UniversityofConnecticut

IncreasingatHomeCookingtoReduceFastFood

Intake:

AChildhoodObesityPreventionStrategy

KaylaMcCabe
 DIET3231W
Dr.Duffy
April30,2017

Introduction

ChildhoodobesityintheUnitedStateshasremainedstableatastaggering17%overthe

pastfiveyears,affectingmorethan12.7millionchildren.1Whileonly8.9%ofpreschoolaged

childrenareobese,bythetimetheyreachages1219yearsold,20.5%ofadolescentsarefound

tobeobese,indicatingagrowingandprogressiveproblem.1Theproblemspansgendersand

ethnicitiesbutevidencehassuggestedthatchildreninpoorercommunitiesaremorelikelyto

becomeobeseandgrowmoreobesethanchildrenfromwealthierareas.2Childhoodobesityis

associatedwithanumberofhealthrisksincluding:cardiovasculardisease,insulinresistance,

type2diabetes,obstructivesleepapnea,nonalcoholicfattyliverdiseaseandvarious

musculoskeletalconditions.3Theseconditions,whichwereformerlythoughtofasprimarily

adultdiseases,canimpactthehealthandnutritionalwellbeingofachildfortherestoftheirlife.

Energyoverconsumption,pairedwithanumberofotherfactorsthatlimitenergy

expenditure,contributestotheriskofchildhoodobesity.4Unhealthyfoodenvironments,where

accesstohealthyfoodislimitedorevennonexistentandenergydensefoodsareeasily

accessible,pairedwithlimitedsocioeconomicresourcescontributetothisenergy

overconsumption.SuchenvironmentsareseenacrosstheUnitedStates.Infact,23.5million

Americansliveinlowincomeneighborhoodsthatarefurtherthan1milefromalarge

supermarket/grocerywhilethousandsoffastfoodrestaurantscurrentlyscatterthecountry,and

continuetopopupeveryday.5Whenaccesstohealthyfoodsislimitedinthesurrounding
neighborhoodconsumingfrequentfastfoodmealsmaybecomethebestoronlyoptionfor

families,particularlyforthoseofeconomicdisadvantage.Infact,onestudyfoundthatchildren

whoattendaschoolwithinahalfmileofafastfoodrestaurant(whichwasmostcommonlyseen

inlowsocioeconomic,urbanareas)weremorelikelytobeobese(OR:1.07)thanchildrenat

otherschools.6

Thelowpriceandconvenienceoffastfoodcanappealtofamiliesofincome

disadvantage.The20112012NationalHealthandNutritionExaminationSurvey(NHANES)

revealedthatonethirdofUSchildreneatfastfoodeveryday,equatingto12.4%ofdailycalories

comingfromfastfood.1Observationalresearchhasshownthatfoodeatenawayfromhomeis

higherinsaturatedfat,sodium,cholesterol,andlowerincalciumandfiberwhencomparedto

homecookedmeals.7Frequentfastfoodconsumptionpromotestheenergyoverconsumptionthat

mayimpacttheincidenceofchildhoodobesity.Stepsmustbetakentoreducethenumberof

caloriesUSchildrenconsumefromfastfoodandencouragehomeprepared,nutrientdense,

balancedmeals.

Thispresentpaperwilladdressthehypothesisthateatingmoremealsthatarepreparedat

homeandfamilymealstogether(inplaceoffastfoodmeals)willpromotethechilds

consumptionofamorenutritiousdietwiththeappropriatelevelofcalories,encouragethe

developmentofhealthydietarybehaviorsinchildren,andsupportahealthyweight.Multilevel

interventionswillsupporthealthierhomebasedmeals,including:atthefamilylevelbyoffering

cookinglessonstoparents(throughprogramssuchasCookingMattersMore);thecommunity

levelbyincreasingaccessandconveniencetogroceriesviafarmersmarketsandschool

programs;andpolicylevelbyregulatingfastfoodmenulabelingandincreasingSupplemental
NutritionAssistanceProgram(SNAP)findingsofamiliescanaccessaffordable,healthy,locally

grownfoods.

