Teaching Nutrition To Children Articles & Resources

The Diet and Health Knowledge Survey (DHKS), a followup to the CSFII, collected information on the nutrition knowledge, health awareness, and dietary attitudes of an adult member from a subset of CSFII households. For this study, we matched 1,825 children between 6 and 17 years of age with one of their parents or grandparents who answered the DHKS questions. Approximately 54 percent of the matched parents were mothers and 42 percent were fathers. Grandmothers or grandfathers made up the remaining 4 percent. Because many households had multiple children in the 6-17 age range, some parents were matched with more than one child. We did not examine the parental influence separately on each sibling. However, we did account for the sampling design features and weights to make our estimates representative for the . population. Our findings indicate that greater parental nutrition knowledge is associated with lower prevalence of overweight conditions among children.

More Children Are Overweight

Based on recommendations in the Pediatrics article, we categorized children with BMI values at or above the 95th percentile of CDC's age- and sex-specific BMI cutoffs as overweight Children with BMI values at or above the 85th percentile cutoff, but below the 95th percentile cutoff, were categorized as at risk of being overweight. Pediatrics recommended evaluating the at-risk group for complications related to obesity by screening for such factors as family history hypertension, and total cholesterol. Using these criteria, 15 percent of the children in our study were overweight and an additional 14 percent were at risk of being overweight (table 1).

We also compared our findings with a study by Richard Troiano and Katherine Flegal, who used the National Health and Nutrition Examination Surveys (NHANES II & III) and CDC's age- and sex-specific BMI cutoffs to estimate the prevalence of overweight children in 1976-80 and 1988-94. Troiano and Flegal estimated that percent of children age 6-17 were overweight during 1988-94 and an additional 14 percent of children were at risk of being overweight. (Troiano and Flegal provided only an overall figure and did not provide the percentage of children at risk of being overweight by age- and sex-specific groups.) Thus, between 1988-94 and 1994-96, the percentage of children among all 6 to 17 year-olds who were overweight or were at risk of being overweight appears to have increased from about 25 percent to more than 29 percent.

A word of caution: The 1976-80 and the 1988-94 prevalence rates reported by Troiano and Flegal are based on clinically measured height and weight. By contrast, the 1994-96 CSFII-based prevalence rates are based on self-reported height and weight. Self-reported measures tend to be less accurate than clinical measures. Therefore, the 1994-96 data should be interpreted with caution. However, the CSFII-DHKS surveys are the only available sources of nationally representative data by which to examine the link between parental nutrition knowledge and the prevalence of overweight conditions in children. For the rest of the article, we will use the term "overweight" to refer to children who are overweight or are at risk of being overweight.

Parents' Perception of Their Own Weight Status Is Important

How does the parents' weight status, as well as their perception of it, relate to the weight status of their children? To find out, we applied the adult BMI criteria to the parents and classified them as overweight if their BMI was at or above 25. (Therefore parents identified as overweight in this study also included those who are obese.) In the CSFII 1994-96 data, 35 percent of the children of overweight parents were overweight, while only 20 percent of the children of parents not overweight were overweight (fig. 1). Thus, if the parent participating in the survey was overweight, there was a greater chance of his or her child being overweight. The parent-child overweight link is well documented, but no other study has examined the link between parents' perception of their own overweight status and the probability of their children being overweight. We found that, among parents who correctly perceived themselves as being overweight, 32 percent of their children were overweight (fig. 2). However, among parent s who underestimated their weight status--that is, they did not perceive themselves to be overweight, when in fact their reported BMI was at or above 25--42 percent of their children were overweight.

Parental Nutrition Knowledge Is a Factor...

Children's food preferences are influenced by parental eating habits. Once acquired in early childhood, healthful dietary habits tend to be carried into adulthood. Therefore, obesity prevention and/or treatment should focus on early attention and involvement of parents and promotion of healthful eating and exercise. Parental nutrition knowledge is essential for monitoring eating habits of children, identifying high-calorie foods, and understanding the long-term risks of obesity. To assess the link between parental nutrition knowledge and the prevalence of overweight conditions in children, we calculated the percentage of children who were overweight among parents who correctly and incorrectly answered DHKS questions related to nutrition knowledge, beliefs, and nutrition label use. While the DHKS included many questions, we present only nutrition-related questions whose answers of which showed a statistically significant difference.

We found that greater parental nutrition knowledge is associated with lower prevalence of overweight children (table 2). Most parents responding to the survey were knowledgeable about recommended servings and aware of health problems related to nutrient intake. For example, 84 percent of parents knew that a person should eat at least two to four servings of fruit each day (this includes about 10 percent of the parents who gave an answer of more than four servings). Seventy percent of parents were aware of health problems caused by not eating enough fiber. Among this group of parents, the prevalence of overweight children was around 26 percent. Among the parents who were not aware of the health problems caused by not eating enough fiber, the prevalence of overweight children was 34 percent.

