Lesson 13: Child and Adolescent - Feeding Behaviors, Sleep, and Exercise Considerations

Introduction

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.

Feeding behaviors

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.

Click here for summaries of recent publications discussing aspects of feeding behavior in children.

Pre-2021 reviews:

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 subsequent study by the same group has re-demonstrated this.^{(Garcidueñas-Fimbres 2023)}
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.

Click here for additional strategies regarding how to help youth maintain healthy eating habits.

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.
A 2022 SR/MA found that short sleep was associated with 1.17 increased odds of having overweight and obesity, with stronger effects found in younger children than in adolescents (where there were no significant increased odds).^{(Han, 2022)}

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)}

Reproduced from: Stich FM, Huwiler S, D’Hulst G, Lustenberger C. The Potential Role of Sleep in Promoting a Healthy Body Composition: Underlying Mechanisms Determining Muscle, Fat, and Bone Mass and Their Association with Sleep. Neuroendocrinology. 2021 Jul 27. doi: 10.1159/000518691. Epub ahead of print. PMID: 34348331.

Another review has noted that at least in adults insufficient sleep may increase energy expenditure by ~100 calories/day while leading to an increase in energy intake by >250 calories/day.^{(Chaput, 2023)} Circadian misalignment (ie, shift work, or significant social jet lag where people stay up late and sleep in late) can decrease energy expenditure by ~3% or ~50 calories/day. Lack of sleep generally increases the drive to eat related to poor cognitive control and reward mechanisms rather than to hunger hormones. Some of the underlying general mechanisms mediating an association between poor sleep and increased caloric intake, as shown in the following figure.

Reproduced from: Sejbuk M, Mirończuk-Chodakowska I, Witkowska AM. Sleep Quality: A Narrative Review on Nutrition, Stimulants, and Physical Activity as Important Factors. Nutrients. 2022 May 2;14(9):1912. doi: 10.3390/nu14091912. PMID: 35565879; PMCID: PMC9103473.

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.

Exercise considerations

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.

Health benefits

There are many health benefits from physical activity in youth.^{(Julian, 2022)} Many of these benefits are emphasized in the following table:

Reproduced from: Alvarez-Pitti J, Casajús Mallén JA, Leis Trabazo R, Lucía A, López de Lara D, Moreno Aznar LA, Rodríguez Martínez G. Ejercicio físico como «medicina» en enfermedades crónicas durante la infancia y la adolescencia [Exercise as medicine in chronic diseases during childhood and adolescence]. An Pediatr (Engl Ed). 2020 Mar;92(3):173.e1-173.e8. Spanish. doi: 10.1016/j.anpedi.2020.01.010. Epub 2020 Feb 13. PMID: 32061527.

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 2023 SR/MA found the highest vs. the lowest categories of screen time had only a 1.2x increased odds of developing obesity.^{(Ramírez-Coronel, 2023)} 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. Additionally, some children may see food advertisements while engaging in screen time that can provoke increased eating, and for some children this may make a more significant difference.

Conclusion

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.

