Table of Contents
In the last lesson I discussed various nutritional considerations for weight management in childhood. This included general nutritional advice to aid weight management without sacrificing health outcomes in the process. In this lesson I will extend that advice to general behavioral considerations and specific points with respect to feeding, sleeping, and exercise. Quite frequently childhood obesity results from suboptimal lifestyle decisions (from a health perspective) and significant progress can be made by working on generally healthy habits. Sometimes just by working on these modifications significant progress can be made without otherwise worrying about calories, macronutrients, or other aspects of nutrition.
Tip: A 2022 systematic review and meta-analysis (“SR/MA”) found that when mothers work longer hours this increases the odds of childhood overweight/obesity.(Lou, 2022) The authors cite data also finding this association with fathers. They cite several mechanistic aspects that may account for this association, including:
- When longer hours are worked this frequently leads to a less healthy eating pattern regarding structure and food choices.
- Longer working hours can lead to disrupted bedtime routines, negatively impacting sleep.
- When parents work more their children may be more likely to spend time engaging in sedentary activities (ie, watching videos or playing video games) as opposed to engaging in physical activity.
While it would be unreasonable to expect most adults to work fewer hours to aid their child’s health, knowing that this can be a factor in suboptimal health behaviors may prove beneficial. You can discuss with your children and anyone else in the home ways that you can still support your children to engage in healthier behaviors even when you are not present. As you glance or read through this lesson you can think about how you can help your family make healthier changes even while you are working.
Similar to Lesson 6 where I discussed feeding styles and strategies in infants and toddlers, these considerations also apply to children and adolescents and have been discussed in several recent publications. I highlight some of these and then provide a brief summary in the expandable box below; underneath the box I provide practical points from these publications.
- A 2020 SR/MA examining the impact of child feeding practices (determined by parental report) on obesity development included 51 studies and found a small association between restrictive child feeding practices and increased weight gain.(Ruzicka, 2020) In contrast, “pressure-to-eat” associated with lower child weight outcomes. It is unclear what influence weight trajectory had on the influence of feeding practices.
- Intuitively it makes sense that children who are of lower body weight would be the ones who are pressured to eat, as opposed to pressuring causing the children to develop a lower body weight.
- A 2020 review of caregiver influences on eating in young children noted that there is >50% heritability in early childhood eating behaviors; it’s possible this may be due to underlying genetics but it is also possible that this results from parents raising children in a similar manner to how they were raised themselves.(Wood, 2020)
- A 2020 review on positive parenting noted that in early childhood parents should continue responding to child cues while coupling this with structure & limit setting in an authoritative style (exerting control but with warmth and responsiveness).(Balantekin, 2020) In middle childhood this should continue but children can be provided additional autonomy (ie, involving children in food shopping and preparation) while increased parental monitoring may also be needed to set limits on foods purchased outside the home. In adolescence positive mealtime structure is beneficial and family meals can aid health outcomes while it is also important to optimize the food environment in the home and may be helpful to continue to engage in monitoring given increased independence.
- A 2020 position paper on the prevention of childhood obesity noted that authoritative parenting leads to good outcomes whereas parenting styles including restriction, pressure to eat, and strict monitoring can lead to worse outcomes.(Koletzko, 2020)
More recent reviews:
- In a 2021 review of childhood obesity management, the authors highlighted it is more helpful to dwell on what should be eaten than what should be avoided while also controlling portion sizes.(Mittal, 2021) Beginning at age 2-5 years having 3 meals and 2-3 snacks daily is appropriate, fast food and sugar-sweetened beverages should not be offered, age-appropriate portion sizes should be offered without force feeding, meals should be at the table without any media, children should be praised for trying new foods, and parents should model appropriate eating behavior.
- In a 2021 review of eating speed and eating frequency and their relationship with various health markers, fast eating speed associated with having a higher risk of developing overweight and obesity in children while there were more mixed results with eating frequency.(Garcidueñas-Fimbres 2021)
- A 2021 SR/MA of dietary interventions in children found that using portion control tools such as smaller plates and bowl sizes were effective for aiding weight management.(Vargas-Alvarez, 2021) Therefore, you can consider providing smaller portions of the more starchy carbs and snacks while using larger dishes for fruits and vegetables.
