Stress Eating: A Cause of Obesity in Early Childhood

1. Stress Eating: A Cause of Obesity in Early Childhood Julie C. Lumeng, MD University of Michigan Center for Human Growth and Development Department of Pediatrics

2. Increase in Childhood Obesity

3. Increase in Child Obesity by Race and Socioeconomic Status Strauss RS, Pollock HA, Epidemic increase in childhood overweight, 1986 – 1998. JAMA 286(22). 2845-2848, 2001.

4. Obesity Prevalence Among 3- to 5-year-olds, Poor Children v. National Sample (2003) M Feese et al. Prevalence of Obesity in Children in Alabama and Texas Participating in Social Programs. JAMA 289. 1780 – 1781; 2003.

5. Prevalence of obesity among children aged 2-19 years, by poverty income ratio Source: 2005-2008 National Health and Nutrition Examination Survey

6. How Many Children are Poor? • 1 in 3 Americans are low-income (<200% FPL) • 12% of Americans are poor (<100% FPL) • 43% of preschool-aged US children are low-income • 21% of preschool-aged children are ‘poor’ • Michigan ranked 30th among the states for overall child well-being • Between 2000 and 2009 the Michigan child poverty rate increased from 14 to 23%

7. What Causes Childhood Obesity?

8. “I've long suspected that rapidly growing rates of childhood obesity in the United States may be tied, at least in part, to the fact that American children in general seem more out of control and ill-behaved than ever. And that's because their parents seem more ineffective and less likely to tell their children "no" than ever. You've seen it. The screaming, crying, foot-stomping little kids yelling at their parents and making demands in the mall, the grocery store, and virtually every restaurant one enters. It is not particularly surprising kids try that stuff -- what's stunning is watching the impotent, terrified parents looking like deer caught in headlights as it's happening.” – one journalist

9. Parenting Style

10. Authoritarian Neglectful Permissive % obese Authoritative *Adjusted for income-to-needs ratio and race K Rhee, JC Lumeng, et al. Parenting Styles and Overweight Status in First Grade. Pediatrics (117). 2047-2054. 2006.

11. Media Response • “Strict Parenting Raises Risk of Childhood Obesity” • “How Parents Mold Their Children’s Weight” (NYT) • “Do Very Strict Parents Raise Fat Kids” (CBS) • “Insensitive Parents, Chubby Children” • “Study: Mean, Maniacal Mom Made you Fat” • “It’s All Our Fault Anyhow”

12. Eating Behaviors of Children in Poverty: Teachers’ Descriptions • They are always worried because they want seconds and thirds. It’s like we’re holding food back from them. They’re afraid the food’s going to be gone. • They’re so worried they’re not gonna get enough. • Our children are very anxious and very hungry. • I think some are from more chaotic homes - the ones that grab two hands into the chicken nuggets trying to make sure they have enough food. • Sometimes my kids get sick [vomit] because they are that hungry -- shovel, shovel, shovel. Lumeng et al, 2008, Journal of Nutrition Education and Behavior

13. Stress, Self-Regulation, Eating Behavior, and Obesity

14. Stress, Cortisol, and Eating • Stress increases emotional eating and obesity • Children who are less able to cope with stress are more likely to obese • Stress increases cortisol • Cortisol increases appetite • Stress shifts food preferences to comfort food (foods high in added sugars and fats) via cortisol • Comfort food dampens the stress hormone axis in the brain thereby making people ‘feel better’

15. Healthy Patterns of Cortisol • Strong daily pattern • Peak in the morning • Decrease through the day • Reactions to stress • Peak within about 10-45 minutes • Decline over about 40-90 minutes 7am

16. Normal v. Abnormal Patterns of Daily Cortisol

17. Normal v. Abnormal Patterns of Cortisol Reaction to Stress

18. Theory of how daily cortisol patterns could become abnormal Stressful Events Cortisol Stress Response (Reactivity) Cortisol Diurnal Pattern Normal Hyper Hypo Age

19. The Hypothesized Pathways Abnormal patterns of daily cortisol and cortisol reactivity to stress ↑ obesity ↑ Food tantrums ↑ Eating in the absence of hunger ↑ Consumption of comfort food

20. Stress and Eating: Food as Self-Regulation Strategy for Children • Comfort foods are calming ( emotional, physiological arousal) • Emotional eating, and stress physiology, associated with weight gain in adults • Does stress (cortisol) relate to eating behavior and weight gain in very young children?

21. Appetite, Behavior, and Cortisol Study ABC-Preschool (n = 381)ABC-Toddler (n = 250) Funded by NIH and American Heart Association, 2009-2016

22. Study Designs • Daily salivary cortisol and cortisol reactivity to stress • Questionnaire-based measures of dietary intake, emotion regulation, eating behavior, family environment, stress, sleep • Behavioral measures of eating in the absence of hunger and response to stressors

23. Eating in the Absence of Hunger (EAH) • A behavioral style or “phenotype” • relatively stable in individual children • believed to be genetic • Children with low EAH • once they are satiated, are relatively unresponsive to prompts to eat from the environment • Children with high EAH • eat in response to social cues in the environment • eat when they are not hungry • more likely to be obese