Click here to proceed to the conclusion of this course

References

Alvarez-Pitti J, Casajús Mallén JA, Leis Trabazo R, Lucía A, López de Lara D, Moreno Aznar LA, Rodríguez Martínez G. Ejercicio físico como «medicina» en enfermedades crónicas durante la infancia y la adolescencia [Exercise as medicine in chronic diseases during childhood and adolescence]. An Pediatr (Engl Ed). 2020 Mar;92(3):173.e1-173.e8. Spanish. doi: 10.1016/j.anpedi.2020.01.010. Epub 2020 Feb 13. PMID: 32061527.
Balantekin KN, Anzman-Frasca S, Francis LA, Ventura AK, Fisher JO, Johnson SL. Positive parenting approaches and their association with child eating and weight: A narrative review from infancy to adolescence. Pediatr Obes. 2020 Oct;15(10):e12722. doi: 10.1111/ijpo.12722. Epub 2020 Sep 3. PMID: 32881344; PMCID: PMC8018716.
Braaksma P, Stuive I, Garst RME, Wesselink CF, van der Sluis CK, Dekker R, Schoemaker MM. Characteristics of physical activity interventions and effects on cardiorespiratory fitness in children aged 6-12 years-A systematic review. J Sci Med Sport. 2018 Mar;21(3):296-306. doi: 10.1016/j.jsams.2017.07.015. Epub 2017 Jul 20. PMID: 28899655.
Cao M, Quan M, Zhuang J. Effect of High-Intensity Interval Training versus Moderate-Intensity Continuous Training on Cardiorespiratory Fitness in Children and Adolescents: A Meta-Analysis. Int J Environ Res Public Health. 2019 Apr 30;16(9):1533. doi: 10.3390/ijerph16091533. PMID: 31052205; PMCID: PMC6539300.
Cardel MI, Atkinson MA, Taveras EM, Holm JC, Kelly AS. Obesity Treatment Among Adolescents: A Review of Current Evidence and Future Directions. JAMA Pediatr. 2020 Jun 1;174(6):609-617. doi: 10.1001/jamapediatrics.2020.0085. PMID: 32202626; PMCID: PMC7483247.
Carr KA, Black W, Guth C, Shapiro L, Leone LA, Temple JL, Epstein LH. Reinforcing value of food, enriched home environment, and changes in percent overweight in children. Obesity (Silver Spring). 2023 Apr;31(4):1075-1084. doi: 10.1002/oby.23685. Epub 2023 Feb 28. PMID: 36855013.
Chaput JP, McHill AW, Cox RC, Broussard JL, Dutil C, da Costa BGG, Sampasa-Kanyinga H, Wright KP Jr. The role of insufficient sleep and circadian misalignment in obesity. Nat Rev Endocrinol. 2023 Feb;19(2):82-97. doi: 10.1038/s41574-022-00747-7. Epub 2022 Oct 24. PMID: 36280789; PMCID: PMC9590398.
Chinapaw M, Klakk H, Møller NC, Andersen LB, Altenburg T, Wedderkopp N. Total volume versus bouts: prospective relationship of physical activity and sedentary time with cardiometabolic risk in children. Int J Obes (Lond). 2018 Oct;42(10):1733-1742. doi: 10.1038/s41366-018-0063-8. Epub 2018 May 1. PMID: 29717272.
Collings PJ, Grøntved A, Jago R, Kriemler S, Northstone K, Puder JJ, Salmon J, Sardinha LB, Steene-Johannessen J, van Sluijs EMF, Sherar LB, Esliger DW, Ekelund U; International Children’s Accelerometry Database (ICAD) Collaborators. Cross-sectional and prospective associations of sleep duration and bedtimes with adiposity and obesity risk in 15 810 youth from 11 international cohorts. Pediatr Obes. 2021 Dec 1:e12873. doi: 10.1111/ijpo.12873. Epub ahead of print. PMID: 34851038.
Conger SA, Toth LP, Cretsinger C, Raustorp A, Mitáš J, Inoue S, Bassett DR. Time Trends in Physical Activity Using Wearable Devices: A Systematic Review and Meta-analysis of Studies from 1995 to 2017. Med Sci Sports Exerc. 2022 Feb 1;54(2):288-298. doi: 10.1249/MSS.0000000000002794. PMID: 34559725.
Corder K, Winpenny E, Love R, Brown HE, White M, Sluijs EV. Change in physical activity from adolescence to early adulthood: a systematic review and meta-analysis of longitudinal cohort studies. Br J Sports Med. 2019 Apr;53(8):496-503. doi: 10.1136/bjsports-2016-097330. Epub 2017 Jul 24. PMID: 28739834; PMCID: PMC6250429.
