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WIC and Obesity

The focus of this session, moderated by Patricia Crawford, was research on how the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) could have an impact on behaviors that contribute to childhood obesity. The two presenters (Robert Whitaker and Elsie Taveras) identified possible behavioral intervention targets and discussed different aspects of suggested research methods. The discussant (Sara Benjamin Neelon) raised a number of questions about the selection of behavioral intervention targets. The session did not address research on efforts by WIC to address obesity.

RESEARCH PROPOSALS FOR OBESITY PREVENTION AMONG CHILDREN IN WIC

Presenter: Robert C. Whitaker


Whitaker covered four key research findings and their implications for future research. In addition, he mentioned structural constraints in WIC that limit potential research designs, and he proposed a research agenda and a potential staged research design.

Key Research Findings

Four research findings have implications for the WIC research agenda, Whitaker said. They are:



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3 WIC and Obesity The focus of this session, moderated by Patricia Crawford, was research on how the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) could have an impact on behaviors that contribute to childhood obesity. The two presenters (Robert Whitaker and Elsie Taveras) identified possible behavioral intervention targets and discussed different aspects of suggested research methods. The discussant (Sara Benjamin Neelon) raised a number of questions about the selection of behavioral in- tervention targets. The session did not address research on efforts by WIC to address obesity. RESEARCH PROPOSALS FOR OBESITY PREVENTION AMONG CHILDREN IN WIC Presenter: Robert C. Whitaker Whitaker covered four key research findings and their implications for future research. In addition, he mentioned structural constraints in WIC that limit potential research designs, and he proposed a research agenda and a potential staged research design. Key Research Findings Four research findings have implications for the WIC research agenda, Whitaker said. They are: 

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 PLANNING A WIC RESEARCH AGENDA 1. Participation in WIC is not associated with obesity. Because of this, exposure to WIC alone is unlikely to either cause or protect against obesity, and body mass index (BMI) will not be a useful measure of a primary outcome (Hofferth and Curtin, 2005; Ploeg et al., 2008; Rose et al., 2006). 2. The prealence of obesity in WIC children no longer seems to be increasing. Because favorable secular trends are likely to continue among WIC and non-WIC children, careful attention must be given to the control condition when designing studies (Sharma et al., 2009). 3. Within the WIC income range, higher income is associated with a greater rather than a lower prealence of obesity. Thus qualita- tive studies are needed to examine the complex relationship be- tween childhood obesity and household behaviors and resources (Anderson and Whitaker, 2010; Karp et al., 2005; Whitaker and Orzol, 2006). 4. Successful preention or treatment interentions in young children require parental inolement. Therefore, parents should be the pri- mary targets of interventions to prevent childhood obesity (Epstein et al., 1994; Golan and Crow, 2004; Golan et al., 2006). Structural Constraints Because WIC currently has no waivers or wait lists, it is challenging to develop feasible random assignment designs. Interventions must work within WIC’s three core functions: the provision of the food package, nutri- tion education, and referrals. Proposed Research Agenda Whitaker’s research proposal is given below, followed by his criteria for selecting target behaviors. Proposal Develop and test the impact of a coordinated communication strategy among WIC, Head Start, and pediatricians on changing behaviors that help prevent obesity among children 12 to 60 months of age. Target Behaiors The target behaviors selected should meet three criteria, namely, that the behavior (1) has an effect on energy balance or weight, (2) is

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 WIC AND OBESITY BOX 3-1 Menu of Target Behaviors 1. Decrease portion sizes. 2. Increase the frequency of family meals. 3. Limit sweetened beverages. 4. Increase outdoor play time with parents. 5. Decrease time spent watching television and on computers. 6. Increase sleep duration. unlikely to do harm, and (3) has a favorable effect on non-obesity out- comes, such as improving social well-being. The lack-of-harm criterion is especially important when the evidence of benefit is weak. The effect on outcomes other than obesity may provide the key to engaging parents and partners. Whitaker’s menu for target behaviors appears in Box 3-1. According to Whitaker, behavior numbers 5 and 6 in this box, which have consis- tently been associated with a lower prevalence of obesity, also may lead to improvements in children’s moods and decreased aggressive behaviors— possible outcomes that may engage parents. Potential Staged Design Whitaker proposed a multistage research design in which each stage informs the next (Box 3-2). The first four stages entail the development of BOX 3-2 Potential Multistage Research Design Development of the Communication Strategy 1. Conduct formative qualitative research. 2. Help messengers be healthy through staff wellness programs. 3. Convene messengers to help them understand shared goals and challenges. 4. evelop communication tools, and qualitatively assess both the messages and D the medium with messengers and parents. Testing of the Communication Strategy 5. Pilot-test the communication strategy and the outcome measures. 6. Conduct a controlled impact evaluation.