Toaddressthehypothesis,thispaperwillcoverthefollowingmainpoints:whyfamilies

arechoosingfastfoodmeals,howfastfoodconsumptioncontributestoobesity,barriersfamilies

facetoeatinghomecookedmealsregularly,andinterventionsthatcanbetakenonthe

individual,community,andpolicylevelstoaddressthesebarriers.

FamiliesareChoosingConvenientandCheapFastFoodMeals

Figure1:ExpenditureonfoodawayfromhomeasapercentoftotalfoodexpenditureforallUnited
Statesfamiliesandindividualsbetween1970and2012.
 IncreasedconsumptionofFAFHisreflectedinUSeconomicpatterns.FAFHexpenditure

hasincreasedbymorethan15%overthepast45years,reaching43.1%in2012(Figure1).The

USDApredictsthatin2017thevaluewillreach52%.TheUSDApredictsthatin2017thatvalue

willhit52%.8

Inordertodesignandimplementinterventionstoaddresschildhoodobesity,wemust

understandwhyfamiliesareconsumingfastfoodandconveniencefoodstosuchadegreethatit

makesupmorethan40%ofourtotalnationalfoodexpenditure(Figure1).Thus,thissection

identifiesresearchonhowadvertisingandfastfoodavailabilityhascontributedtoeatingoutside

ofthehomethroughPubMedsearchesforfastfoodANDadvertisingandfastfoodAND

childhoodobesityandfastfoodANDpriceANDUnitedStates.

Factorscontributingtoconsumingfastfoodcomesfrombaselineresponsestoalarge

experimentaltrialinurbanandsuburbanareasnearMinneapolis/StPaul,MN.9Participants

included605adolescentandadultparticipantswhowererecruitedtoassesswhethercalorie

listingonfastfoodmenusandeliminatingvaluepricescouldleadtochoosingmealswithless

calories.9Beforeparticipatinginthattrial,participantscompletedaquestionnairewhichaimedto

identifyreasonsforeatingatfastfoodrestaurants.ParticipantsagreedthemostwithTheyre

quick,Theyreeasytogetto,Ilikethetasteoffastfood,andTheyreinexpensive.

ParticipantsdisagreedmostwiththestatementsTheyrefunandentertaining,andTheyhave

manynutritiousfoodstooffer.Inyoungeragegroups,eatingfastfoodasawayofsocializing

wasamorecommonreasonthaninolderageranges.Amajorlimitationofthisstudywasthat

the11statementsmaynothaveencompassedeveryreasonforchoosingfastfood.Also,only

23%oftheparticipantswereaged1624andnoinformationabouthavingchildrenorfamily
compositionwasobtained.Asthepresentpaperisinterestedinchildrenandfamiliestheresults

fromthisstudymaynotreflectthatpopulation.

Thesefindingssupportthatconvenienceandlowpricesupportchoosingfastfoodmeals.

Anadditionalconcernisthatfastfoodadvertisinggearedtowardchildrenismakingthese

unhealthymealsmoreappealingandincreasingtheamountoffoodeatenawayfromhome.

Arandomizedcontroltriallookedattheeffectoffastfoodproductplacementonchildren

andfoundthatitincreasedthechildrensdispositionaboutthebrandandfastfoodasawhole.11

Asampleof483participantseachwatcheda45minuteeditedversionofthefilmRichieRich.

Participantsweredividedinto4groups:thefirstwatchedanoneditedversionandservedasthe

controlgroup,thesecondwatchedthefilmwithMcDonaldsadvertisingeditedin,thethird

watchedaversionthatincludedMcDonaldsproductplacement,andthefourthgroupwatcheda

versionthatincludedbothadvertisingandproductplacement.Anotabledifferencewasseenin

brandawarenessafterwatchingthevideo,butthegreatesteffectwasseenontheattitudesofthe

childrentowardsfastfoodandMcDonalds.Theuseofadvertisingandproductplacementwas

associatedwithsignificantincreaseinpositiveattitudeaboutfastfoodfrom47%inthecontrol

groupto54%inthegroupthatsawbothadvertisingandproductplacement(p=.009).An

increaseispositivedispositionaboutMcDonaldsitselfwasseen,increasingfrom45%to57%

poststudywhenparticipantsratedtheirattitudeandfeelingsaboutthebrand.AsMcDonaldsisa

wellknownbrand,theexternalvalidityofthisstudycantbeknown,andshouldbereplicated

withalessknownbrand.