24. EAH Protocol

25. EAH Foods

26. Results: Weight Status and Cortisol

27. Self-Regulation in Response to Stress • Video removed

28. Preliminary Results: Cortisol Reactivity to Stress

29. Ability to Delay Gratification • Video removed

30. Head Start Exposure and BMI Lumeng and Frisvold, Academic Pediatrics, 2010

31. Mechanism if Head Start Association with BMI • Healthy meals • Increased physical activity • Reduced screen time • Improved sleeping schedules • More structure and less snacking • Reduced food insecurity and more food resources for the families • More resources for families in general and reduced parenting stress • Less stress and better emotion regulation for children Lumeng and Reischl, NIDDK R21

32. The Growing Healthy Study • 600 low-income preschool-aged children and their parents • 3 Head Start agencies in the Michigan • Jackson Community Action Agency (Jackson and Hillsdale Counties) • Michigan Family Resources (Kent County) • EightCAP (Gratiot, Ionia, Isabella, Montcalm) Funded by USDA, 2011-2016

33. The Interventions:POPS: Parents of Preschoolers SeriesIYS: Incredible Years Series

34. 3 Study Arms

35. Appetitive vs. Self-RegulatoryInfluences on Eating Behavior • Appetitive • “Food love” • How hard are you willing to work to get food • Self-Regulatory • Inhibit an impulse • Maintain attention • Future vs. “now” focused

36. Appetitive vs. Self-RegulatoryInfluences on Eating Behavior

37. Decision Fatigue • Deteriorating quality of decisions made after a long session of decision making • Judges make poorer decisions later in the day • Poor impulse control, poor self-regulation • People living in poverty experience decision fatigue • Stress reduces self-regulation capacity

38. What Do Head Start Moms Think? • 1-hour semi-structured interviews • “Tell me about dinnertime in your house?” • “How were you fed growing up?” • “What has weight been like for you?” • “What causes children to be overweight?”

39. “I was not fed well growing up, and I’m doing it better for my children. I’m a good mother. I put a lot of effort in. I care more and I try more.”

40. “My mom never really cooked like lasagna and stuff unless it was like the Stouffer’s . . . I learned how to cook lasagna all by myself now. And it’s so much better than Stouffer’s. But, she tried doin’ the quick and easy stuff.” --- mother and child normal weight • “Dinner, what it is with me and [my child] is nothing like it was with my family. When I was a kid we didn’t have dinners like that. ‘Here’s a hot dog. Here’s a sandwich. Eat it.’ You know? It’s kinda like that. Not with me and my daughter. I make dinner. I don’t throw a hot dog at her and say, ‘Here you go. Eat that. You’re good.’ No. I don’t do that. I just feel I wasn’t…I wish things would have been different for me, but it wasn’t.” --- mother and child obese

41. “My dad raised me by himself. Um, and he had a gambling problem. There was a bar just down the road. So, from like, 10 and up, um -- I don’t remember much from 10 and down -- I fed myself.” --- mother obese, child weight status unknown • “I always make sure my kids have breakfast, lunch, and dinner. My dad never did that, he, just, fend for yourself really, so, that’s, that’s one thing I do. I make sure that they eat and I make sure that we eat together.” --- mother obese, child weight status unknown

42. “Children are overweight because their parents don’t care about them.”

43. “I definitely blame overweight children on the parents. One hundred percent . . .I think it’s because they’re not educated, because they don’t know any better, because they’re feeding them things that are making [them] overweight and not giving them a healthy diet. Um, too much fast food. Um, a lot of parents just don’t care. I mean, honestly, there’s a lot of parents that just don’t care…Um, exercise, you know, some, parents, feed their kids fat and let them be lazy in front of the TV all day, every day. Don’t have them participating in sports. Um, I think children are overweight because of parents neglecting to do their jobs the way that they should, and [not] caring about their weight and their health.” --- mother and child normal weight

44. “[Children are overweight] if they have a parent that just lets them sit around and eat and watch TV.” --- mother obese, child obese • “The mothers give them Twinkies, candy and ice cream and – everyday, this is an everyday thing -- cookies and, you know, to me that’s what causes a child to be overweight.” --- mother and child obese

45. “The terms overweight and obese are offensive. The words describe people who are ugly, lazy, unmotivated, depressed and do not care about themselves.”

46. “Fat. Heavy. Disgusting.”- Overweight, white • “Obese is very, very fat, kind of grotesque, um . . . someone that has completely let themselves go.”- Obese, white • “Overweight is somebody that you can tell that is fat, lazy, and is not active at all.” - Normal weight, white • “I think it’s like, kind of big, lazy . . . they want to eat a lot.”- Obese, biracial • “Not caring about yourself anymore and really not taking initiative.” –Obese, black • “I think the majority of the [obese] people are probably miserable with themselves.” –Obese, white

47. Implications • Mothers’ belief that children are obese due to inept or neglectful parenting • May contribute to their rejection of the diagnosis in their own child • Mothers may simply not be able to reconcile the idea that their own child could be obese when they view their own parenting as loving, attentive, and competent

48. Next Steps? • Reduce stigma • Reduce “parent blaming” • More than nutrition education, more than just information • Reduce cues to eat (appetitive drive) • Improve self-regulation capacity for children AND mothers • Understand which components of the Head Start setting are most effective at preventing obesity • Provide resources and support • Start younger – in Early Head Start (and before) • Researchers need to understand the biology better