... And So Are Dietary Attitudes and Nutrition Label Use

Parental nutrition knowledge represents just one dimension of the prerequisites for improving the parents' own eating habits as well as those of their children. Health authorities note that parents unwilling to change may express a lack of concern about a child's obesity or believe the obesity is inevitable and cannot be changed. Our data support this observation. Among parents responding to the survey who agreed with the statement "Some people are born to be fat and some thin; there is not much you can do to change this," 33 percent of their children were overweight (table 3). In contrast, among parents who disagreed with that statement, only 22 percent of the children were overweight--an 11 percentage-point difference in prevalence. A similar contrast exists between parents who expressed frustration with dietary recommendations--believing there is too much conflicting advice--and those who did not. The difference in the proportion of overweight children between the two groups is 14 percentage points.

In general, recommendations in the Dietary Guidelines for Americans were important to parents responding to the survey. For example, 94 percent of the parents felt that choosing a diet with plenty of fruits and vegetables was personally important to them and only 6 percent of parents expressed a lack of interest in this recommendation. However, a relatively high 25 percent of parents felt that choosing a diet with plenty of grains (breads, cereals, rice, and pasta) was not important to them. The recommended 6-11 daily servings from the grains group form the "base" of the Food Guide Pyramid. Parents who are not attuned to this recommendation may have difficulty putting together healthful menus. Indeed, the prevalence of overweight children among this group of parents was about 14 percentage points higher than among parents who felt the grains recommendation was important to them.

Nutrition labeling on processed foods has been in effect since mid-1994. Consumer surveys indicate that the labeling influences food choice. For example, a 1995 American Dietetic Association survey showed that 56 percent of people interviewed claimed to have modified their food choices due to nutrition labeling. Among the parents in our sample, one-half to two-thirds reported using some aspect of nutrition labels at least some of the time. However, a substantial proportion of parents reported that they rarely or never used nutrition labels. Among this group of label nonusers, the prevalence of overweight children was consistently higher (table 4). On average, the prevalence of overweight children was 6 percentage points higher among parents who did not use an aspect of nutrition labels than among parents who did.

We examined whether the relationship between parents' nutrition knowledge and the prevalence of overweight children varied depending on whether the parent responding to the survey was the mother or the father. We found no statistically significant difference in prevalence of overweight children by nutrition knowledge, beliefs, or attitudes between mothers and fathers. However, the prevalence of overweight children was significantly lower among fathers who used three aspects of nutrition labels (list of ingredients, amount of nutrients in a serving, and size of a serving), compared with mothers who used these same aspects of nutrition labels. For example, among fathers who reported using the list of ingredients on nutrition labels, only 22 percent of children were overweight. Among mothers who reported using the list of ingredients on nutrition labels, 29 percent of children were overweight. This finding suggests that nutrition awareness among fathers may play a greater role in the prevalence of overweight children than generally believed.

Assessing Parental Nutrition Knowledge, Attitudes, and Habits Is An Important First Step

It is understandable that health authorities consider obesity in children and adolescents a frustrating and difficult condition to treat. A successful approach toward weight control treatment for children requires parental readiness for change. A lack of parental readiness could cause weight control efforts to fail. Lack of readiness can range from the belief that obesity is inevitable and nothing can be done about it to the nonuse of appropriate tools, such as nutrition labels. Our findings show how some aspects of parental readiness are related to the prevalence of overweight conditions among children. Besides readiness, a parent's own weight status, and, more importantly his or her perception of that status, can also factor into a child's weight condition. Parents who are overweight are more likely to have overweight children; the prevalence rate among overweight parents who underestimate their own weight status is even higher. Clearly, assessing parental and family readiness is an important step in addressing obesity in children.

While parental readiness may be an important factor in weight control efforts of children, nutrition knowledge alone is not a panacea. Large percentages (around 20 in almost every case) of children whose parents have appropriate attitudes and knowledge are overweight. Nutrition knowledge has to be translated into actual behavior and accompanied by other changes, particularly increased physical activity and exercise. In addition, weight control efforts must take into account the obesity status and nutrition knowledge of the other parent or adults in the family. Thus, much work remains in gaining a full understanding of the factors associated with childhood and adolescent obesity.

The author is an agricultural economist with the Food and Rural Economics Division, Economic Research Service, USDA.

References

Allison, ., . Fontaine, . Manson, J. Stevens, and . VanItallie. "Annual Deaths Attibutable to Obesity in the United States," Journal of the American Medical Association, Vol. 282, No. 16. October 1999.

Barlow, Sarah E., and William H. Dietz. "Obesity Evaluation and Treatment: Expert Committee Recommendations," Pediatrics, Vol. 102, No. 3. September 1998.

