Key Words: Grandparents, childhood obesity, nutrition, acculturation
Running Title: Role of Grandparents in Childhood Obesity
Abstract: Childhood obesity is a public health problem in United States. Numerous factors have contributed to this situation, but one consideration that remains relatively unexplored is the influence of the grandparent on weight status of the grandchild. Studies indicate that grandparent engagement is associated with increased risk of overweight in preschoolers, but the evidence in ages 0-2 years is lacking. Recent investigations have suggested that relative weight-for-length BMI trajectory over the first 2 years is an important predictor of subsequent obesity. The aim of this paper is to summarize the literature on a) influence of grandparents’ involvement on breastfeeding behaviors in mothers and the associated obesity risk; b) effects of grandparents’ support about nutrition and cooperative co-parenting, nutrition knowledge, attitudes, beliefs and BMI on feeding practices and subsequent weight gain trajectories; c) impact of child temperament and weight status on grandparent feeding practices, and d) contribution of cultural norms and acculturation on child weight gain. Identification of grandparent characteristics associated with lower obesity risk will provide health professionals the tools to create effective interventions that incorporate grandparents as important partners in obesity prevention.
Childhood obesity is a public health problem in the United States (U.S.). According to the most recent National Health and Nutrition Examination Survey (NHANES) data of 2015-2016, the prevalence of obesity in children ages 2-5 years is 13.9% (1). For infants and toddlers from birth to age 2 years, the high-weight for recumbent length years was 8.1% in 2012 (2). A racial disparity exists, with a prevalence of high-weight for recumbent length of 6.6% for Whites, 9.4% for Hispanics and 8.4% for Blacks (2). The risk of obesity in low-income households is even greater; with 14.5% of those aged 2 to 4 years in Women, Infants and Children programs classified as obese (3).
The obesogenic environment in the U.S. and other countries has been related to the high availability, variety and portion size of food (4); an exponential increase in screen time (5); and a greater number of working women. In particular, working moms have less time for meal preparation (6) and rely more on caregivers outside the home who feed the infant (7). One consideration for increased obesity that remains relatively unexplored is the influence of the grandparent on the weight status of the grandchild in early infancy. Grandparents may have a significant impact, as epidemiological evidence suggests that obesity is transmitted across multiple generations (8, 9). It is well established that obese children tend to have grandparents and parents who also are obese. In the British Millennium Cohort of children, ages 9 months to 3 years, those who were cared for mainly by their grandparents were more likely to be overweight at the age of 3 years, compared to those who had parents that were primarily the caregivers (10). Whether this is due to genetics or environment is unknown. Yet environment must undoubtedly play a critical role, as the genes of humans have not changed significantly in the past few decades.
2. Significance and Background
According to the U.S. Census Bureau, the percentage of children living in grandparent-maintained households has doubled from 3% in 1970 to 6% in 2012 (11). In the households of the 7 million grandparents who live with grandchildren, about 2.7 million are the primary caregivers for their co-resident grandchildren (<18 years) (Figure 1). In addition, one-third of infants (11) and 30% of toddlers of working mothers have grandmother caregivers (11). This is not a relatively recent trend, as the percentage of children living with grandparents increased between 1992 and 2012 only minimally among non-Hispanic Whites (3%), Hispanics (3%) and Blacks (1%) (11). Yet, the involvement of grandparents with children of Hispanic descent has always been greater than other ethnicities, with 43% acting as care providers (11). Geographical variation of grandparent-led households also exists, with more grandchildren living in their grandparents’ home in the West coast and Southwestern U.S than other locations (11).
In the past and in traditional societies, grandmothers positively impacted nutritional status of grandchildren and augmented survival rates. Yet as societies have evolved, grandmother engagement has been associated with increased risk of child overweight (7-9, 12). Why and how does presence of a grandparent have potential adverse health effects for enhanced child weight and obesity risk? The paradox certainly merits attention in obesity prevention efforts.
Table 1 illustrates detailed findings of studies to date that have investigated associations between children living with, or cared for, by grandparents and risk of overweight/ obesity (9, 11, 13, 14, 15, 16, 17, 18, 19, 20).
In a recent systematic review by Pulgaron et al., five studies showed an adverse association between grandparents’ involvement and weight gain in children (14). In three-generation households in Japan, the risk of being overweight or obese was higher in 3-6-year olds with a grandparent (15). In contrast, Cunningham et al found no significant associations (19); while Jiang et al. reported a negative association between residence with grandparent and infant’s weight (14). Table 1 illustrates detailed findings of studies to date that have investigated associations between children living with, or cared for, by grandparents and risk of overweight/ obesity. Note that minimal research has been conducted on grandparents’ influence on child weight in children less than the age of 3 years.
