).
- Infants should not be forced to finish the bottle (Hagan et al., 2008; Li et al., 2010).
- Infants should be “off the bottle” and drinking from a cup around 1 year of age, but no older than 18 months of age (Shelov, 2009).
Complementary solid foods should be introduced at around 6 months of age (AAP, 2005). However, a substantial percentage of mothers introduce solid foods before their infant is 4 months of age (Fein et al., 2008), particularly if they perceive the infant to be “fussy” (Wasser et al., 2011). Mothers may also add cereal to the bottle in the belief that doing so will help the infant sleep longer (Kavanagh
TABLE 4-1 Infant Feeding Cues
|Age||Hunger Cues||Fullness Cues|
|Birth through 5 months||
|4 months through 6 months||
|5 months through 9 months||
|8 months through 11 months||
|10 months through 12 months||
|SOURCE: USDA, 2009.|
et al., 2010). Yet complementary foods introduced too early do not benefit the infant and may even be harmful because of the possibility of the infant’s choking (since the infant may not have the neuromuscular mechanisms needed for swallowing), developing food allergies, or consuming less than the appropriate amount of breast milk or infant formula (Fiocchi et al., 2006; Grummer-Strawn et al., 2008; Walker et al., 1996). Additionally, an infant’s gut is not sufficiently mature for solid food prior to 4 months of age (USDA, 2001). Research on the effects of early introduction of complementary foods and obesity risk is inconsistent, with some studies reporting a possible association (Huh et al., 2011) and others reporting no clear association (Moorcroft et al., 2011).
The foods and beverages offered to infants during the transition to solid foods are important in setting the foundation for eating patterns later in life; those that become familiar early in life will tend to be preferred to those that are unfamiliar. A preponderance of energy-dense foods, high in sugar, fat, and salt, provides an eating environment that can foster preferences for these foods, resulting in diets that are inconsistent with the Dietary Guidelines for Americans (DGA) (Birch, 1999). Children are predisposed to like sweet and salty foods but must learn to like those that are not (Cowart et al., 2004; IOM, 2010). Healthy foods such as vegetables will be accepted if they become familiar and if children see others eating and enjoying them (Addessi et al., 2005; Harper and Sanders, 1975). As children are being introduced to the adult diet, all foods are new. They will tend to reject new foods initially, but with frequent opportunities to try these foods, will accept many of them. At home and in child care settings, therefore, young children should be introduced to healthy foods and given frequent opportunities to try them. It is important to note that, according to recent evidence, children attending child care programs that participate in the Child and Adult Care Food Program (CACFP) consume diets of better nutritional quality than children not attending such programs (Bruening et al., 1999; Crepinsek and Burstein, 2004; Whaley et al., 2008).
Recommendation 4-2: To ensure that child care facilities provide a variety of healthy foods and age-appropriate portion sizes in an environment that encourages children and staff to consume a healthy diet, child care regulatory agencies should require that all meals, snacks, and beverages served by early childhood programs be consistent with the Child and Adult Care Food Program meal patterns and that safe drinking water be available and accessible to the children.
Children who consume a diet rich in nutrient-dense whole grains, fruits, vegetables, and low-fat or nonfat milk and other dairy products and low in energy-dense, nutrient-poor foods are less likely to be overweight or obese (Bradlee et al., 2010; Frank, 2008). As noted in Chapter 1, overweight and obese children are more likely to become obese adolescents and adults (Taveras et al., 2009; Whitaker et al., 1997) and more likely to suffer from the chronic diseases associated with excess weight. Some of these diseases that are associated with obesity and that may be present during childhood include type 2 diabetes, hypertension, hyperlipidemia, dyslipidemia, hepatic steatosis, obstructive sleep apnea, gallbladder disease, and musculoskeletal and psychosocial disorders (Daniels et al., 2009; Freedman et al., 2007). Overweight and obese adults are more likely to develop cardiovascular diseases, type 2 diabetes, stroke, certain types of cancer, and osteoarthritis (Pi-Sunyer, 2009).