Thus, as children grow it is still beneficial to set appropriate limits and structure while responding to child cues and respecting growing autonomy. Teaching and supporting children to engage in healthy eating behaviors (ie, slowing the pace of eating, using appropriate portion sizes) is also very helpful. The goal of all of this is to help the child intuitively understand what nutrition their body needs and how to respond accordingly.
Key practical tips from the above publications:
- Similar to younger children, it seems best to utilize an authoritative feeding style (exerting structure and limits with warmth and responsiveness) as opposed to overly restrictive, pressuring-to-eat, or indulgent feeding styles.
- The heritability of childhood eating behaviors is >50%; this implies many parents feed their children similar to how they were raised. If this is leading to undesirable outcomes, consider if different strategies may be worthwhile even if you are not very familiar with them initially.
- It is better to focus on what should be eaten than what should be avoided.
- Fast eating speeds can increase the risk of overweight and obesity. This has also been found to associate with other metabolic abnormalities in children and especially adults.(Yuan, 2021)
- When eating quickly this may not allow sufficient time for the release and processing of satiation hormones as well as gastric distension (from the consumed food) to signal to the brain that this is an appropriate time to stop eating. Thus, this can lead to overconsumption.
- Using smaller plates and bowl sizes can aid with portion control.
- In early childhood you can create structure and limits for feeding while responding to the child’s cues, this may entail:
- 3 meals and 2-3 snacks daily
- no fast food or sugar-sweetened beverages (except on special occasions)
- offer appropriate portions but do not force the child to eat them
- meals should be consumed at the table without any media
- praise the children for trying new foods
- model desirable feeding behaviors
- In middle childhood much of the above advice applies with additional considerations:
- provide more autonomy with food shopping and food preparation
- monitor the children regarding food purchases outside the home
- In adolescence much of the above advice applies with additional considerations:
- continue to emphasize mealtime structure
- attempt to optimize the home food environment as adolescents are more likely to snack mindlessly (particularly after school and in the evening)
If curious, in the following expandable box I elaborate on some of these points to a greater degree. If you are looking for more strategies to implement with children, feel free to look at this box.
- Setting limits: the parent can provide healthy food options with appropriate portion sizes. If the child does not want to eat this food and demands something else, the parent should not give in. Rather, they can take the currently offered food and put it in the refrigerator, offering it again at a later point in time.
- This is somewhat similar to Ellyn Satter’s Division of Responsibility in Feeding. You can look at that link for additional suggestions.
- Structure: meals can be consumed as a family at the table, within a set period of time, and without any viewable media. Snacks can be consumed in a similar manner if needed. During this structured eating time the family can have discussions about any of various topics.
- Fast eating speed: appropriate strategies can be used to slow down the pace of eating, if needed. Examples include:
- using smaller utensils
- having sips of water between bites
- eating with your off hand (ie, your left hand if you are right-handed)
- alternatively, the eating speed can be maintained but a time period such as 20 minutes can be utilized between servings of food
- Responding to child cues: if a child indicates they are not hungry they should not be forced to eat. Similarly, if a child indicates they are full before they have finished their plate, they should not be made to finish their plate.
- Toddlers and young children in particularly can have normal, good, and bad days of eating, where they want a normal amount of food, a lot of food, or very little food, respectively. This is unlike older individuals who typically consume similar amounts of food on a daily basis.
- Respecting growing autonomy:
- You can negotiate to a degree; for example, if a child wants a second helping after waiting 20 minutes to ensure they are not still hungry then they can have one but they should pick from either fruit, vegetables, or a lean protein source, not a starchy carbohydrate.
- Adolescents will have much more say over their food choices; forbidding them from certain items will likely backfire. Allowing the adolescent to help choose food items, ideally from a variety of healthy options, will generally yield better outcomes.