Thesefindingssupportthatadvertisinggearedtowardchildren,especiallyfromfastfood

companiessupportsachildsdesiretoeatfastfood.Thisadvertisingisabundant,McDonalds
alonespent$935millionin2014onadvertising.12Recentestimatespredictthatchildrenseeover

40,000adsonTVperyear,upfrom20,000inthe1980s.12Whilethisadvertisingalonedoesnot

leadtochildrenfrequentlyeatingfastfood,inenvironmentswithscaregrocerystoresand

abundantfastfoodfamiliesmaybemoreinclinedtochoosefastfoodasamealespeciallyifthe

priceisreasonable.13

Thusfar,thepresentpaperhasestablishedthatAmericanfamiliesareeatingan

overwhelmingamountoffastfood,anddecreasedamountofhomecookedfoods.Parentsare

choosingthesemealsbecauseoftheirlowcostandconvenience,andfrequentadvertisingfrom

thesebrandsismakingchildrenmoreeagertoeatthesefoods.Thefollowingsectionwill

continuebyestablishinghowthisfrequentconsumptioniscontributingtoobesity,andwhy

conveniencefoodsarelesshealthythanhomepreparedmeals.

FrequentFastFoodConsumptionContributestoObesity

TofurtherdiscusshowlowfrequencyofathomecookingcanimpactAmerican

childrenshealthitisessentialtoexaminethelinkbetweenfastfoodconsumptionandchildhood

obesity.Thissectionwillreviewmodern(withinthelast10years)studiesthatimplicatethelink

betweenfastfoodconsumptionandchildhoodobesity.ArticleswerefoundbyPubMed

searchingfastfoodANDobesity.Studiesthatfocusedonchildreninlowincomeareaswere

givenprecedenceandarticleswiththegreatestlevelsofevidenceinthosedomainswereselected

forreview.

Acrosssectionalstudythatexaminedtheassociationbetweenweightstatusand

frequencyofFAFHfoundthatpercentbodyfatinbothchildrenandtheirparentswas

significantlyincreasedinthosewhoatefastfoodatleast1timeperweek.14Logisticregression
andgenerallinearmodelinguseddatafromquestionnairesadministeredtochildparentdyadsin

conjunctionwithanthropometricmeasures,includingbioelectricalimpendencetestsforbodyfat

composition.ResultsindicatedasimilaramountoffamilieseatingFAFHaspreviousstudies

havefound.15Abouthalfofthedyads(50.4%)reportedeatingfastfoodatleastonetimeoverthe

pastweek.Kidswhosefamiliespurchasedfastfoodweeklywerenearlytwotimesaslikelytobe

overweight/obese(OR=1.8,CI95%)thankidswhosefamiliesdidnoteatFAFHasfrequently.

Furthermore,thechildrenthathadeatenfastfoodatleastonetimeoverthepastweekhadan

averagepercentbodyfatcompositionof22.4%versus20.5%forthosewhohadnothadfast

foodinthepastweek(p<.05).Thisstudyusedasampleof723childrenand723parents

providinganadequatesamplesize.

Alimittothisstudyisthatsocioeconomicdatawasnotobtainedfromparticipants.Aswe

know,lowsocioeconomicstatuscanimpactriskofobesity.16Studieslookingattheimpactoffat

foodconsumptiononthispopulationparticularlymayprovideinsightastowhereinterventions

areneeded.