The DGA provide guidance on what constitutes a healthy diet for children 2 years of age and older (USDA and HHS, 2010). In the absence of governmental science-based national dietary recommendations for children younger than 2 years of age, AAP guidelines are used for this age group. For the purposes of this report and to be consistent with the DGA, nutritious foods and healthy foods are defined as lean and low-fat protein foods; whole-grain products; fruits and vegetables prepared with little or no added sugar, salt, or fat; and low-fat or nonfat milk and other dairy products. At the request of the U.S. Department of Agriculture (USDA), the IOM has made recommendations for updating meal patterns served through the CACFP in child care settings (see Box 4-3). The final regulations may vary once the USDA rulemaking process is complete.
Children in the United States are not meeting these nutritional guidelines. Their diets are low in whole fruits, dark green and orange vegetables and legumes, and whole grains, key sources of nutrients. Although children aged 2–5 meet the DGA recommendations for total fruit and milk, their diets are high in saturated fat, sodium, added sugar, and calories (Fungwe et al., 2009; Guenther et al., 2008). Indeed, many young children consume discretionary calories from added sugars or fat every day (Fox et al., 2010). These are considered energy-dense, nutrient-poor foods, which provide many calories in a small volume with few essential nutrients. In layman’s terms, these are “junk foods” and “fatty foods.” Preventing obesity early in life is easier than treating it. Thus, it is critical that health care providers, researchers, and policy makers explore ways to limit access to energy-dense, nutrient-poor foods for even young children. Whole grains, fruits,
Recommended Daily Meal Patterns for CACFP Breakfast, Lunch/Supper, and Snacks: Number of Servings and Range of Serving Sizesa
|Food Group||Number of Servings||Range of Serving Size|
|Fruits or nonstarchy vegetables||1||¼ to ½ cup|
|Grains/breads||1||½ to 2½ ounce equivalent|
|Lean meats/meat alternatives
(3 times weekly)
|1||½ to 1 ounce equivalent|
|Milk||1||½ to ¾ cup|
|Fruits||1||¼ to ½ cup|
|Vegetables||2||¼ to 1 cup|
|Grains/breads||1||½ to 2 ounce equivalent|
|Lean meats/meat alternatives||1||½ to 2 ounce equivalent|
|Milk||1||½ to 1 cup|
(Choose two food groups per snack)
|Fruits||2 per week||½ to 1 cup|
|Vegetables||2 per week||1/8 to 1 cup|
|Grains/breads||2 per week||½ to 2 ounce equivalent|
|Lean meats/meat alternatives||2 per week||½ to 1 ounce equivalent|
|Milk||2 per week||½ cup|
|aServing sizes vary by age group.
SOURCE: Adapted from IOM, 2011a.
and vegetables are excellent sources of complex carbohydrates, fiber, vitamins, and minerals, and because they tend to have higher water and fiber content, they are relatively low in energy density and can help children feel fuller longer. If energy density is reduced in the diet through an increase in consumption of vegetables instead of a total reduction in meal size, children are likely to consume fewer calories and more vegetables (Leahy et al., 2008). Establishing preferences for foods with lower energy density and higher nutritional content, such as fruits and vegetables, not only increases the intake of important nutrients at the time of consumption but also may reduce caloric intake, in turn reducing the risk for obesity and chronic disease in the future.
Sugar-sweetened beverages are an energy-dense, nutrient-poor food commonly consumed by children. Defined as beverages that contain caloric sweeteners, they include carbonated beverages, fruit drinks, sweetened bottled waters, sports drinks, and energy drinks. More than half of toddlers and preschoolers consume one or more servings of such beverages per day (Fox et al., 2010). Sugar-sweetened beverages are the primary source of added sugar in the American diet (Hu and Malik, 2010). They account for a significant number of discretionary calories in the diets of young children—60 kcal per day at 2–3 years of age and 121 kcal per day at 4–8 years of age (Reedy and Krebs-Smith, 2010). It is not surprising, then, that strong evidence links the consumption of sugar-sweetened beverages and excess weight gain in children, including young children (Hu and Malik, 2010; Vartanian et al., 2007; Wang et al., 2009). One study found, for example, that 5-year-old girls who consume more than two servings of sugar-sweetened beverages per day have a higher body fat percentage through age 15 than girls with lower intake of such beverages (Fiorito et al., 2009).