- You can also negotiate the number of snacks/treats the child or adolescent can have per week or month. Rather than completely forbid fast food, acknowledge that it can taste good but isn’t great for your health so you will only have it sparingly. Then, when you do get fast food, snacks, or treats, eat them outside the home and/or try to find ways to promote healthier varieties.
- Optimize the food environment: this entails getting the nonnutritious food items out of sight, either by removing them from the home, locking them up, or putting them some place where the children cannot get to them without your permission.
- If the children protest this then removing them from the home may be the best option. This would be a form of “covert control” (where you control the child’s eating without them realizing it), as opposed to “overt control” (where you control the child’s eating in a way that they recognize, such as having the food in plain sight but telling the child they cannot have it); in general covert control works better.
- This does not mean children can never have these nonnutritious items. You can teach the children that all foods are ok to eat but some should be eaten less frequently than others. Then if you want to get that food you can go out somewhere with the child to get it and eat it without bringing it back into the home. You can emphasize in the home is where the family will stick to nutritious foods while treats are a separate thing for special occasions.
- Focusing on healthy food choices: you can create a menu of various healthy food items and meals with a child that the child finds appealing and enjoys eating. Then you can ensure that these types of food items or meals are readily available. It is much easier to help children eat healthily if they can look forward to food they enjoy. Some examples may include:
- Use fruits as dessert, or mix yogurt with berries.
- You can blend frozen fruits/vegetables with milk to make smoothies and increase fruit/vegetable intake.
- You can use flavored water or 0 calorie drinks if needed.
- You can add cinnamon as flavoring (consider purchasing Ceylon cinnamon if you intend to use this a lot (discussed more here)).
- Try preparing foods in different ways to generate different textures/flavors/combinations and ask the child to try them and tell you which they like best.
Additionally, there is no need to be “perfect” all the time. It is generally not wise to punish children for suboptimal choices or habits. Rather, try to determine what led to a poor choice and work on removing that triggering circumstance while also praising children when they do make good choices and this will naturally help children make better choices in the future.
Note: There is evidence of a bidirectional association between executive function and weight status in children and adolescents.(Likhitweerawong, 2022) The authors of this analysis did find evidence of publication bias, but nonetheless the analysis indicates that youth with poorer executive function, in particular poorer inhibitory control, are prone to gaining excess weight long-term, and the excess weight gain may further worsen overall executive functioning. While it may be possible to teach or to train a child to exert greater inhibitory control, this further showcases the benefit of putting children in a position where they will not need to exert inhibitory control in the first place. This supports the beneficial aspects of optimizing the food environment as stated above.
Sleep considerations for weight management
According to the American Academy of Sleep Medicine, and endorsed by the American Academy of Pediatrics, recommended amounts of sleep for children at the following ages include:
- 4-12 months: 12-16 hours per day (including naps)
- 1-2 years: 11-14 hours per day (including naps)
- 3-5 years: 10-13 hours per day (including naps)
- 6-12 years: 9-12 hours per day
- 13-18 years: 8-10 hours per day
As noted in the following publications, there has been a substantial amount of literature evaluating the impact of sleep duration on obesity risk:
- A 2020 study analyzing multiple cohorts to determine the influence of sleep patterns on obesity in children aged 2-5 years found that bedtime did not have much of an influence (unlike in older children and teenagers where a later bedtime is associated with obesity risk) but longer total sleep time in 24 hours did associate with a lower risk of obesity (similar to findings in other age groups).(Roy, 2020)
- A 2021 cross-sectional & prospective analysis including 11 studies evaluated the impact of total sleep duration and bedtime with adiposity as well as overweight and obesity.(Collings, 2021) The authors found that sleeping >10 hours and particularly >11 hours associated with decreased odds (13% and 28%, respectively) of developing overweight and obesity in children (age <12 years old) while sleeping >10 hours nightly associated with 24% decreased odds of developing overweight and obesity in adolescents (age ≥12 years). A bed time between 10-11 pm and particularly before 9 pm associated with decreased odds of overweight and obesity in children (32% decreased odds if before 9 pm). Controlling for TV viewing and having a TV in the bedroom diminished the associations in children.