Kuczmarski, Robert J., and others. "CDC Growth Charts: United States," Advance Data, No. 314. Centers for Disease Control and Prevention, . Department of Health and Human Services, National Center for Health Statistics. May 30, 2000.

Mokdad, ., . Serdula, . Dietz, . Bowman, . Marks, and . Koplan. "The Spread of the Obesity Epidemic in the United States, 1991-1998," Journal of the American Medical Association, Vol. 282, No. 16, October 1999.

Troiano, Richard P., and Katherine M. Flegal. "Overweight Children and Adolescents: Description, Epidemiology, and Demographics," Pediatrics, Vol. 101, No. 3, March 1998.

Table 1

Children and Adolescents Are at Greater Risk of Being Overweight

 1994-96
 Overweight At risk of
 Overweight being
Age group/gender 1976-80 (2) 1988-94 (3) overweight

 Percent

Age 6-17 NA 

Age 6-11 NA 
 Male 
 Female 

Age 12-17 NA 
 Male 
 Female 

NA = Not available.

(1)From 1994-96 CSFII

(2)From 1976-80 NHANES II.

(3)From 1988-94 NHABES III.

Sources: Traiano and Flegal, 1998; USDA's Economic Research Service.
Table 2

Greater Parental Nutrition Knowledge Is Related to Lower Prevalence of
Overweight Children

 Share of children overweight
 or at risk of being
 overweight (1)
 Parent answered
Survey Items Incorrectly
 Percent

Knowledge of recommended fruit
servings a person should eat
each day. 

Knowledge of recommended vegetable
servings a person should eat
each day. 

Awareness of any health problems
caused by not eating enough fiber. 

Knowledge of which foods have more
fat, fiber, or cholesterol. 

 Share of
 children
 overweight
 or at risk
 of being
 overweight
 (1)
 Parent
 answered
Survey Items Correctly
 Percent

Knowledge of recommended fruit
servings a person should eat
each day. 

Knowledge of recommended vegetable
servings a person should eat
each day. 

Awareness of any health problems
caused by not eating enough fiber. 

Knowledge of which foods have more
fat, fiber, or cholesterol. 

(1)Represents children of parents responding to DHKS.

Source: 1994-96 CSFII-DHKS, USDA.
Table 3

Parents' Beliefs Are Associated With Children's Probability of Being
Overweight

 Share of children overweight
 or at risk of being
 overweight (1)
 Parent
Survey statements Agreed
 Percent

Some people are born to be fat and
some thin; there is not much you
can do to change this. 

There are so many recommendations
about healthy ways to eat, it's
 hard to know what to believe. 

 Share of
 children
 overweight
 or at risk
 of being
 overweight
 (1)
 Parent
Survey statements Disagreed
 Percent

Some people are born to be fat and
some thin; there is not much you
can do to change this. 

There are so many recommendations
about healthy ways to eat, it's
 hard to know what to believe. 
 Parent believed

 Not important Important

 Percent

To you personally how important is
it to choose a diet with plenty of
breads, cereals, rice, and pasta? 

(1)Represents children of parents responding to DHKS.

Source: 1994-96 CSFII-DHKS, USDA.
Table 4

Prevalence of Overweight Children Lower Among Parents Who Use Nutrition
Labeling

Survey questions Share of children overweight
 or at risk of being
 overweight (1)

Think about food labels. When you Parent
buy foods, do you use Did not Use

 Percent

The list of Ingredients? 

The short phrases on the label like
"low-fat" or "light" or "good
source of fiber?" 

The nutrition panel that tells the
amount of calories, protein, fat,
and such in a serving of the food? 

The information about the size of
a serving? 

Statements on the label that
describe health benefits of
nutrients or foods? 

Survey questions Share of
 children
 overweight
 or at risk
 of being
 overweight
 (1)
Think about food labels. When you Parent
buy foods, do you use Used

 Percent

The list of Ingredients? 

The short phrases on the label like
"low-fat" or "light" or "good
source of fiber?" 

The nutrition panel that tells the
amount of calories, protein, fat,
and such in a serving of the food? 

The information about the size of
a serving? 

Statements on the label that
describe health benefits of
nutrients or foods? 

(1)Represents children of parents responding to DHKS.

Source: 1994-96 CSFII-DHKS, USDA.
Figure 1

Overweight Parents Are More Likely To Have Overweight Children

Percent of children overweigh


Parents overweight 35
Parents not overweight 20

Source: 1994-96 CSFII-DHKS, USDA.

Note: Table made from bar graph
Figure 2

Children of Parents Who Underestimate Their Own Weight Status Have a
Greater Likelihood of Being Overweight

Percent of children overweight



Parental perception of own
overweight status
Accurate 32
Underestimate 42

Source: 1994-96 CSFII-DHKS, USDA.

Note: Table made from bar graph