Possible reasons for an increase in the risk of overweight/obesity in children could be that grandmothers influence both breastfeeding behaviors and initiation of complementary foods (Table 2).Some studies have suggested that lack of support from grandparents for breastfeeding has a negative influence on the probability of initiation (21) and duration of breastfeeding in women (22, 23, 24). In contrast, Mahoney et al. reported that grandmother’s encouragement for breastfeeding increased the likelihood of breastfeeding by 12-fold.
The effects of early introduction of complementary food by grandmothers have been investigated by a number of researchers (27, 28, 29, 30, 31). In Australia, mothers reported that older women in their house pressurised them to introduce complementary food before the age of 6 mo. (31). But none of these studies have investigated the effect of these practices on child weight.The timing of the introduction of solid food is critical because early introduction of solid food is associated with rising weight gain trajectories (32) for those weaned prior to 2 (32), 3 (33), 4 (34, 35), or 5 mo. (36). Meta-analysis studies have found an inverse association between duration of breastfeeding and risk of childhood obesity (37, 38, 39). Yet, a systematic review by Vail et al. reported that weaning between 3 and 6 months had a neutral effect on infant growth in high income countries (40). To date there remains a lack of evidence on feeding practices and weight in U.S. children younger than age 2, except for breastfeeding studies. Grandparents are likely to influence when parents introduce solid foods, as well as parents’ feeding styles and choices of what to feed. Therefore, the first two years may be a particularly important time to investigate the effects of grandparents on parental feeding practices.
3. Critical periods of weight gain during first two years
A question that arises is whether there are critical time periods during the first 2 years of life that are associated with later obesity risk, as numerous studies have indicated that weight gain during this age increases the odds of obesity in later life (41, 42, 43, 44, 45, 46, 47, 48, 49). A meta-analysis by Mei et al. documented that infant weight gain in the first-year improved prediction of obesity at age 8, as compared to a model containing birth weight, sex and mothers’ BMI (47). In fact, birth weight itself may be a risk factor for obesity (50, 51); as well as critical periods for weight gain at 4-6 (52), 6 (53) or 18-24 mo. (54); relative weight-for-length BMI trajectories (55); and rapidity of weight gain. Thus, it is important to examine the influence of grandparents on early childhood feeding practices during these critical time periods.
4.1. Influence of grandparent influence on parents’ development of child feeding practices and their impact on weight gain trajectory from 0-2 years
In preschoolers, it is known that feeding practices of the parents, such as responsiveness to hunger cues, are central to preventing child obesity. These practices include parental restriction of food intake (56, 57, 58, 59, 60, 61, 62, 63) and discouragement of eating when the child is hungry, rather than giving encouragement (64, 65). Both practices have been related to greater child weight (56, 57, 58, 59, 60, 61, 62, 63). Although parenting styles were not related to infant weight in 4-month-olds (66) it is plausible that parenting styles are not developed until the post-weaning age.
Grandparents are expected to influence child weight and obesity risk as well, directly via responsiveness to child cues during feeding as they may affect what the child is fed. Parents have reported that grandparents indulge children by feeding unhealthy foods such as sweets to gain approval (67, 68, 69), with an undermining of parental authority (sneaking snacks, disparaging comments) (70). In 217 mother-infant dyads, mothers reported that grandmother involvement in feeding increased the odds of juice consumption by 97% (71). A focus group study of 39 parents observed that grandmothers shopped for foods high in sugar and fat. Such practices by the grandparent undermine parent authority and increases the accessibility of unhealthy foods to children (72).
Yet few investigations have specifically queried the grandparents on their feeding-related behaviors. In a U.K study, grandparents scored higher (compared to the parents) on restricting child food intake due to weight concerns (73) and used food to regulate emotion (73). None of these studies, however, included child weight or examined the grandmothers’ role or level of involvement in these children’s lives. Thus, the impact of feeding practices of the grandparents on child weight remains to be elucidated.
Co-Parenting: The effect of the quality of mother-father co-parenting on health outcomes in children has been the subject of several reports (74, 75, 76). In competitive co-parenting, each parent attempts to have control of the child and places the child in the middle of conflicts. This behavior predicts impulse control by the toddler above and beyond the parental negativity of the individual or negative emotional climate of the family.