Asimilarcrosssectionalstudywherethemedianfamilyincomeofparticipantswasless

thanhalfthatforthearea(SanDiego,CA)usedbaselinedataobtainedfromaseparate,larger,

interventiontrial,toexaminetheassociationbetweenfastfoodconsumptionandchildweight

status.17Oftheparticipants,34%namedafastfoodchainastheirfamiliesmostfrequented

restaurant.Logisticregressionshowedthatchildrenfromthosefastfoodseatingfamilies,in

comparisontofamiliesthatlistedsitdownortakeourrestaurantsastheirmostfrequentFAFH,

weremostlikelytobeatriskforbeingoverweight(OR=2.2forBMI>85thpercentile).Their
overallfindingwasthatfrequentfastfoodconsumptionsignificantlycorrelated(p=.018)witha

BMI>85thpercentileforchildrenandadolescents.

Thisstudyallowsustoseethatthecorrelationspanssocioeconomicstatuses.However,

thisstudyislimitedinthatitonlyaskedaboutthetypeofthefamiliesmostfrequentFAFH

source,andnotthefrequencyofFAFH.Additionally,likethelaststudydiscussed,thelevelof

evidenceforcrosssectionaldesignsislimited.

Theprevioustwostudieshaveestablishedthatfastfoodconsumptioncancontributeto

childhoodobesity,butdonotclarifyifFAHcanhavetheoppositeeffectandimprovehealthand

weightinAmericanchildren.Acrosssectionalstudyestablishedthatfrequentfoodeatenat

home,andspecificallyfoodpreparedatleastinpartbythechild,contributestoimproveddietary

qualityandhealthyeatingpatterns.18Over2,000childparticipantsandtheirparentscompleted

questionnairesaskingquestionsaboutwhopreparesmealsathome,whothemealsareprepared

for(themselvesvsthefamily),andeatingpatterns.Additionally,afoodfrequencyquestionnaire

wasusedtoassessdietaryquality.Agreatadvantageofthisstudyisthatparticipantswerevery

ethnicallyandsocioeconomicallydiverse.Childrenwereconsideredtobeinvolvedinmeal

preparationiftheyhelpedwithatleast3mealsperweek.Thosechildrenincluded42.2%ofthe

femaleparticipantsand28.4%ofthemaleparticipants.Thestudyfoundasignificantassociation

betweenchildinvolvementinpreparingfamilymealsandincreasedfruitandvegetableintake

(+.4servingsofvegetablesoverthosewhodidnothelppreparemeals,p<.001),increased

nutrientintake,andincreasedfrequencyoffamilymealstogether(afacilitatortohealthyeating

behaviors).19Surprisingly,thestudyalsofoundthatthoseparticipantswhowereinvolvedinmeal

preparation,andthereforehadhealthierdietarypatternsandbehavioratefastfood.52more
timesweeklythanthosewhodidnothelppreparemeals(p<.01).Anotherunexpectedresultfrom

thisstudywasthatmotherandfatherinvolvementinmealpreparationwasnotassociatedwith

betterdietqualityintheirchildren.Thisresultcontradictswhatotherstudieshavefoundandthe

researchersindicatedthatitmayhavebeenaresultofthenatureofthequestionnaire.20

Throughoutthissection,wehaveseenthatincreasedfastfoodconsumption,and

decreasedfoodathome,iscontributingtoincreasedBMIandbodyfatcompositioninAmerican

children,andevidentiallycontributingtochildhoodobesity.Eachofthestudiesdiscussedwasof

anobservationalnature,asthatisthehighestlevelofevidenceavailableonthistopic.This

clearlyindicatesaneedformoreresearchintheareasothatcausalrelationshipscanbeexplored.

Movingforward,gainingabetterunderstandingofwhyfamiliescontinuetoeatfastfood(with

greatfrequency)despitetheimplicationscanhelptoidentifyareasthatinterventionsshould

target.

BarrierstoEatingHomeCookedMeals

Knowledgeabouttheimportanceofeatingbalanced,homecookedmealstoprevent

childhoodobesityisnotenoughifbarriersareinplacethatpreventfamiliesfrompreparing

healthymealsathome.Identifyingthesebarriersiscriticaltodesigningappropriateinterventions

thatwillhaveapositiveimpactonimprovingtheamountandqualityofhomecookedmeals.

ResearchforthissectionwasidentifiedthroughPubMedsearchingforbarriersANDcooking.