There are other reasons to limit the intake of sugar-sweetened beverages among young children. Those who drink such beverages consume more sugars and fewer whole grains, fruits, vegetables, and low- or nonfat dairy products than their peers who do not consume these beverages (Fiorito et al., 2010; Kranz et al., 2005). Moreover, because infants are born with a preference for sweet tastes, intake of sugar-sweetened beverages in early childhood may result in a preference for sweet beverages later in life (Birch, 1999), an issue discussed further below. High intake of these beverages in adolescence also may directly increase the risk of type 2 diabetes, independently of the risk from excessive caloric intake.
Clear and undisputed evidence shows that children benefit from consuming a diet rich in low- or nonfat milk and other dairy products. Flavored milk should be avoided as it contains added calories in the form of high fructose corn syrup
or sucrose, which may contribute to excess energy in the diet. Evidence shows that young children who drink flavored milk consume more total calories and more added sugars than children who drink only plain milk (Murphy et al., 2008; Wilson, 2000).
The second-largest source of energy in the diet of 2- to 3-year-old children is 100 percent fruit juice, contributing nearly 100 calories per day to their intake (Reedy and Krebs-Smith, 2010). Although no association was found between overweight and intake of 100 percent fruit juice (Nicklas et al., 2008), children who consumed such juices had higher energy intakes. Therefore, 100 percent fruit juice should be limited to no more than one serving per day, from a cup rather than a bottle, for toddlers and preschoolers. This recommendation is consistent with the AAP guideline issued in 2001 (Baker et al., 2001).
Providing drinking water as an alternative to sugar-sweetened beverages and fruit juice helps reduce discretionary energy intake and resultant obesity risk. Replacing these beverages with water reduces children’s total calorie intake (Wang et al., 2009), and the availability of drinking water has been found to increase water intake and decrease overweight among early elementary students (Muckelbauer et al., 2009). Drinking water not only improves hydration but also may reduce the risk for the development of early dental caries (Kleinman, 2009). Children are well served by developing the habit of seeking water to quench their thirst. Drinking water should be available and accessible to young children throughout the day.
As alluded to earlier, the foods to which infants and young children are exposed help develop their food and flavor preferences, and these preferences tend to persist throughout life (Birch, 1999). Recent evidence indicates that the first months of life may be a particularly sensitive period for learning flavors (Mennella et al., 2009), and flavor preferences developed as early as infancy can influence food selection during childhood and later in life (Mennella et al., 2008). While infants are born with a genetic predisposition to prefer sweet tastes (Birch, 1999; Steiner and Glaser, 1995), then, childhood food exposures can either increase (Beauchamp and Moran, 1984; Benton, 2004) or decrease (Sullivan and Birch, 1990) these preferences.
Recommendation 4-3: The Department of Health and Human Services and the U.S. Department of Agriculture should establish dietary guidelines for children from birth to age 2 years in future releases of the Dietary Guidelines for Americans.
The DGA provide evidence-based nutrition recommendations intended to promote health and reduce the risk of obesity and chronic disease for Americans aged 2 years and older (USDA and HHS, 2010). These guidelines are updated every 5 years and form the basis for nutrition recommendations for the public and for federal nutrition assistance programs. As noted above, no governmental science-based national dietary recommendations are available for children under the age of 2 years. Such recommendations are critical as the basis for national dietary intake studies, and in their absence, no standard for comparison exists. In 2010 the DGA committee recommended that starting in 2015, guidelines be issued for children from birth to 2 years of age (Van Horn, 2010). Including children in this age group in future updates of the DGA would provide specific, actionable dietary recommendations for all of America’s children, including the youngest. These recommendations could help inform effective obesity prevention efforts.
Recommendation 4-4: State child care regulatory agencies should require that child care providers and early childhood educators practice responsive feeding.
Potential actions include
- for infants—holding infants in one’s arms or sitting up on one’s lap while feeding and not propping bottles, recognizing infant feeding cues (e.g., rooting, sucking), offering an age-appropriate volume of breast milk or formula to infants and allowing infants to self-regulate their intake, and introducing developmentally appropriate solid foods in age-appropriate portions and allowing all infants to self-regulate their intake; and
- for toddlers/preschoolers—providing meals and snacks as part of a daily routine, requiring adults to sit with and eat the same foods as the children, allowing children to serve themselves when serving from common bowls (family-style service), providing age-appropriate portions and allowing children to determine how much they eat when offering foods that are served in units (e.g., sandwiches), and reinforcing children’s internal cues of hunger and fullness.