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 PLANNING A WIC RESEARCH AGENDA a communications strategy, which is tested in the fifth and sixth stages. The first stage is the most important. It includes framing messages on behav- ioral targets and reconciling differences between the frames1 held by those delivering and those receiving the messages. A key part of the fourth stage is a qualitative assessment of how well both the messages and the medium resonate with the messengers and the parents. The pilot test (stage 5) would focus on assessing the acceptability, fea- sibility, and fidelity of delivering the message. If the results of the pilot test are unfavorable, stage 6 would not go forward. If the results of the first five stages warrant a controlled evaluation of the impact of the communi- cation strategy (stage 6), this stage would probably be conducted using a group- or community-randomized design that compares traditional WIC services with WIC services plus an enhanced coordinated communication strategy. The primary outcome should be the target behavior or behaviors. A process and cost evaluation would be an important element of the study in order to determine how to implement the intervention on a larger scale and then to sustain it. Closing Comments In closing, Whitaker emphasized that any interventions that are part of the research agenda should target behaviors rather than BMI, that the target behaviors must matter to the WIC partners and to the parents, and that qualitative research is more important and feasible than quantitative research in the WIC setting. RESEARCH OPPORTUNITIES IN WIC FOR CHILDHOOD OBESITY Presenter: Elsie M. Taeras Although the most recent statistics show that the prevalence of child- hood obesity has reached a plateau, the prevalence is still high, and obe- sity is affecting even the nation’s youngest children. In 2007–2008, the prevalence of high weight for recumbent length among U.S. children from birth to 2 years of age was 9.5 percent (Ogden et al., 2010), where “high” is defined as weights at or above the 95th percentile of the Centers for Disease Control and Prevention (CDC) growth charts (Kuczmarski et al., 2000). The prevalence of obesity varied by racial and ethnic background, 1 The term frames refers to people’s perceptions and the meaning that people attribute to objects, events, and behaviors. Frames are likely to differ among WIC staff and WIC partners, such as pediatricians and parents. 2 Taveras’ participation was via conference call, with slides shown on site.

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 WIC AND OBESITY BOX 3-3 Proposed Targets for Behavioral Counseling— Prenatal to Early Childhood • Gestational weight gain (Oken et al., 2006) and gestational diabetes • Maternal smoking during pregnancy (Oken et al., 2006) • Rapid infant weight gain (Taveras et al., 2009) • Breastfeeding promotion (Taveras et al., 2004) • Sleep duration and quality (Taveras et al., 2008) • Television viewing (Taveras et al., 2007) and television sets in bedroom • I mproved responsiveness to infant hunger and satiety cues (Hodges et al., 2008) • P arental feeding practices, eating in the absence of hunger (Birch and Fisher, 1998; Birch et al., 2003; Taveras et al., 2006a) • Portion sizes (Fisher et al., 2008) • Fast food intake (Taveras et al., 2006b) • Sugar-sweetened beverages (James and Kerr, 2005; Wang et al., 2009) • P hysical activity participation (Gooze et al., 2010; Strong et al., 2005; Tobias et al., 2010) ranging from 8.7 for non-Hispanic white to 12.5 for Hispanic girls and boys (Ogden et al., 2010). Severe obesity (BMI ≥35 kg/m2) was especially high for Black and Hispanic boys and for Black girls 2 to 19 years of age (Wang et al., 2010). Relevant Research Findings Box 3-3 offers a list of proposed targets for behavioral counseling and key references that provide the basis for the inclusion of those targets on the list. Racial and ethnic differences are present in all the early life risk factors for childhood obesity, with children who belong to racial or ethnic minority groups being affected disproportionately. Clearly, prevention must start early, and preventive interventions should be based on the best avail- able evidence for the highest risk populations. WIC fits well with the effort to prevent obesity because of the population groups covered, the structure for screening nutritional status, the nutrition education provided, and the referrals for needed health and social services. Proposed Research Agenda Taveras proposed the following study: Develop and test the impact of coordinated surveillance and communication strategies among