Narrowingthesearchtoincludeonlyclinicaltrialsandstudiespublishedwithinthelast5years

identified2researcharticlesthatdefinitivelyidentifybarriersmodernfamiliesface.

Aqualitativephotovoicestudyprovidedinsighttoperceivedthreatsandfacilitatorsto

healthyathomeeatingforadolescentswhowereobeseoroverweight.21Twentytwoparent
adolescentdyadswererecruitedtoparticipate,themajorityofwhomwerefemalesfromhigh

incomefamilies.Theadolescentsweregivendigitalcamerasandaskedtotake5photographsof

thingsthateithermadeitchallengingorhelpedthemtoeatmealsathome.Interviewswere

performedwiththeparticipantsbeforetheirphototakingtoexplainthestudyandagain

afterwardstofurtherdiscussthephotostheyhadtaken.Quotesfromtheinterviewsand65%of

thetotalphotographssubmittedwereanalyzedusingdirectedconstantcomparativeanalysis.

Theprimarythemesfoundinorderoffrequencydiscussedwere:homecooking,

availabilityandaccessibilityoffood,parentingpractices,familymodeling,celebrations,and

screenuseandstudying.Homecookingwasseenasafacilitatortohealthfuleatingwithimages

depictingsidesaladswithdinnerorfamiliescookingtogether.Moreprocessed,snackfoodsat

homeversushealthyoptionswasseenasabarrierformanyoftheparticipants.Healthyfoods

thatwereeasytograbanddidntrequirepreparation(suchaspeppersthathadalreadybeen

sliced)wereidealoptionsfortheseparticipants.Parentingpracticeseitheractedasabarrieror

facilitatortoconsumingahealthydiet,withthetypesoffoodtheparentschosetoeatandprepare

themselvesimpactingtheadolescentsdiets.Additionally,theadolescentsoftenfeltalackof

controlovertheirfoodchoicesasseenwhenparticipantsdiscussedfamilymodeling.

Thesefindingssupportthathomeenvironmentsandhomecookingplayacrucialrolein

determiningthequalityoftheparticipantsdiets.Individual,social,andphysicalfactorsactin

thehomeasbarrierstohealthyeatingbyadolescentsandrequiretargetedinterventions.This

studywassuccessfulincombiningphotovoiceandinterviewstudystyles,butonlyonasmall

sampleofpeople.Abroaderstudyspanninggendersisrequired.Differentbarriersmayexistin

lowersocioeconomicsettingsaswellwhichwillrequiredifferentinterventions.
 Barriersandfacilitatorstocookingwerealsoexaminedamongadultsviaqualitative

interviews.22Twentysevenadultswithvariedlevelsofemploymentparticipatedofwhich33%

hadchildrenintheirhouseholdthattheycookedforatleastonetimeperweek.Whenaskedto

ranktheircookingabilitiesfrom1beingnoabilityto7beingveryskilledatcooking,59%

fellinthe45,averagecookingskillrange.

Transcriptionsandcodingoftheinterviewsidentified5commonlymentionedbarriersto

homecooking:timepressures,needingtosavemoney,adesireforeasy,effortlessmeals,family

foodlikesanddislikes,andthedeterrenceofpastcookingfailures.Additionally,fourfacilitators

tohomecookingwere:topromotehealth,forcreativeinspiration,becauseonehastheabilityto

planandpreparesuchmeals,andfinallytofurtherselfefficacyincooking.

Thesefindingsareconsistentwiththoseotherresearchandprovideasolidfoundationfor

interventionplanninganimplementation.23,24Limitationstothissurveyincludethesmallsample

sizeandthelimiteddiversitywithinit.Alargersurveyofthesamenatureincludingparticipants

fromvaryingsocioeconomicbackgroundsmayprovidefurtherinsight.Specifically,askingthe

samequestionsofparentsinfooddesertsinourcountrycouldbeuseful.

EvidencehassuggestedthatintheUnitedStates,thosewhoarethemostlikelytobecome

obesearethosewholiveintheareaswiththehighestdocumentedratesofpoverty.25Thus,

emphasisshouldbeputonidentifyingthebarriersfamiliesfaceinthoselowincomeareas.