The influence of grandparents on co-parenting with the mother is less clear. When a grandparent disagreed with a parent about feeding, higher BMI z scores were documented in 5-12 yr. old of Hispanic descent (11). On the contrary, responsiveness and support of parents by a grandparent may promote healthy eating behaviors and reduce overly controlling or indulgent feeding practices associated with child overweight (77). Observational ratings of support and responsive communication in grandmother/mother interactions have been associated with increased sensitivity and responsiveness of mothers to infant cues during feeding at 6 and 9 mo. (78, 79). Additionally, expectant mothers who describe their own parents as responsive and sensitive (vs. unloving, rejecting) exhibited comparable qualities with their children at 8 (80, 81), 12 to 15 (82) and 24 mo. (83, 84) and were more likely to recognize and respond appropriately to cues of satiety by the baby and were less likely to restrict food intake (85). Thus, patterns of feeding may be transmitted across generations.
One result of cooperative co-parenting is that it may facilitate the maintenance of a structured environment at home. In a recent longitudinal analysis in UK, Anderson et al. documented that emotional self-regulation in children at the age of 3 years was a predictor of risk of obesity at age 11 (86). The incorporation of consistent daily mealtime and bedtime patterns in children was associated with an increased ability of the child to regulate his emotions and subsequently, reduce obesity risk (86). In such a scenario, grandparents can play a positive role in shaping and regulating these daily patterns, especially for those with working parents. Cooperative grandparent-parent interactions, and grandparent’s support for reducing the inconsistencies in the daily mealtime patterns of the child, could all lead to better emotion regulation in children and prevent weight gain. It is known that some grandparents assume greater responsibility than others for the child’s health, while others co-parent jointly or assist only part-time (87). The degree of involvement of grandparents with the grandchild presumably affects the quantity and nutritional quality of the food the child consumes, and ultimately, the obesity risk.
4.2. Effect of successful grandparent characteristics on eating and subsequent reduction in grandchild obesity risk
A new baby represents a window of opportunity for transmission of knowledge and eating practices across generations. At this time in life, adolescents and young adults often turn to their parents to seek assistance on how, and how much, to feed the new baby. Thus, grandparent characteristics [high diet quality, knowledge, attitudes and beliefs about nutrition; and Body Mass Index (BMI)] may influence feeding practices and subsequent weight gain trajectories in grandchildren.
The degree of nutrition knowledge of the grandparent may be critical in influencing obesity risk in the grandchild. Although knowledge of nutrition does not always translate into desirable eating behaviors, sound information is needed to plan a nutritionally adequate diet. Greater fruit and vegetable intakes of children have been linked to better nutrition knowledge of the mother (88). Table 3 shows characteristics of studies that assessed nutrition knowledge and eating behaviors of grandparents (89-100). Ganthavorn et al. observed increased consumption of fruits and vegetables by grandparents after participation in a nutrition and physical activity intervention (95). In a nutrition education program in Sierra Leone, it was observed that the percentage of grandmothers who advocated initiation of breastfeeding within an hour of birth, increased from 78% to 100% at the end of the 3 years of the program (96).
Yet translation of knowledge into action is modulated considerably by one’s beliefs. A review of qualitative studies of parents of preschoolers (100) identified beliefs about eating that promoted obesogenic behaviors. These included uses of food to shape a child’s behavior (101), perceptions that underweight is a cause for concern (102, 103). and depriving a child from eating is like starving a child (104). In an intervention tailored for mothers of young children, Freeland-Graves concluded that overweight/obese mothers who modified their eating related cognitions (attitudes/beliefs) made comparable changes in the diet quality of their 1-3year-old children (105). No reports have been found that document how grandparents affect grandchild diet quality in post weaning.
Only a few studies have investigated the effect of parent/grandparents’ BMI on the BMI of the child (106, 107). In 84 three-generational families of Native Americans and African Americans, a significant correlation was observed between BMIz scores of the child and BMI of grandparents (10). Yet, in U.S. elementary school children, grandparent involvement was associated with lower BMI z-scores in Hispanics, but not with Cubans (11). To date there is a lack of research on the influence of grandparents’ characteristics on feeding practices and weight gain in post weaning children up to 2 years.