- Having a TV in the bedroom makes it more likely a child will be put to bed but stay awake longer watching TV, thus decreasing the benefit of an earlier bedtime.
- A 2021 SR/MA evaluated the relationships between short sleep and sleep interventions with obesity and weight gain in preschool-age children.(Miller, 2021) The authors found that short sleep duration led to a 54% increased risk of overweight or obesity. There were relatively few interventions for improving sleep but these did lead to average decreases of BMI (-0.27, 3 interventions) and BMI standard deviation score (-0.14, 2 interventions with 3 cohorts).
- A 2021 MA of prospective cohort studies included 33 articles and found short sleep duration yielded a relative risk of 1.57 for obesity development in youth while prolonged sleep yielded a relative risk of 0.83.(Deng, 2021) This association peaked at age 6 years and was otherwise similar when comparing ages 1-2 years and 14-17 years.
It is clear that short sleep duration is substantially associated with increased prevalence of obesity. The authors of the last MA cited above speculate that sleep deprivation may increase sympathetic nervous system activation, which leads to increased catecholamine and cortisol secretion. This may subsequently increase general inflammation and decrease leptin and growth hormone concentrations. Along with general fatigue from too little sleep, this will dysregulate homeostatically-mediated energy intake, decrease motivation to engage in regular physical activity, and likely decrease involuntary energy expenditure. Additional potential mechanisms and insights from the literature regarding the impact of sleep on various aspects of body composition were reviewed recently, with the findings summarized in the following figure (you can look at the open-access article itself for a caption to the figure – the authors note that more research is needed to clarify all of these potential mechanisms).(Stich, 2021)
These mechanisms as well as others can generate an association between poor sleep and increased caloric intake, as shown in the following figure.
Thus, while the mechanisms may not be fully clear, there is a physiologic basis for the observed association of decreased sleep and increased obesity risk, and thus optimizing sleep habits and duration in youth is a key step for working towards and maintaining a healthy body composition.
Note: For multiple reasons children with obesity may have worse sleep quality than children without obesity, generally related to sleep-disordered breathing, such that even if they sleep the same total number of hours as children without obesity the benefit of the sleep may be inferior. As shown in a recent study, this even extends to children with obesity who are not suspected of having sleep-disordered breathing; in this study children with obesity without suspected sleep-disordered breathing were compared to children without obesity (also without suspected sleep-disordered breathing) and the subset with obesity were still found to have more apnea & hypoxic events throughout the night as well as less total time in rapid eye movement sleep.(Danielsen, 2022)
Since poor quality sleep can contribute to obesity as discussed above, for children with obesity with any signs of poor quality sleep it is worth considering if a sleep study and more definitive treatment (ie, an adenotonsillectomy, use of a CPAP machine, etc) should be pursued.
Tip: Regarding advice to obtain better sleep:
- Children should have a consistent bedtime routine and a consistent bedtime, ideally on both weekdays and weekends. They should not look at screens within 1 hour of bedtime.
- Moderate-to-vigorous intensity exercise done for at least 1 hour daily at any time of day other than late at night will likely prove helpful.
- If children have trouble falling asleep at night and are beyond the toddler stage they should likely not take naps.
- Using blackout curtains to drown out ambient light can be helpful. Alternatively, using a nightlight for children scared of the dark can be helpful.
- Using something to drown out various noises, such as a bedside fan, a white or brown noise generator machine or app, or earplugs, can be beneficial.
- If children wake up overnight to urinate and have trouble going back to sleep, consider restricting fluids 2 hours before bedtime and having the children urinate 15 minutes before and right before bed.
- If children have nightmares that wake them up or they are worried or stressed at night and this makes it harder to fall asleep, talk to the child about what is on their mind to see if you can help them through this, and if you need additional support talk to their healthcare provider.
- If there is snoring or a separate concern for breathing issues and any concern for allergies, consider trying over-the-counter allergy medications such as Flonase or Zyrtec for 2-4 weeks, and if this is not helpful then talk to their healthcare provider.