Whilethetwostudiesdiscussedinthissectionhavesuccessfullypresentedareasthatrequire

intervention,neitherofthemhavehadaparticipantpoolbroadenoughtoaddresstheneedsof

lowincomefamilies.UsingGoogleScholartosearchforbarriers,cooking,lowincomeI

identifiedastudythatspecificallyaddressedthisresearchgap.
 Aqualitativestudywithfocusgroupsin3rurallowincomeareasofMichiganaimedto

improvetheunderstandingofwhatcaregiversperceiveasbarriersinestablishinghealthyeating

patternsintheirtoddlers.26ParticipantswererecruitedfromlocalWICandEarlyHeadStart

programsandvariedinrace/ethnicityandemploymentstatus.

Openendedquestionsposedbyafacilitatorofthesamegenderwereused.Questions

suchas:Whatdoyoudowellwhenfeedingyourchildren?andWhatconcernsdoyouhave

abouthowyourchildreneat?wereasked.Threemainbarrierstoconsistentlyprovidinghome

cookedhealthymealswereidentified.Thefirstwasalackoftimeforshopping,preparing,and

cookingrelatedtolimitedaccesstotransportation,lackofmoneytopurchasenutritiousfoods,

andbeingawayfromthehomeforlonghoursduetowork.Havingchildrenwithspecialdietary

needs,suchasincerebralpalsy,placedanadditionalstrainonthecaregiversabilitytoprovide

theirchildrenwithnutritiousbalancedmeals.Duringthefocusgroups,participantsalso

expressedadesireforeducationabouthowtheycouldsuccessfullyprovidetheirchildrenwith

suchmealsintheirsocioeconomicposition.

Thisstudyisconsistentyetextendsthebarriersidentifiedintheprevioustwostudies.

Eachofthestudiesusedqualitativeresearchtoidentifyandrankbarriersparentsofchildrenface

whentryingtoprovidehealthymeals.Thelaststudysummarized,however,focusedonlow

socioeconomicstatusfamilies,andthespecificchallengestheyface.Themostglaringdifference

wasthatsomeofthebiggestbarrierstolowincomefamilieswereexternalfactorsandnothaving

accesstohealthyfoodstofeedtheirchildrenwhileinternalfactors(suchascookingability)were

morecommonlyreferencedinotherpopulations.
 Understandingthesebarrierswillprovidethefoundationfordesigningeffective

interventions.Thissectionhasidentifiedareasthatrequireinterventionsonmultiplelevels.

Teachingfamilieshowtocook,increasingtheaccessibilitytonutritiousfoodsinlowincome

areasandregulatingfastfoodcompanieswhileimprovingpublicassistanceprogramscan

addresssomeoftheneedsthathavebeendiscoveredhere.

FamilyIntervention:ProvidingCookingResources

Interventionsthatreachparentsaimtodecreasebarrierstohomecooking.Thissection

explorespilotinterventionsgearedtowardsparentstoimprovetheircookingskills,andasa

resulttheirchildrensdietquality.Thestudiesinthissectionwerefoundbyperforminga

PubmedsearchforcookingANDinterventionsandhomeANDcooking.Eachsearchwas

filteredforarticlespublishedinthelast5yearsandforclinicaltrialssothatthemostappropriate

studiescouldbeidentified.

A10weekpilotinterventionstudyfoundthatprovidinganinstructionalcooking

interventiontochildrenandparentstogetherdecreasedthenumbersofmealseatenawayfrom

home,effectivelyimprovingdietqualityanddecreasingcaloricintakeinchildren.27Sixparents

withchildrenages310yearswhoselfreportedeatingfoodawayfromtheirhomeatleast3

timesperweekwereidentifiedintheMidwestUnitedStates.Eachoftheparentswere

overweight/obeseandtheprimarycaregiver.