Research indicates that young children have some ability to regulate their food intake, a potential that should be tapped through responsive feeding (described in detail in Box 4-4). This ability appears to be present as early as infancy, as demonstrated by infants consuming larger amounts of formula or food when the caloric density of their diet was low and smaller amounts when the caloric density was high (Fomon et al., 1969; Fox et al., 2006). Young children’s caloric intake may vary from meal to meal, but their intake over 24-hour periods is more consistent (Birch et al., 1991), a finding that provides additional evidence for self-regulation.
Caregivers’ approach to feeding practices can either promote or interfere with children’s ability to learn to self-regulate their food intake. Adults’ control of feeding practices by making all decisions about children’s food consumption, including the amount eaten, is associated with a decreased ability to regulate energy consumption (Faith et al., 2004; Johnson and Birch, 1994) and an increased risk of overweight in preschoolers (Baughcum et al., 1998; Carper et al., 2000; Fisher and Birch, 1999; Rhee et al., 2006). Adults concerned about overeating in children may respond by strictly limiting access to high-fat, energy-dense foods (Birch and Fisher, 1998); however, this can paradoxically exacerbate the problem by promoting increased intake of those foods when they are available and discouraging self-regulation of caloric intake (Bante et al., 2008; Birch and Fisher, 1998; Birch et al., 2003; Fisher and Birch, 1999; Johnson, 2000). Conversely, adults who think children will not eat enough may force them to eat everything on their plate or use rewards as a means to get them to eat more than they want. This practice may diminish children’s preference for foods they are forced to eat and reduce their responsiveness to hunger and fullness cues (Birch et al., 1987). Additional controlling feeding practices that can impair children’s self-regulation include using palatable foods as rewards or bribes to control children’s behavior (Birch et al., 1987, 1991; Branen and Fletcher, 1999); using external cues, such as “clean your plate” (Ramsay et al., 2010); and rewarding children for eating certain foods (Birch et al., 1987, 1991). Offering large portions of palatable foods also can impact children’s self-regulation; larger portions promote greater intake, causing young children to eat more (Fisher et al., 2007). When a variety of healthy foods are offered in appropriate portions, and an adult is available to support children and give appropriate cues, children can determine how much they eat.
In addition, adults should sit with children and eat the same foods. In so doing, adults can model the consumption of healthy foods (Nicklas et al.,
What Is Responsive Feeding?
In feeding, adults provide healthy foods to children and allow children to control the amount they eat. Responsive feeding practices help reinforce children’s eating according to their internal hunger and fullness cues (Black and Aboud, 2011; Engle and Pelto, 2011). Examples of responsive feeding include the following:
- Adults sit with and eat with children so they can observe the children’s eating and remind them of their hunger and fullness cues. Adults can observe when children are eating for nonhunger reasons, such as because they want to delay going on to the next activity or because they enjoy the taste of the food, and can redirect them to their hunger and fullness cues.
- Letting children serve themselves allows them to take the amount of food they need to satisfy their hunger.
- —This works best if adults sit at the table and give guidance as to how much food the children can take at one time. Statements such as “You can take one spoonful, and then you can have more if you are still hungry” help children take appropriate amounts of food and reassure them that they will be able to satisfy their hunger.
- —Adults should teach children to serve themselves, model self-serving, and give appropriate verbal or physical assistance when needed.
- —Adults should provide serving utensils that help children serve themselves child-sized portions.
- Providing food on a regular schedule helps children self-regulate their food intake. Young children may need food every 2.5 to 3 hours. These can be considered minimeals, each consisting of healthy foods. Offering food on a regular schedule prevents children from becoming overly hungry, which can lead to overeating.
- Adults should offer child-sized unit foods, such as sandwiches. Foods such as minibagels, sandwiches cut in quarters, and minimuffins help children eat according to their internal cues.
- Child-sized plates and utensils also help support children in self-regulating their food intake.
- Adults can encourage, but not force, children to try healthy foods.
SOURCE: Connecticut State Department of Education, 2010; Fletcher et al., 2005.
2001), which in turn can promote children’s willingness to try and eat such foods (Addessi et al., 2005).