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0 PLANNING A WIC RESEARCH AGENDA 1. WIC providers and obstetricians on promoting healthful behaviors during pregnancy to prevent childhood obesity and improve mater- nal health; and 2. WIC providers, home visitation programs, child care providers, and pediatricians on changing behaviors to help prevent excess weight gain among infants from birth to 12 months. The targets of intervention during pregnancy would be maternal pre- pregnancy BMI, excessive gestational weight gain, maternal smoking, and gestational diabetes. The interventions would occur mainly during the inter-pregnancy interval. Taveras called for improving the surveillance of obesity-related risk factors; coordinated referrals and communication strat- egies; and improvements in parents’ ability to handle infant feeding, sleep, and media exposure. A very important communication goal would be to counter the myth that the pregnant woman needs to “eat for two.” The targets of intervention during infancy would be excessive infant weight gain; breastfeeding initiation, continuation, and exclusivity; respon- sive feeding; portion sizes of bottles and solid food containers; outdoor physical activity; limiting television viewing and televisions in bedrooms; and improving sleep quality and duration. Taveras called for improved surveillance of infant weight gain using the CDC growth charts in combi- nation with the identification of children at high risk of rapid growth and coordinated communication strategies to counter the myth that “bigger is better.” Other possible tactics involve education and support that would be directed mainly toward feeding practices and the promotion of physical activity and healthful sleep. Possible Methodology for Impact Evaluation Taveras supported the multistage design approach presented by Whitaker and focused on two possible evaluation methods: quasi-experiments and cluster-randomized controlled trials. Quasi-Experiments Quasi-experiments, as described by Gortmaker (2004), can have all the attributes of a randomized controlled trial, including pretest and posttest data. The key difference is the lack of random assignment to intervention and control groups. The success of the method depends on appropriate selection of the control sample (e.g., through propensity matching; see Chapter 10). Quasi-experiments make it possible to study programs and policies that are innovative, expensive, and difficult to implement.

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 WIC AND OBESITY Cluster-Randomized Controlled Trials Cluster-randomized controlled trials are studies in which groups (clus- ters) are randomized rather than individuals. This method is useful when the intervention is applied to an entire group. Because of the random- ization, such trials have better internal validity than quasi-experimental studies. They also allow the study of interventions that cannot be directed toward selected individuals. However, the design and analysis of cluster- randomized controlled trials are complex, the required sample sizes are large, the cost is high, and the long time it takes to obtain study results may preclude rapid evaluations of innovations. Concluding Comments Taveras said that WIC can play a substantial role in efforts to prevent childhood obesity during pregnancy, infancy, and early childhood—especially when WIC works in collaboration with partners such as obstetricians, home visitation programs, child care providers, and pediatricians. She concluded that those determining the research agenda should consider innovative study designs and methods as a way of overcoming the barriers to wide-scale inter- vention testing in WIC. RESPONSE Discussant: Sara Benjamin Neelon Questions Triggered by the Obesity Session Presentations Benjamin Neelon asked all those present to consider the presentations by Whitaker and Taveras and think about four questions, and she provided her own responses, as follows: 1. What is WIC already doing and already doing well to preent childhood obesity? Response: Screening and measuring growth, addressing competing issues within families. 2. What can WIC do to include more obesity preention within its current structure? Response: Target various family members and caregivers, not just the mother. 3. Are there missed opportunities for obesity preention within WIC? Response: Reaching women during interconceptional periods, en- gaging fathers and partners.

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 PLANNING A WIC RESEARCH AGENDA 4. Where does obesity preention rank among other behaioral tar- gets within WIC? How would you prioritize obesity preention when you consider other health concerns? Response: None provided. Benjamin Neelon also asked attendees to consider behavioral targets according to three different considerations: (1) those that have the great- est effect on obesity prevention, (2) those that WIC is in a good position to address, and (3) those that are or should be integral to the mission of WIC. Some behavioral targets may move WIC nutritionists beyond their training and comfort zone. With these points in mind, Benjamin Neelon highlighted those behavioral intervention targets that she considered to be more promising—that is, the ones for which WIC could have a greater impact (see bolded items in Box 3-4). Concluding Comments According to Benjamin Neelon, WIC can play a substantial role in obe- sity prevention, although it cannot provide the entire answer. WIC needs to engage collaborative partners. Target behaviors must matter to partners and caregivers and must extend beyond weight and obesity. The research design should compare WIC to an enhanced form of WIC. Most importantly, a combination of qualitative and quantitative formative processes and impact evaluation will be needed to assess the effectiveness of new measures. BOX 3-4 Behavioral Intervention Targetsa Pregnancy Infancy Early Childhood Excess weight gain Excess weight gain Sweetened beverages Family meals Smoking Breastfeeding Pre-pregnancy BMI Portion sizes Portion sizes Gestational diabetes Responsive feeding Play/physical activity Play/physical activity Screen time TV viewing/TV bedroom Sleep quality/duration Sleep quality/duration aBold font indicates the targets for which WIC could have a greater impact.