There is a general exercise course on this website applicable to all ages, including guidelines for exercise amounts in Lesson 3 and considerations specifically for children & adolescents in Lesson 15. I will not rehash all of that information here, but I will emphasize some of the key points and additional information that pertains to health and weight management.
There are many health benefits from physical activity in youth.(Julian, 2022) Many of these benefits are emphasized in the following table:
Benefits of physical activity extend to children with various medical conditions as well as intellectual disability.(Alvarez-Pitti, 2020; Kapsal, 2019) Muscle and bone-strengthening activities seem particularly important to aid in bone mineral content and lean body mass accrual that may carry forward with health benefits throughout the lifespan; low levels of skeletal muscle mass in youth seem to correlate with increased cardiometabolic risk factors.(Westerterp, 2018; Orsso, 2019) A recent analysis indicated that at 18 years of age very active females and males would have 1.7 and 3.4 kg more fat-free mass than sedentary females and males, respectively.(Westerterp, 2021) As fat-free mass is lost later in life, building up more at an earlier age may help maintain functionality in later years. Additionally, as indicated in Lesson 10, increased levels of lean body mass improve overall health regardless of the degree of obesity.
Exercise and obesity
There are several lines of evidence that exercise has a role in obesity management:
- Impact of general activity: Increased sedentary behavior is highly associated with developing obesity and regaining lost weight while increased moderate-to-vigorous physical activity (“MVPA”) decreases the risk of developing obesity and helps maintain weight loss long-term.(van Ekris, 2016; Styne, 2017;Cardel, 2020; Headid III, 2021; Julian, 2022) Increased physical activity contributes to healthy body weight and adiposity in children <6 years old.(Pate, 2019; Wiersma, 2020)
- Impact of cardiorespiratory fitness (“CRF”): A prospective cohort study including children aged 6-9 years found that those with higher or lower CRF levels had lower or greater odds of developing obesity, respectively, over the following 4 years, and increasing individual fitness levels over time correlated with a decreased risk of developing obesity.(Ho, 2020) A recent SR/MA with an average follow-up of 8.6 years found that increased baseline CRF as well as increasing fitness over time both had beneficial associations with anthropometric measurements and overall cardiometabolic health risks.(García-Hermoso, 2020) A more recent study also found that high levels of CRF seem to mitigate cardiometabolic risks associated with obesity.(Sehn, 2021)
- Impact of resistance training: Resistance training will aid in lean body mass gain (and by extension skeletal muscle mass gain) while also helping to decrease body fat.(Lopez, 2022) While speculative, there is some thought that combining aerobic and resistance training will better allow the metabolically active tissue to outcompete adipose tissue for nutrients, thus helping to prevent adipocyte expansion and the development of obesity, based on the notion that adipocyte expansion occurs more quickly and at an earlier age in individuals with obesity than in those without obesity.(Spalding, 2008; Hanks, 2015) If this is correct then increasing activity levels at an early age may play a significant role in obesity prevention.
- Impact on appetite: More research is needed, but there does seem to be a benefit of regular exercise for appetite control in individuals with obesity.(Schwartz, 2017; Julian, 2022)
Changes with age
As shown in the following publications, in general exercise levels decrease throughout childhood and adolescence, and perhaps this contributes to obesity development:
- A 2019 SR/MA including 52 studies (31 in the MA) found on average that the length of time spent engaging in MVPA declined 5.3% per year in girls from age 6 years onward and 3.5% per year in boys from age 8 years onward.(Farooq, 2019) The overall average annual decline was 3.4 minutes per day.
- A 2019 SR/MA found that when transitioning from adolescence to adulthood people on average decrease their MVPA by 1.9 minutes per day each year.(Corder, 2019)
- A 2021 SR/MA found sedentary behavior seems to increase continuously throughout childhood and adolescence, averaging ≥2 hours increase per day over a 4-year time period.(Kontostoli, 2021)
- A 2022 SR/MA found that a decline in walking and other activity increases in adolescence relative to earlier in childhood.(Conger, 2022)
As physical activity generally diminishes over time, it can be quite helpful to establish and build upon good habits early in life so that there is a better chance these will carry forward. Making sufficient physical activity part of the family’s lifestyle will likely benefit everyone in the family and set the foundation for continued success.