Danielsen YS, Skjåkødegård HF, Bjorvatn B, Juliusson PB, Pallesen S. Polysomnographic comparison of sleep in children with obesity and normal weight without suspected sleep-related breathing disorder. Clin Obes. 2022 Feb;12(1):e12493. doi: 10.1111/cob.12493. Epub 2021 Nov 15. PMID: 34781415.
Deng X, He M, He D, Zhu Y, Zhang Z, Niu W. Sleep duration and obesity in children and adolescents: evidence from an updated and dose-response meta-analysis. Sleep Med. 2021 Feb;78:169-181. doi: 10.1016/j.sleep.2020.12.027. Epub 2020 Dec 29. PMID: 33450724.
Eddolls WTB, McNarry MA, Stratton G, Winn CON, Mackintosh KA. High-Intensity Interval Training Interventions in Children and Adolescents: A Systematic Review. Sports Med. 2017 Nov;47(11):2363-2374. doi: 10.1007/s40279-017-0753-8. PMID: 28643209; PMCID: PMC5633633.
Farooq A, Martin A, Janssen X, Wilson MG, Gibson AM, Hughes A, Reilly JJ. Longitudinal changes in moderate-to-vigorous-intensity physical activity in children and adolescents: A systematic review and meta-analysis. Obes Rev. 2020 Jan;21(1):e12953. doi: 10.1111/obr.12953. Epub 2019 Oct 23. PMID: 31646739; PMCID: PMC6916562.
García-Hermoso A, Ramírez-Vélez R, García-Alonso Y, Alonso-Martínez AM, Izquierdo M. Association of Cardiorespiratory Fitness Levels During Youth With Health Risk Later in Life: A Systematic Review and Meta-analysis. JAMA Pediatr. 2020 Oct 1;174(10):952-960. doi: 10.1001/jamapediatrics.2020.2400. PMID: 32870243; PMCID: PMC7489376.
Garcidueñas-Fimbres TE, Paz-Graniel I, Nishi SK, Salas-Salvadó J, Babio N. Eating Speed, Eating Frequency, and Their Relationships with Diet Quality, Adiposity, and Metabolic Syndrome, or Its Components. Nutrients. 2021 May 15;13(5):1687. doi: 10.3390/nu13051687. PMID: 34063439; PMCID: PMC8156274.
Garcidueñas-Fimbres TE, Paz-Graniel I, Gómez-Martínez C, Jurado-Castro JM, Leis R, Escribano J, Moreno LA, Navas-Carretero S, Portoles O, Pérez-Vega KA, Gil-Campos M, López-Rubio A, Rey-Reñones C, De Miguel-Etayo P, Martínez JA, Flores-Rojas K, Vázquez-Cobela R, Luque V, Miguel-Berges ML, Pastor-Villaescusa B, Llorente-Cantarero FJ, Salas-Salvadó J, Babio N; Childhood Obesity Risk Assessment Longitudinal Study (CORALS) study investigators. Associations Between Eating Speed, Diet Quality, Adiposity, and Cardiometabolic Risk Factors. J Pediatr. 2023 Jan;252:31-39.e1. doi: 10.1016/j.jpeds.2022.08.024. Epub 2022 Aug 24. PMID: 36027978.
Han SH, Yee JY, Pyo JS. Impact of Short Sleep Duration on the Incidence of Obesity and Overweight among Children and Adolescents. Medicina (Kaunas). 2022 Aug 2;58(8):1037. doi: 10.3390/medicina58081037. PMID: 36013503; PMCID: PMC9415582.
Hanks LJ, Simpson T, McCormick K, Casazza K. Pediatric obesity prevention: From naïve examination of energy imbalance towards strategies that influence the competition for nutrient resources among tissues. World J Clin Pediatr. 2015 Nov 8;4(4):50-4. doi: 10.5409/wjcp.v4.i4.50. PMID: 26566477; PMCID: PMC4637809.
Headid Iii RJ, Park SY. The impacts of exercise on pediatric obesity. Clin Exp Pediatr. 2021 May;64(5):196-207. doi: 10.3345/cep.2020.00997. Epub 2020 Aug 4. PMID: 32777917; PMCID: PMC8103043.
Ho FK, So HK, Wong RS, Tung KTS, Louie LHT, Tung J, Mirpuri S, Chow B, Wong WHS, Lee A, Ip P. The reciprocal relationship between body mass index categories and physical fitness: A 4-year prospective cohort study of 20 000 Chinese children. Pediatr Obes. 2020 Sep;15(9):e12646. doi: 10.1111/ijpo.12646. Epub 2020 May 12. PMID: 32395902.
Julian V, Haschke F, Fearnbach N, Gomahr J, Pixner T, Furthner D, Weghuber D, Thivel D. Effects of Movement Behaviors on Overall Health and Appetite Control: Current Evidence and Perspectives in Children and Adolescents. Curr Obes Rep. 2022 Jan 12. doi: 10.1007/s13679-021-00467-5. Epub ahead of print. PMID: 35020189.