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 WIC AND OBESITY GROUP DISCUSSION Moderator: Patricia B. Crawford The following topics were addressed during the discussion period: • Methods: Considerable evidence shows that quasi-experimental designs such as regression discontinuity and propensity scoring place large demands on the sample size, often requiring sample sizes much larger than those needed for randomized controlled tri- als (RCTs). When RCTs are feasible, they may be relatively simple and straightforward. • Healthy Habits for Life kits and the Around Food Insecurity pro- gram: These products of a partnership between the National WIC Association and the Sesame Workshop include evaluation compo- nents, and they tie in with suggestions for behavior change made during this session. • Efforts to encourage appropriate infant feeding (exclusive, long- term breastfeeding): These efforts tie together behaviors related to maternal health (postpartum fat loss) and infant health. • The screening component of WIC: (1) The use of the new World Health Organization growth charts results in identifying overweight children earlier than with the CDC growth charts. (2) Crowded liv- ing conditions can lead to positive responses to questions such as, “Is there a TV in the room in which your child sleeps?” • Formative research related to obesity prevention: This approach has value for 1-year-old children as well as for the older ones. SUMMARY OF SUGGESTED RESEARCH TOPICS The research proposals made during this session focused on developing and testing strategies to change behaviors linked with excess weight among infants and young children. Emphasis was placed on collaboration with a range of partners. The method proposed here would involve a multistage research design that would be used to identify target behaviors that matter to partners and caregivers and that extend beyond weight and obesity. The design would also help determine effective ways to address those behaviors. Both qualitative and quantitative research designs will be needed. REFERENCES Anderson, S. E., and R. C. Whitaker. 2010. Household routines and obesity in US preschool- aged children. Pediatrics 125(3):420–428.

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 PLANNING A WIC RESEARCH AGENDA Birch, L. L., and J. O. Fisher. 1998. Development of eating behaviors among children and adolescents. Pediatrics 101(3 II Suppl.):539–549. Birch, L. L., J. O. Fisher, and K. K. Davison. 2003. Learning to overeat: Maternal use of restrictive feeding practices promotes girls’ eating in the absence of hunger. American Journal of Clinical Nutrition 78(2):215–220. Epstein, L. H., A. Valoski, R. R. Wing, and J. McCurley. 1994. Ten-year outcomes of behav- ioral family-based treatment for childhood obesity. Health Psychology 13(5):373–383. Fisher, J. O., N. F. Butte, P. M. Mendoza, T. A. Wilson, E. A. Hodges, K. C. Reidy, and D. Deming. 2008. Overestimation of infant and toddler energy intake by 24-h re- call compared with weighed food records. American Journal of Clinical Nutrition 88(2):407–415. Golan, M., and S. Crow. 2004. Parents are key players in the prevention and treatment of weight-related problems. Nutrition Reiews 62(1):39–50. Golan, M., V. Kaufman, and D. R. Shahar. 2006. Childhood obesity treatment: Targeting par- ents exclusively v. parents and children. British Journal of Nutrition 95(5):1008–1015. Gooze, R. A., C. C. Hughes, D. M. Finkelstein, and R. C. Whitaker. 2010. Reaching staff, parents, and community partners to prevent childhood obesity in Head Start, 2008. Preenting Chronic Disease 7(3):A54. Gortmaker, S. L. 2004. Scenario : Preention of childhood obesity. Paper presented at the May 4–5, 2004, Workshop on Research Designs for Complex, Multi-level Health Interventions and Programs, Bethesda, MD. http://obssr.od.nih.gov/news_and_events/ conferences_and_workshops/FY_2004/complex_interventions.aspx#dates (accessed Sep- tember 7, 2010). Hodges, E. A., S. O. Hughes, J. Hopkinson, and J. O. Fisher. 2008. Maternal decisions about the initiation and termination of infant feeding. Appetite 50(2-3):333–339. Hofferth, S. L., and S. Curtin. 2005. Poverty, food programs, and childhood obesity. Journal of Policy Analysis and Management 24(4):703–726. James, J., and D. Kerr. 2005. Prevention of childhood obesity by reducing soft drinks. Inter- national Journal of Obesity 29(Suppl. 2):S54–S57. Karp, R. J., C. Cheng, and A. F. Meyers. 2005. The appearance of discretionary income: In- fluence on the prevalence of under- and over-nutrition. International Journal of Health Inequities 4:10. Kuczmarski, R. J., C. L. Ogden, L. M. Grummer-Strawn, K. M. Flegal, S. S. Guo, R. Wei, Z. Mei, L. R. Curtin, A. F. Roche, and C. L. Johnson. 2000. CDC growth charts: United States. Adance Data from vital and Health Statistics 314:1–27. http://www.cdc.gov/ nchs/data/ad/ad314.pdf (accessed September 24, 2010). Ogden, C. L., M. D. Carroll, L. R. Curtin, M. M. Lamb, and K. M. Flegal. 2010. Prevalence of high body mass index in US children and adolescents, 2007–2008. Journal of the American Medical Association 303(3):242–249. Oken, E., Y. Ning, S. L. Rifas-Shiman, J. S. Radesky, J. W. Rich-Edwards, and M. W. Gillman. 2006. Associations of physical activity and inactivity before and during pregnancy with glucose tolerance. Obstetrics and Gynecology 108(5):1200–1207. Ploeg, M. V., L. Mancino, B. H. Lin, and J. Guthrie. 2008. US food assistance programs and trends in children’s weight. International Journal of Pediatric Obesity 3(1):22–30. Rose, D., J. N. Bodor, and M. Chilton. 2006. Has the WIC incentive to formula-feed led to an increase in overweight children? Journal of Nutrition 136(4):1086–1090. Sharma, A. J., L. M. Grummer-Strawn, K. Dalenius, D. Galuska, M. Anandappa, E. Borland, H. Mackintosh, and R. Smith. 2009. Obesity prevalence among low-income, preschool- aged children—United States, 1998–2008. Morbidity and Mortality Weekly Report 58(28):769–773.

