Promoting eating self-regulation to reduce obesity risk: The role of caregivers

Nearly 20% of youth have an obese weight status putting them at increased risk of cardiovascular disease, type II diabetes, and certain types of cancer (1, 2). Despite efforts to reverse this trend, obesity rates continue to rise among young children, particularly among Hispanic and non-Hispanic African American children (2, 3). A major benefit of targeting young children (0-5 years) with obesity prevention strategies is that deeply entrenched diet and activity habits have not been established. Optimal dietary and activity behaviors in early childhood may promote a lifetime of health promoting habits.

Eating behaviors or appetitive traits refer to patterns in decisions about what, when and how much to eat (4). Obesogenic eating behaviors in early childhood include eating in the absence of hunger, satiety insensitivity, food responsiveness, and emotional eating (5). These eating behaviors reflect dysregulation or an inability to initiate and terminate eating episodes in response to physiological hunger and satiety drives. Eating behaviors are moderately to highly heritable (6). However, conditions of the environment shape behaviors through operant and classical conditioning (7). Rewards for a behavior increase the likelihood of the behavior occurring again under similar circumstances and punishments for a behavior decrease the likelihood of the behavior occurring again under similar circumstances (7). As curators of the food environment and influential attachment figures in children’s lives, caregivers may play a role in shaping their children’s eating behaviors in early childhood. Whether children’s eating behaviors that are conditioned by caregivers endure into adulthood or not remains to be seen. Research cited by Wood et al., shows that the environmental influence over children’s eating behaviors decreases as children age and gain more autonomy over their environments (8). This may be because behaviors shaped by operant conditioning are highly context dependent, and as children age, exposure to the home environment conditions that once reinforced healthy eating behaviors decreases (7).

It has been understood for years, that caregiver feeding behaviors and child eating behaviors are related (9). However, recent research has shown that caregivers and children influence each other within the feeding relationship (10-12). In general, when caregivers provided a healthy environment, monitored their child’s dietary intake, restricted the amount of foods they offered to children, and avoided overly controlling and emotional feeding behaviors, children developed fewer obesogenic eating behaviors over time (10-12). In addition, children’s obesogenic eating behaviors led to increases in emotional feeding and caregiver use of food as a reward and decreases in parental covert control over time (11, 12). It seems children may be born with a genetic tendency toward certain eating behaviors and the ways that caregivers respond to those behaviors may encourage or discourage those behaviors from occurring again under similar conditions. Likewise, caregivers may enter the feeding relationship with preconceived notions about their role and expectations for the child’s eating behaviors, and over time, children’s responses to the caregiver’s feeding behaviors will encourage or discourage parental use of those behaviors under similar conditions.

Although we are only beginning to understand the bidirectional associations between caregiver feeding behaviors and child eating behaviors, Wood et al. do a nice job providing well-founded recommendations for caregivers to support eating self-regulation and lower obesity risk in this AHA scientific statement. In pregnancy, the recommendations focus on entering pregnancy at a healthy weight, optimizing diet quality throughout pregnancy, and adhering to gestational weight gain recommendations. When feeding infants, toddlers, and preschoolers, the recommendations are, briefly, to provide access to a variety of healthy foods when children are hungry, to respect child satiety and fullness cues, to model healthy eating, to set age appropriate limits around food, and to avoid overly controlling children’s eating and focusing on specific foods and/or child weight.

The writing group ends with the acknowledgement that there are a number of challenges for parents to implement their recommendations. Some of these challenges have to do with the unpredictable nature of children’s behaviors due to variations in children’s growth, language, socialization, autonomy needs, and cognitive abilities across development and individual differences in child temperament. The writing group advises that caregivers recognize that children and caregivers influence each other and that research has not yet provided information about how to overcome these challenges. In the meantime, the American Academy of Pediatrics (AAP) suggests caregivers rely on positive parenting strategies to manage and shape children’s behaviors (13). The Centers for Disease Control and Prevention and the AAP have a number of resources for parents on age appropriate expectations, communication, positive reinforcement, and positive discipline.

A second set of challenges parents face in implementing the recommendations posed by Wood et al. have to do with sociocultural and economic constraints like poverty, caregiver mental health, and under- resourced environments. Policies and system changes may be needed to support caregivers in implementing the feeding recommendations of the writing group.

In conclusion, caregivers may have a small to moderate influence over the development of their child’s eating behaviors in early childhood. The caregiver-child feeding relationship is dynamic and influenced by individual qualities of caregivers and children, and sociocultural and economic conditions of the environment. Despite the complexities and gaps in the literature, Wood et al. provide a set of recommendations for caregivers to support eating self-regulation in early childhood.