Maternal child nutrition practices and pediatric overweight/obesity in the united states and chile: A comparative study
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(2) Nutrition Practices and Pediatric Overweight/Obesity to overweight/obesity and lifelong health consequences (Daniels, Jacobson, McCrindle, Eckel, Sanner, 2009). Research is needed that adds to our knowledge of the underlying and modifiable risk and protective factors for pediatric overweight/obesity that can lead to effective prevention programs. In the case of school-age children, potentially modifiable factors include the nutrition practices of both school-age children and their mothers. Previous research in developed countries has demonstrated that mothers' child-feeding practices are correlated with children's food preferences, energy expenditure, and weight status (Birch & Fisher, 2000). No comparative studies were found that compared maternal–child nutrition practices between developed countries and those experiencing the nutrition transition. A next necessary step in the global effort to identify modifiable risk and protective factors for childhood obesity is to identify similarities and differences that may exist in maternal and child nutrition practices across countries to develop targeted strategies that will support health promotion and obesityrelated disease prevention. The purpose of this study was to compare maternal and child nutrition practices within the context of overweight/obesity for school-age children in the United States and Chile.. Methods This descriptive, cross-sectional, comparative study was conducted with school-age children and their mothers from two capital cities: Washington, DC, and Santiago, Chile. Boys and girls, with ages 9 to 12 years, from two schools in each of the study cities were invited to participate. Both study sites in Washington, DC, were elementary schools in the city's public school system. One school in Chile was a private Montessori school that enrolls students from preschool through secondary school, whereas the second one was a public school that enrolls elementary and middle school students. After completion of procedures for child assent and parental consent, the children participated in anthropometric measurements and completed pencil-and-paper study instruments. In addition, they delivered the study instruments to their mothers and returned the completed forms in their backpacks within 1 week after receiving them. Only children and mothers who completed the consent forms and measurements were included in the study. The final study sample was composed of 246 children (United States = 125, Chile = 121) and 217 mothers (United States = 116, Chile = 101). The George Mason University Human Subjects Review Board, the Ethics Committee of the School of Nursing at Pontificia Universidad Católica de Chile, and committees consisting of school administrators for the participating schools approved the study protocol. The researchers maintained confidentiality of all data. Children's. e45 privacy during anthropometric measurements was maintained (Moore et al., 2011).. Instruments Maternal nutrition practices. This variable was operationalized with the Moore Index of Nutrition—Parent (MIN-P), a questionnaire available in English and Spanish (Moore, 2008), which is composed of 50 items in a five-choice, Likert scale format. Higher scores signify healthier maternal nutrition practices implemented on behalf of their children. The preface for all instrument items is “I encourage my child to…,” with subsequent items such as “try new foods,” “ask me questions about which foods are healthy,” or “eat a variety of foods.” Experts established content validity of the instrument. Alpha coefficients for the instrument in previous studies were .75 for the English version with U.S. mothers and .82 for the Spanish version with Nicaraguan mothers (Moore et al., 2005). The instruments were adapted for Chilean Spanish speakers by nursing faculty at Universidad Catόlica in Santiago, Chile. In this study, alpha coefficients were .98 for mothers of children in the United States who completed the English version and .89 for mothers of Chilean children who completed the Spanish version of the measure. Child nutrition practices. This variable was operationalized with the Moore Index of Nutrition—Child (MIN-C; Moore, 2008). Like the parallel parent measure, this instrument is available in English and Spanish and is composed of 50 items in a five-choice Likert scale format that measures frequency of nutrition behaviors. Higher scores signify healthier child nutrition practices. Children's items parallel mothers' items such as “I try new foods,” “I ask questions about which foods are healthy,” or “I eat a variety of foods.” Experts established content validity of the instrument (Moore et al., 2005). Alpha coefficients for the instrument in previous studies were .83 for the English version with U.S. children and .91 for the Spanish version with Nicaraguan children (Moore et al., 2005). The instruments were adapted for Chilean Spanish speakers by nursing faculty at Universidad Catόlica in Santiago, Chile. Content validity of the instrument was established using experts (Moore et al., 2005). Alpha coefficients for this study were .94 for children in the United States who completed the English version and .89 for Chilean children who completed the Spanish version. Overweight/obesity. Children's weight status was operationalized as their BMI. Epi Info was used to calculate BMI percentiles. The program divides weight in kilograms by the square of height in meters (kg/m 2) and assigns values using Center for Disease Control and Prevention's children's BMI charts for age and gender (Kuczmarski et al., 2002; Kuczmarski et al., 2000; NCHS, 2000). The designations of weight were linked with BMI percentile values and categorized as underweight (b5th percentile), normal weight (5th to b85th percentile), overweight (85th to b95th percentile), and obese (95th to 100th percentile). The researchers measured weight without shoes using a.