Thestudyfocusedondinner,themealofmostparentalcontrol.Theproportionofmeals

consumedoutsideofthehome(measuredinnumberperweek),theenergyintakeanddietary

qualityofthedinners,anduseofthesuggestedinterventionswerecoveredinweekly,6090

minutesessions.Thesessionswerekitchenbasedandledbyaregistereddietitiananda
psychologydoctoralstudentwhohadexperiencewithnutritionandbehaviormodification.The

first6parentonlysessionsfocusedoncookingskillsandskillstomanagetheirchildsbehavior.

Duringthelastfoursessions,thechildrenattendedwiththeirparents,wherethedyadscooked

togetherandtheparentswereabletopracticeanddisplaythebehaviormanagementskillsthey

hadlearned.Anumberofrecipes,spanningfoodgroups,withappropriatesubstitutions(to

simulateathomecooking)werepreparedeachweek.

Parentscompleteda7dayfoodrecordbeforeandafterthestudy,notingthetypeofmeal

theyhadfordinner(fastfood,homeprepared,frozen,etc.).Frompretopostinterventionat11

weeks,dinnerseatenoutsidethehomedecreasedfrom56%to25%andhomepreparedmeals

increasedfrom44%to75%.Theaveragedinnerenergyintakedidnotsignificantlydecrease,but

childenergyintake(65kcal)decreasedmorethanthatoftheirparents(14kcal).Theonlydiet

qualitychangewasa30mgdropincholesterolfrompretopostintervention.Alloftheparents

reportedcookingwiththeirchildathomeand5ofthe6reportedusingthebehaviormanagement

toolswiththeirchildrentohelpcombatpickyeating.

Whilethestudyshowedpromisingresults,itwasverysmallandlimitedindiversity,both

ethnicallyandsocioeconomically.Additionally,longtermbehavioralchangeswerenot

measuredinthestudy.Alongerterm,largerstudyofthisnaturewouldberequiredtoseeeffects

onthechildrensadiposityanddietquality.Theindividualizationoftheeducationandsupport

forparentsinthisstudyprovedtobeveryeffectivebutwouldbedifficulttoduplicateinlarger

settings.Astudyfocusingonlowsocioeconomicfamiliesandtheeffectivenessofcooking

interventionsinthatpopulationisrequiredtofurthertestthehypothesis.
 Anotherpilotstudyemployedhomevisitsto104parentsofHeadStartenrolledchildren

(lowsocioeconomicstatusfamilies)toincreasevegetableconsumptionthroughcookinglessons

andvegetablerelatedactivities.28Onceamonthforthedurationofthestudy(8months)

participantshomeswerevisitedandresearchersleadacookingandlearningactivityfocusedon

variousvegetables.Preandpostinterventionsurveyswereusedtogatherdataonparticipants

cookingconfidenceandwhetherornottheylikedthevegetables.Resultsfromtheparticipants

indicatedalargeincreaseincookingconfidence,especiallyinbaking,roasting,andgrillingof

vegetables.Parentsfeltcompetentincooking6ofthe10vegetablestheyweretaughtand,on

average,tried7ofthe12offeredtothem.Mostparticipants(86%)feltthattheinterventionwas

understandableanddoable,withtherightsupport.

Thisstudyshowedthatparentsinareaslowinresourcescanstillbenefitfromcooking

directedinterventions.Cookinginterventionsareoneroutetotakeintryingtoimprovethediet

qualityofobeseoratriskchildrenfromvulnerablepopulation.Unfortunately,nofollowupwas

donewiththisstudysoinformationonlastingeffectsoftheinterventionisnotknown,butwould

bevaluableinformation.

Anoverbearingthemefoundthroughtheresearchonthistopicisthataccesstoresources

suchasaccesstogrocerystoresandhealthyfoodoptionsisapredictorofdietquality.29,30,31

Interventionsgearedtowardsprovidingparentswiththeresourcestheyrequiretoprovidehealthy

athomemealsfortheirchildrenareneeded.

Arecentfeasibilitystudywasdesignedtotestthepracticalityofimprovingchildrens

nutritionalstatusthroughafamilymealfocusedintervention.Tenfamilieswithadolescentsaged

1317participated.32Aprestudysurvey,weeklytelephonecheckins,andapoststudysurvey
wereusedtogatherdataontheefficacyoftheintervention.For8weeks,familiesweredelivered

recipes,ingredients,andcookingsuppliestoprepare5dinnermealsperweekatnocosttothem.