Tip: There are many ways children can increase the time they spend engaging in physical activity and exercise. Good things to keep in mind are that:
- Young children have several physiologic distinctions from adults that impact their exercise patterns, favoring intermittent activity and benefiting from a thermoneutral environment.(Skinner, 2021) Young children typically perform exercise in short spurts (ie, sprinting, as opposed to running on a treadmill continuously), and exercise duration as little as 1 minute in length can yield health benefits.(Chinapaw, 2018; Tarp, 2018)
- In older children and adolescents, high-intensity interval training is beneficial for improving CRF, several health markers, and seems optimal when performed at least 3 days per week with a 1:1 work-to-rest ratio.(Eddolls, 2017; Braaksma, 2018; Cao, 2019; Martin-Smith, 2020; Menezes Junior, 2020) Fitting this in on top of general physical activity can be quite beneficial.
- Bone-strengthening activity can include anything with joint impacts, such as jumping rope, though if this causes any pain or discomfort in individuals with obesity this should not be done and can be reconsidered after some of the excess weight is lost and general muscle strength has increased.
- Muscle-strengthening activity can include many different modalities, such as body weight movements, lifting weights, using resistance bands, using sand bags (by purchasing sand, placing it in trash bags, and placing the trash bags in a backpack or a duffel bag), or lifting any other heavy object.
- People with obesity may find general aerobic activity to be quite uncomfortable and not very enjoyable, so finding some type of movement activity that is enjoyable will be helpful. On the other hand, strength training is generally not as uncomfortable and people can make significant progress with strength gains in only 2-3 workouts; thus this is a great modality to build confidence and motivation for exercising more in general.
- Younger children will generally want to engage in physical activity with caregivers while adolescents may prefer to exercise alone; this will vary by individual.
Overall, while any activity is likely better than sedentary behavior, to meet the actual physical activity guidelines (discussed here) it is important to strive for 60 minutes of moderate-to-vigorous physical activity daily. Ideally you can include muscle and bone-strengthening activity with resistance training and potentially various jumping exercises 2-3 days weekly; this will provide additional health benefits and help with skeletal muscle maintenance while losing excess body fat.
Note: One topic I have not specifically addressed is “screen time”, or how much time youth spend watching screens. A 2022 SR/MA found that interventions specifically targeting decreasing screen time were not effective in decreasing a child’s BMI.(Zhang, 2022) A separate 2022 SR/MA found in controlled trials that children show no increase in caloric intake when watching TV, though the authors acknowledge longitudinal studies need to be done and it is possible that greater engagement in TV-viewing may lead to increased caloric consumption.(Martins, 2022)
Thus, working on decreasing screen time alone will likely not help treat childhood obesity. Rather, ensuring children do not mindlessly eat while watching screens and in some way replace screen time with physical activity (or incorporating physical activity while watching screens) will likely prove more beneficial.
In this lesson I have discussed practical advice regarding feeding behaviors, the importance of working towards sufficient sleep, and the benefit of regular exercise regarding childhood obesity outcomes. In summary:
- Feeding behaviors – this is where most of the changes are likely going to be beneficial both for preventing and treating childhood obesity. As adults generally have more control over what children eat, putting children in a position to succeed and using behavioral strategies as indicated above to help children make healthy choices are the primary factors in preventing and managing childhood obesity.
- Sleep – it is worth the effort to enforce appropriate bedtime routines (ie, no screen viewing) and an appropriate bedtime while addressing other potential obstacles to ensure children sleep well. Poor sleep not only makes individuals feel worse physically, it can also make it more challenging to avoid impulsively making suboptimal decisions and as shown above it can make several aspects of obesity prevention and management more difficult.
- Exercise – in addition to the many general health benefits of obtaining sufficient physical activity levels, exercise may aid appetite control and resistance exercise in particular can aid lean body mass retention while body fat is lost, which should help improve body composition long-term.
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