(3) e46. J.B. Moore et al.. bioelectrical impedance scale. Height measurements were determined without shoes using a portable anthropometer.. Data Analysis T tests, Chi-square, and analysis of variance (ANOVA) were conducted to identify significant differences between U.S. and Chilean children on both demographic and study variables. Correlations were used to examine the relationships between the children's BMI status and maternal and child nutrition practices. Prediction of children's MIN-C scores from mothers' MIN-P scores was examined using simple linear regression.. Results Demographic characteristics of the study sample are depicted in Table 1. There were significant differences in ethnicity between countries (χ 2 = 241, p b .001). All of the children in Chile were considered Hispanic, whereas 89.6% of children in the U.S. sample were African American. There were significant differences between countries for mothers' Table 1. Demographic Characteristics of Study Sample Characteristics. Child's age 9 years 10 years 11 years 12 years Child's gender Boys Girls Child's race/ethnicity African American Hispanic Other Missing Mother's age b30 years 31–40 years 41–50 years 51–60 years Missing Mother's education Did not complete high school High school diploma Some college College degree Graduate school Missing. United States, n (%). Chile, n (%). 16 (12.8) 56 (44.8) 47 (37.6) 6 (4.8). 21 41 43 16. (17.4) (33.8) (35.5) (13.2). 46 (36.8) 79 (63.2). 52 (43.0) 69 (57.0). age (t = 4.47, p b .001), with Chilean mothers being older (x̄ = 39.57) than U.S. mothers (x̄ = 35.56). Mother's education was significantly different in the two countries (χ 2 = 17.40, p = .002), with more Chilean mothers having completed college. No significant differences were found between countries for children's age or gender. As seen in Table 2, U.S. and Chilean mothers demonstrated significant differences in the nutrition practices they exercised on behalf of their school-age children. Specifically, the mean score for U.S. mothers on the MIN-P reflected fewer healthy nutrition practices compared with their Chilean counterparts. The children in the two countries were found to be similar in their performance on the MIN-C. For both mothers' and children's groups, the mean nutrition scores reflect a midrange performance of healthy nutrition practices. There were significant correlations between scores on the MIN-C and the MIN-P for children and mothers in both the United States (r = .233, p = .014) and Chile (r = .344, p ≤ .001). No significant correlations were found between children's BMI and either maternal or child nutrition practices in these countries. A simple regression was run on MIN-P and MIN-C. For the U.S. sample, MIN-P was a significant predictor of MIN-C (F = 6.249, p = .014); however, MIN-P predicted only 5.4% of the variance in MIN-C. In the Chilean sample, MIN-P was a significant predictor of MIN-C (F = 13.29, p b .001); MIN-P predicted 11.8% of the variance in MIN-C. The percentage of children in each weight category from normal to obese is displayed in Table 3. With respect to overweight/obesity, 57.3% of the school-age children in the U.S. sample were found to have a BMI above or on the 85th percentile, compared with 37.5% for the children in Chile. The U.S. group had a significantly higher proportion of children in the 95th percentile or above (F = 6.426, p = .014).. Table 2 Maternal (MIN-P) and Child (MIN-C) Nutrition Practices Scores and BMI: United States and Chile. 112 (89.6) 121 (100). United States. 8 (6.4) 5 (4.0) 23 (19.8) 55 (47.4) 20 (17.2) 6 (5.2) 12 (10.3). 2 52 43 4. (2.0) (51.5) (42.6) (4.0). 6 (5.2) 37 (31.9) 31 (26.7) 26 (22.4) 7 (6.0) 9 (7.8). 8 37 8 39 3 6. (7.9) (36.6) (7.9) (38.6) (3.0) (6.0). Note: Because of statistical rounding, not all totals equal 100%. United States: children = 125, mothers = 116; Chile: children = 121, mothers = 101.. Maternal nutrition practices (MIN-P) M SD Range Child nutrition practices (MIN-C) M SD Range BMI percentiles M SD Range. Chile. t. p. n = 116. n = 101. 164.59 33.67 59–215 n = 120. 175.73 23.19 116–228 n = 121. 158.13 23.87 92–215 n = 124 76.99 26.24 0.43–99.59. 157.46 0.21 .833 24.79 103–221 n = 120 71.26 1.79 .075 23.80 5.08–98.89. 2.87 .005. Note: United States: children = 125, mothers = 116; Chile: children = 121, mothers = 101..