Adults also can help children learn the skills needed for “family-style” meals, including taking turns, passing foods, and serving themselves (Fletcher and Branen, 2004). Family-style service, where children serve themselves from common serving bowls, has been recommended as a way of helping children eat according to their own hunger and fullness cues (Branen et al., 1997). This eating style, which is supported by the CACFP and Head Start (Connecticut State Department of Education, 2010; ECLKC, 2011), enhances children’s understanding of their internal hunger and satiety cues.
Taken together, the available research indicates that parents’ and care providers’ feeding practices can play an important role in preventing early childhood obesity. Consistent messages about the positive effect of responsive feeding practices, as opposed to nonresponsive, controlling practices, are necessary for young children to achieve competence in self-regulating energy intake (see Box 4-5). Evidence supports the presence of self-regulation abilities in young children as early as infancy. The degree of responsiveness of caregivers’ approaches to child feeding is associated with children’s continuing ability to self-regulate caloric intake and the risk of overweight in preschoolers. In addition, a number of states have licensing standards related to responsive feeding practices. In Delaware, for example, licensed centers must hold an infant while bottle feeding and serve food on demand. In Tennessee the regulations require that the feeding schedule for infants be in accordance with the child’s needs rather than the hour of day (http://www.nrckids.org). Therefore, in the committee’s judgment, a recommendation in support of responsive feeding in child care settings is appropriate.
Recommendation 4-5: Government agencies should promote access to affordable healthy foods for infants and young children from birth to age 5 in all neighborhoods, including those in low-income areas, by maximizing participation in federal nutrition assistance programs and increasing access to healthy foods at the community level.
Translating Responsive Feeding Ideas for Parents
Childcare Mealtime and Active Play Partnerships (ChildcareMAPP, http://www/childcaremapp.org) is a joint effort of the University of Colorado Anschutz Medical Campus, the University of Idaho, Washington State University, and the U.S. Department of Agriculture to provide information and educational resources regarding healthy eating and physical activity in child care settings and in children’s homes. Although the main target audience is child care providers and educators, parents can freely access the resources available on ChildcareMAPP’s website. Child care providers are encouraged to share with parents information and resources, such as best practices in child care settings, that can be translated into homes.
Below is a list of strategies ChildCareMAPP developed for use by child care providers in communicating with parents about helping their children develop healthy eating habits:
- Teach the family to recognize their child’s eating behaviors and help them determine what to look for when a child is eating according to his or her own feelings of hunger and fullness.
- Ask about a family’s dreams for their child’s health. Listen to their dreams for their child’s short-term health and long-term health.
- Talk with families about the closeness of families and its impact on children in early childhood. Discuss the child’s most supportive family member and how he or she can allow a child to listen to internal cues of hunger and fullness.
- Explain to families why you set out specific foods and utensils and what you expect the children to do with the foods or utensils. Explain your center’s strategies for helping children to stay in touch with their feelings of hunger and fullness.
- Take notes on what happens with children’s eating and mealtime skills in your program. Include the child’s preferences, attempts at trying new foods or serving skills, and progress over time. Share what you learn with families often. Also, document the child’s eating skills, which include judging amounts to serve themselves, recognizing hunger and fullness cues, pouring from pitchers, choosing how much to put in their mouths so they can chew and swallow comfortably and without choking, using utensils, choosing what to eat, trying unfamiliar foods, and eating a variety of foods.
SOURCE: http://www.cals.uidaho.edu/feeding/fortrainers/handouts/pdf/PWP1_Talking_with_Families_about_Healthy_ Weight.pdf (accessed May 9, 2011).
Potential actions include
- for children that qualify, the U.S. Department of Agriculture and state agencies maximizing participation in federal nutrition assistance programs serving children from birth to age 5, including the Special Supplemental Nutrition Program for Women, Infants, and Children, the Child and Adult Care Food Program, and the Supplemental Nutrition Assistance Program; and
- the federal government assisting state and local governments in increasing access to healthy foods.