4.4. Effects of child temperament and weight on grandparent and parent feeding practices
It is well established that child temperament and weight status affect parent feeding practices, resulting in weight gain in children (108, 109). When children are calm and easy, it is enjoyable to feed them. But fussy and irritable infants are more demanding for both grandparent and parent who may disagree about best responses to the child. Such disagreements can reduce receptiveness of the parent to advice, resulting in less grandparent responsiveness and support of parents’ feeding practices. Although previous studies have established the existence of a bidirectional relationship between parent and child (108, 109), there is a lack of research on the tri-directional effects of child temperament and weight status on parent and grandparent feeding practices.
The fussy child may be more prone to gaining weight. Slining et al. (109) reported that infant distress to limitations was associated with increased weight at 3, 6, 9, 12 and 18 mo of age and greater weight-for-length at 12 mo. In a cross-sectional investigation of 217 mothers, mothers were more likely to initiate complementary food before 4 months if they perceived their infants to be fussy (110). In a systematic review, Bergmeier et al. documented that the temperament characteristics of being difficult to feed, distress to limitations and low soothability were all significantly associated with weight gain rates in infants (111). These relationships appear to be mediated by maternal feeding practices of using food to calm a fussy or difficult child.
Infant Weight and Feeding Practices: The effect of infant’s weight on feeding practices of parents has been investigated. (112, 113). A high concern by mothers about the weight of the infant, assessed retrospectively at 3 yrs, influenced the amount and type of food fed and predicted higher fat mass in children at age 5 (112). It is well known that perceptions of grandparent and parent that “bigger is healthier” may contribute to obesogenic feeding practices of young children (114). Thus, weight status may influence grandparent and parent beliefs about child feeding practices, with subsequent effects on child diet and weight.
4.5. Influence of cultural norms, race/ethnicity and degree of acculturation on child weight
Human behavior is shaped extensively by the social and cultural environment. Transmission of cultural norms over generations can significantly influence feeding practices and child weight. Table 4 highlights studies that reported the influence of cultural norms and race/ethnicity in feeding practices and subsequent obesity risk in children (115, 116, 117, 118, 119, 120, 121). In Hispanics, mothers perceived a “chubbier” body type as ideal for infants and toddlers (122). Latino mothers have reported that child weight was reflective of parenting skills, such that a skinny child suggested a bad parent and only fat kids were perceived to be healthy (115). In African-American mothers, it was reported that it was culturally acceptable to have a large body size, as long as the child was healthy and held high self-esteem (117).
The degree of acculturation is known to significantly change breastfeeding behaviors in women (123, 124). Kimbro et al. observed that Mexican immigrants were more likely to breastfeed for longer time periods than Mexican-Americans who exhibited similar behaviors as U.S. white mothers (118). In mothers enrolled in the Women, Infant and Children’s Program, less acculturated mothers were more concerned about the weight of their children and pressurized them to eat more (125). Also, Spanish-speaking Hispanic participants had a greater tendency to use food to calm their children, as compared to those who spoke English (120). In Latino mothers living in the U.S., Sussner et al. concluded that exclusive use of the native language was associated with greater BMI in children as young as age 24 months (OR=1.94) (126). Additional research is needed to understand the influence of grandparents’ involvement on childhood obesity within the context of culture, race/ethnicity and degree of acculturation.
The birth of a new baby gives grandparents a new chance to reenter and reconnect with their adult children who typically seek parental assistance. Thus, the first two years are a unique opportunity for grandparents to promote healthy eating for children. At present, few studies that include the actual grandparent have investigated whether grandparent involvement is related to feeding practices and subsequent weight outcomes in children aged 0-2 years.
Interventions for childhood obesity are increasingly incorporating a family-focused approach. Whereas co-parenting between parents is well documented, the nature of co-parenting between parents and grandparents, (competitive or cooperative) and its influence on feeding practices and weight gain in child remains a missing link in the puzzle. A need exists to discover successful characteristics of the grandparent/parent who co-parent in triadic feeding interactions, which could promote healthy feeding practices and reduce the risk of obesity in child.
Other areas that warrant further investigation are the effect of grandparents’ healthy eating, appropriate nutrition knowledge, attitudes and beliefs about nutrition; and Body Mass Index (BMI) on child feeding practices and obesity risk at multiple time points between 3-24 months.
Finally, it is critical to investigate the relative contribution of the above factors within the context of race/ethnicity, degree of acculturation and cultural norms of the grandparents and parents. These critical barriers in obesity prevention need to be addressed in order provide child and health care professionals the tools to create robust, effective interventions that incorporate grandparents as important partners in obesity prevention.
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