(4) Nutrition Practices and Pediatric Overweight/Obesity Table 3 ANOVA Comparison of BMI Percentiles for Children in the United States (n = 125) and Chile (n = 121) U.S. Chilean Children, Children, n (%) n (%). F. p. Normal weight (5th to 52 (42.6) 75 (62.5) 1.158 .284 b85th percentile) Overweight (85th to 27 (22.1) 32 (26.7) 0.007 .931 b95th percentile) Obese (≥95th percentile) 43 (35.2) 13 (10.8) 6.426 .014 Note: Because of statistical rounding, not all percentages equal 100%. Because of missing data, not all totals equal study totals.. Using ANOVA, there were no significant differences by U.S. mothers' level of education for their MIN-P score (F = 1.875, p = .121), their children's MIN-C score (F = 2.273, p = .067), or children's BMI (F = 0.374, p = .827). For Chilean mothers, there was no significant difference by mothers' level of education for their children's MIN-C score (F = 0.787, p = .504). There were significant differences by mothers' level of education for MIN-P score (F = 3.087, p = .031) and children's BMI (F = 3.125, p = .030). Mothers with high school diplomas scored significantly lower than mothers with some college (p = .02) on the MIN-P. Children's BMI was significantly lower in those whose mothers had college or graduate degrees (x̅ = 64.564) than those whose mothers had high school diplomas (x̅ = 80.054; p = .02).. Discussion This study provides new evidence that may advance clinical practice related to the global epidemic of childhood overweight/obesity. The significant finding that children in the United States and Chile had remarkably similar levels of nutrition practices is important. Traditionally, Chilean diets have included healthy choices of fish, fruits, and vegetables. The country's nutrition transition has been accompanied, however, by a proliferation of fast-food restaurants and other less healthy food options similar to the diet in the United States. Despite the potential differences in these two geographically diverse regions, the school-age children reported common behaviors that, on average, demonstrated substantial need for improvement. Likewise, mothers' nutrition practices for their children need improvement. The finding that U.S. and Chilean children's nutrition scores were highly correlated with their mothers' scores suggests that nurses, nutritionists, and other health care providers should place emphasis on the mother–child dyad, rather than solely on the individual students, when designing school-based programs. The link between mothers and children in this study suggests that as children make. e47 decisions about their own nutrition practices, they may be highly influenced by maternal nutrition practices. By empowering mothers' with obesity-prevention information and strategies, the indirect effect may be the improvement of child nutrition practices and an improved BMI. A high percentage of children in both national groups were found to be overweight/obese. The proportion that was so classified in Washington, DC, is alarmingly high and portends a high risk for early onset of Type 2 diabetes, elevated serum lipid levels, hypertension, asthma, and psychosocial problems (Fagot-Campagna, Saadinem, Flegal, & Beckles, 2000; Ford, 2005; Swatz & Puhl, 2003). Further, accumulating evidence suggests that overweight/obesity in childhood is predictive of obesity through the adult years (Monteiro & Victora 2005; Nader et al., 2006). Although the study findings illustrate that the need for intervention is urgent in this U.S. capital city, they are also a signal for nurses in countries experiencing the nutrition transition to accelerate plans to stave off similar prevalence rates as more children from these countries consume more foods with high fat, low fiber, increase consumption of sugar sweetened beverages, and participate in less physical activity (Albala et al., 2008; Jaimovich, Campos, Campos, & Moore, 2009; Mulder et al., 2009). The reason for the lack of a significant association found between the nutrition practices and childhood weight status is not clear. There may have been some confounding factors that were not included in our analysis. For instance, it would have been informative to have data about the socioeconomic status of the families in the study. The children who attended the private school in Chile may have had some social advantages that influence nutrition practices and weight status, whereas the children in Washington, DC, may have had fewer of these advantages. Future research may evaluate the interaction between maternal–child nutrition practices and socioeconomic factors. This study had some other important limitations. Measures of some factors that comprise the nutrition transition were not included. For instance, future study may measure daily physical activity with a pedometer or daily log. It would be particularly informative to include data about the amount of screen time, that is, television viewing and computer usage, that may consume a substantial portion of a child's day. It would also be useful to assess family history of overweight/obesity, particularly maternal weight status. Recent research has demonstrated a link between maternal prepregnancy weight and childhood overweight/obesity (Kitsantas, Pawloski, & Gaffney, 2010). In addition to these limitations, this study has some important strengths. First, the weight status for each child was determined by standardized clinical measurement and therefore not subject to the self-report bias that often weakens obesity studies (Kolbo et al., 2006). Second, the measures of maternal and child nutrition practices (MIN-P and MIN-C) were found to be easily understood and completed in both English and Spanish. This experience.