Kapsal NJ, Dicke T, Morin AJS, Vasconcellos D, Maïano C, Lee J, Lonsdale C. Effects of Physical Activity on the Physical and Psychosocial Health of Youth With Intellectual Disabilities: A Systematic Review and Meta-Analysis. J Phys Act Health. 2019 Dec 1;16(12):1187-1195. doi: 10.1123/jpah.2018-0675. Epub 2019 Oct 2. PMID: 31586434.
Koletzko B, Fishbein M, Lee WS, Moreno L, Mouane N, Mouzaki M, Verduci E. Prevention of Childhood Obesity: A Position Paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN). J Pediatr Gastroenterol Nutr. 2020 May;70(5):702-710. doi: 10.1097/MPG.0000000000002708. PMID: 32205768.
Kontostoli E, Jones AP, Pearson N, Foley L, Biddle SJH, Atkin AJ. Age-related change in sedentary behavior during childhood and adolescence: A systematic review and meta-analysis. Obes Rev. 2021 Sep;22(9):e13263. doi: 10.1111/obr.13263. Epub 2021 Jun 3. PMID: 34080284.
Likhitweerawong N, Louthrenoo O, Boonchooduang N, Tangwijitsakul H, Srisurapanont M. Bidirectional prediction between weight status and executive function in children and adolescents: A systematic review and meta-analysis of longitudinal studies. Obes Rev. 2022 May 4:e13458. doi: 10.1111/obr.13458. Epub ahead of print. PMID: 35508917.
Lopez P, Taaffe DR, Galvão DA, Newton RU, Nonemacher ER, Wendt VM, Bassanesi RN, Turella DJP, Rech A. Resistance training effectiveness on body composition and body weight outcomes in individuals with overweight and obesity across the lifespan: A systematic review and meta-analysis. Obes Rev. 2022 Feb 21:e13428. doi: 10.1111/obr.13428. Epub ahead of print. PMID: 35191588.
Lou Y, Zhu Y, You Q, Jiang Q, Meng X, Di H, Xu H, Gan Y, Lu Z, Cao S. Maternal long working hours and offspring’s weight-related outcomes: A systematic review and meta-analysis. Obes Rev. 2022 Mar 15:e13439. doi: 10.1111/obr.13439. Epub ahead of print. PMID: 35293115.
Martin-Smith R, Cox A, Buchan DS, Baker JS, Grace F, Sculthorpe N. High Intensity Interval Training (HIIT) Improves Cardiorespiratory Fitness (CRF) in Healthy, Overweight and Obese Adolescents: A Systematic Review and Meta-Analysis of Controlled Studies. Int J Environ Res Public Health. 2020 Apr 24;17(8):2955. doi: 10.3390/ijerph17082955. PMID: 32344773; PMCID: PMC7215828.
Martins NC, Bezerra AP, Godoy ACV, Andrade EF, Gonçalves TMSV, Pereira LJ. Influence of eating with distractors on caloric intake of children and adolescents: a systematic review and meta-analysis of interventional controlled studies. Crit Rev Food Sci Nutr. 2022 Mar 28:1-10. doi: 10.1080/10408398.2022.2055525. Epub ahead of print. PMID: 35343848.
Menezes Junior F, Jesus Í, Lins Ferreira V, Wiens A, Mota J, Leite N. Effect of different interval training protocols on adiposity indicators in overweight-obese children and adolescents: a systematic review and meta-analysis. Journal of Physical Education. 2020;31. e-3161. doi:10.4025/jphyseduc.v31i1.3161.
Miller MA, Bates S, Ji C, Cappuccio FP. Systematic review and meta-analyses of the relationship between short sleep and incidence of obesity and effectiveness of sleep interventions on weight gain in preschool children. Obes Rev. 2021 Feb;22(2):e13113. doi: 10.1111/obr.13113. Epub 2020 Aug 15. PMID: 33237635.
Mittal M, Jain V. Management of Obesity and Its Complications in Children and Adolescents. Indian J Pediatr. 2021 Dec;88(12):1222-1234. doi: 10.1007/s12098-021-03913-3. Epub 2021 Oct 5. PMID: 34609654; PMCID: PMC8491444.
Orsso CE, Tibaes JRB, Rubin DA, Field CJ, Heymsfield SB, Prado CM, Haqq AM. Metabolic implications of low muscle mass in the pediatric population: a critical review. Metabolism. 2019 Oct;99:102-112. doi: 10.1016/j.metabol.2019.153949. Epub 2019 Jul 23. PMID: 31348927.