Federal nutrition assistance programs provide an existing infrastructure for supporting food access for low-income families, who are at greatest risk for food insecurity. The federal government funds several nutrition assistance programs that aim to prevent hunger and improve dietary quality among families with young children (Box 4-6). In 2008, the last year for which the data are available, the federal government spent $53 billion supporting federal nutrition assistance programs, including the Supplemental Nutrition Assistance Program (SNAP), WIC, and other child nutrition programs (Kimbro and Rigby, 2010). It is possible that participating in programs that subsidize nutritious foods and meals may reduce obesity risk among young children (Kimbro and Rigby, 2010), although these results have not been replicated. Yet while the link between food insecurity and obesity risk in children is unclear (IOM, 2011b), evidence of the numerous impacts of food insecurity on other aspects of cognitive and behavioral development are sufficient to support these efforts. Many who are eligible for these benefits do not receive them: more than one-third of those eligible for SNAP and 40 percent of those eligible for WIC do not participate (White House Task Force on Childhood Obesity, 2010). Increasing the participation of all eligible families in these programs is essential to maximize the accessibility of nutritious foods and improve dietary quality, especially among low-income and minority families.
Participation in federal nutrition assistance programs benefits the diets and health of young children (Bitler et al., 2003; Stang and Bayerl, 2010; VerPloeg et al., 2009). Children whose families participate in SNAP consume diets that align more closely with the diets of the general U.S. population than do those of nonparticipating low-income children (Cole and Fox, 2008). Likewise, children attending child care centers that participate in the CACFP consume a more nutri-
U.S. Nutrition Programs That Can Promote Healthier Eating
The U.S. Department of Agriculture’s Food and Nutrition Service oversees nutrition programs. They include the following:
- The Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program) provides funds via an EBT (electronic benefit transfer) card that can be used to purchase food at most grocery stores and some other food stores and markets.
- The Special Supplemental Nutrition Program for Women, Infants, and Children, better known as the WIC Program, provides assistance to low-income women, infants, and children up to age 5 who are at nutritional risk by supplying vouchers for the purchase of nutritious foods to supplement their diets, information on healthy eating, and referrals to health care.
- The National School Lunch Program provides cash subsidies and donated commodities to school districts and independent schools that choose to take part in the program. In return, they must serve lunches that meet federal requirements, and they must offer free or reduced-price lunches to eligible children.
- The School Breakfast Program operates in the same manner as the National School Lunch Program.
- The Fresh Fruit and Vegetable Program provides free fresh fruits and vegetables in selected low-income elementary schools nationwide.
- The Summer Food Service Program provides free, nutritious meals and snacks to help children in low-income areas get the nutrition they need throughout the summer months when they are out of school.
- The Child and Adult Care Food Program is a nutrition education and meal reimbursement program helping providers serve nutritious and safely prepared meals and snacks to children and adults in day care settings.
- The Farmers’ Market Nutrition Program provides fresh fruits and vegetables from local, certified farmers’ markets to WIC recipients.
- The Emergency Food Assistance Program makes commodity foods available to states. States provide the food to local agencies, usually food banks, which in turn distribute it to soup kitchens and food pantries that directly serve the public.
SOURCE: USDA, 2011.
tious diet than children in non-CACFP centers and low-income children who bring meals from home (Bruening et al., 1999; Whitaker et al., 2009). Because many young children routinely spend time in out-of-home care, they consume a substantial proportion of their meals and snacks in child care settings. The CACFP allows child care providers to serve healthy foods and give children opportunities to learn positive food behaviors, which are an important part of their development in this environment. Young children need opportunities to explore and try healthy foods (Birch and Marlin, 1982; Birch et al., 1998; Sullivan and Birch, 1994). Learning about different foods and seeing others eat them are conducive to children’s willingness to try and accept new foods, an important part of their early exploratory development.
Community efforts to enhance access to affordable nutritious foods, specifically fruits and vegetables, also should be supported. Low-income families spend significantly less on fruits and vegetables relative to higher-income families, and are more likely to purchase no fruits or vegetables in a given week (Blisard et al., 2004; Sturm and Datar, 2005). Low-income families also eat fewer total vegetables, dark green and orange vegetables, legumes, and whole grains than higher-income families (Guenther et al., 2008). Whether this differential is related to the lack of access in their neighborhoods or to the relatively high cost of fruits and vegetables has not been established (Lovasi et al., 2009). It is known, however, that disparities exist in access to fruits and vegetables in low-income communities as compared with middle- and high-income communities. Many low-income families live in neighborhoods in which nutritious foods are not easily available. If local markets do sell whole grains, fruits, vegetables, and low- or nonfat milk and other dairy products, their cost often puts these products out of reach for a family of limited means. These “food deserts” in low-income communities (Ver Ploeg et al., 2009) are associated with higher rates of obesity (Lovasi et al., 2009).