(5) e48 supports the feasibility of the measures for clinicians and researchers who seek to evaluate the effectiveness of interventions designed to improve nutrition practices and decrease obesity among school-age children. Third, the study was innovative in that it compared the nutrition practices of mothers and children in a developed country with their counterparts in a country experiencing nutrition transition. Despite their geographic, cultural, and demographic differences, both countries share a substantial problem, namely, growing rates of childhood overweight/obesity.. Conclusion The findings of this study suggest that future research and practice should focus on the development of interventions that capitalize on the similarities found between mother and child nutrition practices. Data suggest that children adhere to nutrition practices similar to those implemented by their mothers. This is similar to previous findings by Birch and Fisher (2000) about the relationship of mothers' feeding behavior to their children's weight, activity, and food choices. By addressing the mother–child dyad as a unit rather than focusing on the child as an individual student, Interventions are likely to have a more powerful impact.. Acknowledgments The authors acknowledge the nursing faculty at the Universidad Catόlica in Santiago, Chile, especially Maria Sylvia Campos; the administrators and Paola Perez at the College of Cardinal Raul Silva Henriquez; the administrators and Nicole Garay, Consuelo Quintanilla, and Muriel Poirot at Pucalan College; Kathleen Chappell, Doctoral Student at George Mason University; and the College of Health and Human Services, the Center for Global Studies, and the Epsilon Zeta Chapter of Sigma Theta Tau at George Mason University, Fairfax, VA, for funding this project.. References Albala, C., Ebbeling, C., Cifuentes, M., Lera, L., Bustos, N., & Ludwig, D. (2008). Effects of replacing the habitual consumption of sugarsweetened beverages with milk in Chilean children. American Journal of Clinical Nutrition, 88, 605–611. Albala, C., Vio, F., Kain, J., & Uauy, R. (2002). Nutrition transition in Chile: Determinants and consequences. Public Health Nutrition, 5, 123–128. Birch, L. L., & Fisher, J. O. (2000). Mothers' child-feeding practices influence daughters; Eating and weight. American Journal of Clinical Nutrition, 71, 1054–1061. Daniels, S. R., Jacobson, M. S., McCrindle, B. W., Eckel, R. J., & Sanner, B. M. (2009). American Heart Association childhood obesity research summit: Executive summary. Circulation, 119, 2114–2123.. J.B. Moore et al. Fagot-Campagna, A., Saadinem, J. B., Flegal, K. M., & Beckles, G. L. (2000). Emergence of Type 2 diabetes mellitus in children: Epidemiologic evidence. 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Maternal prepregnancy body mass index in relation to Hispanic preschooler overweight/obesity. European Journal of Pediatrics, 169, 1361–1368. Kolbo, J., Penman, A., Meyer, M., Speed, N., Molaison, E., & Zhang, L. (2006). Prevalence of overweight among elementary and middle school students in Mississippi compared with prevalence data from the Youth Risk Behavior System. Prevention of Chronic Disease, 3, 1–10. Retrieved from http://www.cdc.gov/PCD/issues/2006/jul/05_0150.htm. Kuczmarski, R., Ogden, C., Grummer-Strawn, L., Flegal, K., Guo, S., Wei, R., et al. (2000). CDC growth charts: United States. Advance Data, 1–27. Kuczmarski, R., Ogden, C., Guo, S. S., Grummer-Strawn, L. M., Flegal, K. M., Mei, Z., et al. (2002). 2000 CDC growth chart for the United States: Methods and development. Vital Health Statistics 11, 246, 1–190. Lissau, I., Overpeck, M. D., Ruan, W. J., Due, P., Holstein, B. E., & Hediger, M. L. and the Health Behaviour in School-aged Children Obesity Working Group. 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(6) Nutrition Practices and Pediatric Overweight/Obesity Spurgeon, D. (2002). Childhood obesity in Canada has tripled in past 20 years. British Medical Journal, 324, 1416. Swatz, M. B., & Puhl, R. (2003). Childhood obesity: A societal problem to solve. Obesity Reviews, 4, 57–71. Willms, J. D., Tremblay, M. S., & Katzmarzyk, P. T. (2003). Geographic and demographic variation in the prevalence of overweight Canadian children. Obesity Research, 11, 668–673.. e49 World Health Organization. (1998). Obesity: Preventing and managing the global epidemic: Report of a WHO consultation on obesity, Geneva, June 3–5, 1997, Program of Nutrition, Family and Reproductive Health. Geneva, Switzerland: WHO. World Health Organization. (2008). Childhood overweight and obesity. Retrieved from http://www.who.int/dietphysicalactivity/childhood/en/ index.html..
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