Pate RR, Hillman CH, Janz KF, Katzmarzyk PT, Powell KE, Torres A, Whitt-Glover MC; 2018 PHYSICAL ACTIVITY GUIDELINES ADVISORY COMMITTEE*. Physical Activity and Health in Children Younger than 6 Years: A Systematic Review. Med Sci Sports Exerc. 2019 Jun;51(6):1282-1291. doi: 10.1249/MSS.0000000000001940. PMID: 31095085; PMCID: PMC6527328.
Ramírez-Coronel AA, Abdu WJ, Alshahrani SH, Treve M, Jalil AT, Alkhayyat AS, Singer N. Childhood obesity risk increases with increased screen time: a systematic review and dose-response meta-analysis. J Health Popul Nutr. 2023 Jan 23;42(1):5. doi: 10.1186/s41043-022-00344-4. PMID: 36691087; PMCID: PMC9869536.
Roy M, Haszard JJ, Savage JS, Yolton K, Beebe DW, Xu Y, Galland B, Paul IM, Mindell JA, Mihrshahi S, Wen LM, Taylor B, Richards R, Te Morenga L, Taylor RW. Bedtime, body mass index and obesity risk in preschool-aged children. Pediatr Obes. 2020 Sep;15(9):e12650. doi: 10.1111/ijpo.12650. Epub 2020 May 6. PMID: 32372572; PMCID: PMC7745736.
Ruzicka EB, Darling KE, Sato AF. Controlling child feeding practices and child weight: A systematic review and meta-analysis. Obes Rev. 2021 Mar;22(3):e13135. doi: 10.1111/obr.13135. Epub 2020 Aug 24. PMID: 32840023.
Schwartz C, King NA, Perreira B, Blundell JE, Thivel D. A systematic review and meta-analysis of energy and macronutrient intake responses to physical activity interventions in children and adolescents with obesity. Pediatr Obes. 2017 Jun;12(3):179-194. doi: 10.1111/ijpo.12124. Epub 2016 Feb 24. PMID: 26916833.
Sehn AP, Brand C, Welser L, Gaya AR, Agostinis-Sobrinho C, Cristi-Montero C, de Mello ED, Reuter CP. Neck circumference and cardiometabolic risk in children and adolescents: the moderator role of cardiorespiratory fitness. BMC Pediatr. 2021 May 17;21(1):234. doi: 10.1186/s12887-021-02696-y. PMID: 34001053; PMCID: PMC8127299.
Sejbuk M, Mirończuk-Chodakowska I, Witkowska AM. Sleep Quality: A Narrative Review on Nutrition, Stimulants, and Physical Activity as Important Factors. Nutrients. 2022 May 2;14(9):1912. doi: 10.3390/nu14091912. PMID: 35565879; PMCID: PMC9103473.
Skinner J. Comparison of Children and Adults During Exercise. ACSM’s Health & Fitness Journal. 2021;25(4):29-32. Doi:10.1249/FIT.0000000000000686
Spalding KL, Arner E, Westermark PO, Bernard S, Buchholz BA, Bergmann O, Blomqvist L, Hoffstedt J, Näslund E, Britton T, Concha H, Hassan M, Rydén M, Frisén J, Arner P. Dynamics of fat cell turnover in humans. Nature. 2008 Jun 5;453(7196):783-7. doi: 10.1038/nature06902. Epub 2008 May 4. PMID: 18454136.
Stich FM, Huwiler S, D’Hulst G, Lustenberger C. The Potential Role of Sleep in Promoting a Healthy Body Composition: Underlying Mechanisms Determining Muscle, Fat, and Bone Mass and Their Association with Sleep. Neuroendocrinology. 2021 Jul 27. doi: 10.1159/000518691. Epub ahead of print. PMID: 34348331.
Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH, Yanovski JA. Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017 Mar 1;102(3):709-757. doi: 10.1210/jc.2016-2573. PMID: 28359099; PMCID: PMC6283429.
Tarp J, Child A, White T, Westgate K, Bugge A, Grøntved A, Wedderkopp N, Andersen LB, Cardon G, Davey R, Janz KF, Kriemler S, Northstone K, Page AS, Puder JJ, Reilly JJ, Sardinha LB, van Sluijs EMF, Ekelund U, Wijndaele K, Brage S; International Children’s Accelerometry Database (ICAD) Collaborators. Physical activity intensity, bout-duration, and cardiometabolic risk markers in children and adolescents. Int J Obes (Lond). 2018 Sep;42(9):1639-1650. doi: 10.1038/s41366-018-0152-8. Epub 2018 Jul 13. Erratum in: Int J Obes (Lond). 2019 Nov;43(11):2346. PMID: 30006582; PMCID: PMC6160399.