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 WIC AND OBESITY Strong, W. B., R. M. Malina, C. J. Blimkie, S. R. Daniels, R. K. Dishman, B. Gutin, A. C. Her- genroeder, A. Must, P. A. Nixon, J. M. Pivarnik, T. Rowland, S. Trost, and F. Trudeau. 2005. Evidence based physical activity for school-age youth. Journal of Pediatrics 146(6):732–737. Taveras, E. M., K. S. Scanlon, L. Birch, S. L. Rifas-Shiman, J. W. Rich-Edwards, and M. W. Gillman. 2004. Association of breastfeeding with maternal control of infant feeding at age 1 year. Pediatrics 114(5):e577–e583. Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry, and M. W. Gillman. 2006a. To what extent is the protective effect of breastfeeding on fu- ture overweight explained by decreased maternal feeding restriction? Pediatrics 118(6): 2341–2348. Taveras, E. M., T. J. Sandora, M. C. Shih, D. Ross-Degnan, D. A. Goldmann, and M. W. Gillman. 2006b. The association of television and video viewing with fast food intake by preschool-age children. Obesity 14(11):2034–2041. Taveras, E. M., A. E. Field, C. S. Berkey, S. L. Rifas-Shiman, A. L. Frazier, G. A. Colditz, and M. W. Gillman. 2007. Longitudinal relationship between television viewing and leisure- time physical activity during adolescence. Pediatrics 119(2):e314–e319. Taveras, E. M., S. L. Rifas-Shiman, E. Oken, E. P. Gunderson, and M. W. Gillman. 2008. Short sleep duration in infancy and risk of childhood overweight. Archies of Pediatrics and Adolescent Medicine 162(4):305–311. Taveras, E. M., S. L. Rifas-Shiman, M. B. Belfort, K. P. Kleinman, E. Oken, and M. W. Gillman. 2009. Weight status in the first 6 months of life and obesity at 3 years of age. Pediatrics 123(4):1177–1183. Tobias, D. K., C. Zhang, R. M. van Dam, K. Bowers, and F. B. Hu. 2010. Physical activity before and during pregnancy and risk of gestational diabetes mellitus: A meta-analysis. Diabetes Care. (Electronically published September 27, 2010). Wang, Y. C., D. S. Ludwig, et al. 2009. Impact of change in sweetened caloric beverage con- sumption on energy intake among children and adolescents. Archies of Pediatrics and Adolescent Medicine 163(4):336–343. Wang, Y. C., S. L. Gortmaker, and E. M. Taveras. 2010. Trends and racial/ethnic disparities in severe obesity among US children and adolescents, 1976–2006. International Journal of Pediatric Obesity. (Electronically published March 18, 2010). Whitaker, R. C., and S. M. Orzol. 2006. Obesity among US urban preschool children: Rela- tionships to race, ethnicity, and socioeconomic status. Archies of Pediatrics and Ado- lescent Medicine 160(6):578–584.

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