Establishing supermarkets and grocery stores in low-income neighborhoods increases access to healthy foods, including fresh fruits and vegetables, at lower cost (Story et al., 2008). Farmers’ markets and mobile fruit stands also can increase access to fruits and vegetables in low-income communities. Box 4-7 describes an effort undertaken by New York City to increase access in underserved communities by licensing 1,000 Green Carts to sell reasonably priced fresh fruits and vegetables in its poorest neighborhoods.
Green Carts: Increasing Access to Fresh Fruits and Vegetables
in Low-Income Urban Neighborhoods
The New York City Department of Health and Mental Hygiene (NYCDOHMH) launched a Green Cart initiative in 2007. The purpose of this project was to increase access to affordable fresh fruits and vegetables in high-risk neighborhoods in New York City. These neighborhoods have high child and adult obesity rates and have limited access to stores that sell a variety of fresh produce.
Green Carts, which are easily recognized with their colorful umbrellas, are mobile food carts that sell only fresh produce. The fruits and vegetables must be sold raw, and only whole fruits and vegetables may be sold. Frozen and processed produce cannot be sold at Green Carts.
NYCDOHMH made provisions to approve 1,000 permits for Green Carts. Cart owners must register for, and be granted, a permit to operate a Green Cart. This permit identifies a neighborhood in which the Green Cart can sell produce; the exact location of the cart and its hours of service are determined by the operator. New York City received a grant from a private foundation that allows vendors to apply for reduced-interest loans to cover startup costs and receive free technical assistance on setting up a Green Cart business. Many neighborhood businesses and organizations have offered assistance as well, such as by providing a site in which a vendor can set up his or her Green Cart, assistance with cart storage and cleaning, referrals of clients, healthy recipes to offer customers, connections to local farmers and fruit and vegetable vendors, and facilities for produce storage.
NYCDOHMH is conducting a multiyear evaluation of the Green Cart initiative. Thus far, data have been collected at baseline and 1 year after the start of the program. Fewer than 200 of an eventual 1,000 carts had been permitted before year 1 data were collected. Nonetheless, those data documented increases in fruit and vegetable availability in both Green Cart and comparison neighborhoods. Future data will be needed to truly understand the impact of the Green Cart program on fruit and vegetable availability in low-income New York City neighborhoods.
SOURCE: NYCDOHMH Green Carts, http://www.nyc.gov/html/doh/html/cdp/cdp_pan_green_carts.shtml (accessed June 13, 2011).
Recommendation 4-6: Health and education professionals providing guidance to parents of young children and those working with young children should be trained and educated and have the right tools to increase children’s healthy eating and counsel parents about their children’s diet.
As discussed previously, millions of young children spend substantial amounts of time in child care and early childhood education programs. The social and physical environments provided by these programs exert an important influence on children’s diets. Those environments are established by the administrators, child care providers, and early childhood educators who design, manage, and deliver the programs. Thus, opportunities may exist for enhanced health promotion in these settings. Collaboration between pediatricians and early child care and education professionals has the potential to improve the breadth and effectiveness of such health promotion education (Gupta et al., 2005).
A survey of child care staff in five western states revealed that fewer than half of the responding centers allowed children to serve themselves (Sigman-Grant et al., 2008), although, as discussed earlier, this is recommended practice. The use of inappropriate feeding practices may be due to the fact that training in feeding young children for child care staff is limited, particularly in programs that do not participate in the CACFP. Child care health consultants who serve these centers receive little training in the basic nutrition and physical activity principles important to the promotion of healthy weight in children (Benjamin et al., 2008).
This recommendation is intended to ensure that health and education professionals are able to implement the recommendations on healthy eating in this report. Such training can take different forms. For example, degree programs in early childhood education and child development could include content on feeding young children. Ongoing staff development in child care settings could include training on planning healthy meals, serving as a role model for healthy eating, creating a healthy mealtime environment, and leading nutrition education activities for children. The IOM report on standards for the CACFP also recognizes the need for training and technical support for providers and suggests paths for developing their competencies and skills (IOM, 2011a).
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