van Ekris E, Altenburg TM, Singh AS, Proper KI, Heymans MW, Chinapaw MJ. An evidence-update on the prospective relationship between childhood sedentary behaviour and biomedical health indicators: a systematic review and meta-analysis. Obes Rev. 2016 Sep;17(9):833-49. doi: 10.1111/obr.12426. Epub 2016 Jun 3. Erratum in: Obes Rev. 2017 Jun;18(6):712-714. PMID: 27256486.
Vargas-Alvarez MA, Navas-Carretero S, Palla L, Martínez JA, Almiron-Roig E. Impact of Portion Control Tools on Portion Size Awareness, Choice and Intake: Systematic Review and Meta-Analysis. Nutrients. 2021 Jun 9;13(6):1978. doi: 10.3390/nu13061978. PMID: 34207492; PMCID: PMC8229078.
Westerterp KR. Changes in physical activity over the lifespan: impact on body composition and sarcopenic obesity. Obes Rev. 2018 Dec;19 Suppl 1:8-13. doi: 10.1111/obr.12781. PMID: 30511504.
Westerterp KR, Yamada Y, Sagayama H, Ainslie PN, Andersen LF, Anderson LJ, Arab L, Baddou I, Bedu-Addo K, Blaak EE, Blanc S, Bonomi AG, Bouten CVC, Bovet P, Buchowski MS, Butte NF, Camps SGJA, Close GL, Cooper JA, Das SK, Cooper R, Dugas LR, Ekelund U, Entringer S, Forrester T, Fudge BW, Goris AH, Gurven M, Hambly C, El Hamdouchi A, Hoos MB, Hu S, Joonas N, Joosen AM, Katzmarzyk P, Kempen KP, Kimura M, Kraus WE, Kushner RF, Lambert EV, Leonard WR, Lessan N, Martin CK, Medin AC, Meijer EP, Morehen JC, Morton JP, Neuhouser ML, Nicklas TA, Ojiambo RM, Pietiläinen KH, Pitsiladis YP, Plange-Rhule J, Plasqui G, Prentice RL, Rabinovich RA, Racette SB, Raichlen DA, Ravussin E, Reynolds RM, Roberts SB, Schuit AJ, Sjödin AM, Stice E, Urlacher SS, Valenti G, Van Etten LM, Van Mil EA, Wells JCK, Wilson G, Wood BM, Yanovski J, Yoshida T, Zhang X, Murphy-Alford AJ, Loechl CU, Luke AH, Pontzer H, Rood J, Schoeller DA, Wong WW, Speakman JR; International Atomic Energy Agency Doubly Labeled Water database group. Physical activity and fat-free mass during growth and in later life. Am J Clin Nutr. 2021 Nov 8;114(5):1583-1589. doi: 10.1093/ajcn/nqab260. PMID: 34477824; PMCID: PMC8574623.
Wiersma R, Haverkamp BF, van Beek JH, Riemersma AMJ, Boezen HM, Smidt N, Corpeleijn E, Hartman E. Unravelling the association between accelerometer-derived physical activity and adiposity among preschool children: A systematic review and meta-analyses. Obes Rev. 2020 Feb;21(2):e12936. doi: 10.1111/obr.12936. Epub 2019 Dec 13. PMID: 31833645; PMCID: PMC7050502.
Wood AC, Blissett JM, Brunstrom JM, Carnell S, Faith MS, Fisher JO, Hayman LL, Khalsa AS, Hughes SO, Miller AL, Momin SR, Welsh JA, Woo JG, Haycraft E; American Heart Association Council on Lifestyle and Cardiometabolic Health; Council on Epidemiology and Prevention; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; and Stroke Council. Caregiver Influences on Eating Behaviors in Young Children: A Scientific Statement From the American Heart Association. J Am Heart Assoc. 2020 May 18;9(10):e014520. doi: 10.1161/JAHA.119.014520. Epub 2020 May 11. Erratum in: J Am Heart Assoc. 2020 May 18;9(10):e014551. PMID: 32389066; PMCID: PMC7660848.
Yuan SQ, Liu YM, Liang W, Li FF, Zeng Y, Liu YY, Huang SZ, He QY, Quach B, Jiao J, Baker JS, Yang YD. Association Between Eating Speed and Metabolic Syndrome: A Systematic Review and Meta-Analysis. Front Nutr. 2021 Oct 20;8:700936. doi: 10.3389/fnut.2021.700936. PMID: 34746200; PMCID: PMC8564065.
Zhang P, Tang X, Peng X, Hao G, Luo S, Liang X. Effect of screen time intervention on obesity among children and adolescent: A meta-analysis of randomized controlled studies. Prev Med. 2022 Apr;157:107014. doi: 10.1016/j.ypmed.2022.107014. Epub 2022 Mar 3. PMID: 35248682.

Lesson 13: Child and Adolescent – Feeding Behaviors, Sleep, and Exercise Considerations

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