Adolescentswereencouragedtoassistinthecookingofthemeals,andallofthemdidforat

leastsomeportionofstudy.Over85%ofthedeliveredmealswerepreparedtogether,andof

thosemeals96%wereeatenwiththeparentandadolescenttogether.Acommoncommentfrom

parentsandadolescentswasthattheyenjoyednothavingtoputtheeffortintoplanningout

meals,andworkingtomakethemhealthy/meettheirnutrientneeds.Theyoverallenjoyedtrying

newthings,andtheconvenienceofhavingrecipesandfoodsavailabletothem.Nineoftheten

participatingdyadsreportedeatingmoremealsathomeoverthecourseoftheinterventionthan

theydidonaveragebeforeitwasimplemented.Bothparentsandadolescentsreportedbeing

apprehensiveofthechildcookingwiththem,butoverallenjoyeditandlearnedfromthe

experience.Oneparentstatedthattheydidnotrealizetheyhadnottaughttheirchildbasic

cookingskillsbefore,likechoppingvegetables,becauseitwasneversomethingtheythoughtof,

buttheyaregladtheinterventiongavethemtheopportunity.

Insummary,thesepilotinterventionssuggestthatincreasingfamilyaccesstocooking

educationandhealthyfoodscanimprovedietqualityandweightstatusinchildren,although

thesearepreliminaryfindings.33However,thisevidenceispreliminaryandlargerrandomized

controltrialsareneededtoassesstheirimpact.

CommunityIntervention:IncreasingAccessibility

Increasingathomemealsanddecreasingfastfoodconsumptiongoesbeyondteaching

parentsandchildrentocook,especiallyiftheydonothaveaccesstohealthyfoodtoprepareat

home.Fromthediscussiononbarriers,ithasbeenestablishedthataccesstoaffordablehealthy
foodoftenpreventsfamiliesfromachievinganadequatedietaryqualityandeatingmealsat

home.21Acriticalcomponenttocombatingchildhoodobesityiscommunitylevelintervention.

ThearticlesdiscussedinthissectionwereidentifiedthroughresearchonAmericanfooddeserts

throughtheUSDAlistofcurrentfooddesertsandthroughaPubMedsearchforcommunity

ANDfood.34Interventionsgearedtowardsincreasingfoodaccessibilityonthecommunitylevel

werechosenfordiscussion.

Alderson,WestVirginiaisasmalltown(315families)inWestVirginiathatrecently

becameafooddesertafteritsonlygrocerystoreshutdown,leavingcitizens11milesawayfrom

thenextgrocerystore.35WithinthetownofAlderson,52%ofthechildrenliveinpoverty.An

observationalstudylookedattheresultsofaGreenGroceropeningupinthecommunityin

responsetobecomingafooddesert.AGreenGrocerisasmallcoopdesignedandrunby

membersofthecommunityinresponsetobecomingafooddesert.Itisnotacomprehensive

grocerystoreinthatitdoesnotcarrytoiletries,aluminumfoil,andotherfrequentlyrequested

nonfooditems.Ofthefoodoffered,1832%werelocalproducts,whichprovidesanadditional

benefitofhelpingthelocaleconomy.

AsurveyaboutfamilyacquisitionoffoodbeforeandaftertheGreenGroceropenedwas

completedby49%ofthefamiliesinthetown.Ofthosefamilies,25%wereSNAPrecipients.

Thesurveyfoundthat91%ofparticipantsusedtheGreenGrocer.However,changeinfrequency

invisitstothegrocerystore11milesawaydidnotchange.FamiliesreportedusingtheGreen

Grocertosupplementgroceryshoppingwhentheydidnothavetimetotraveltotheotherstore.

Mostfamiliesboughttheirproduce,meat,eggs,andbreadthereandpurchasedotheritemsin

bulkfromthetraditionalgrocerystorewhentheycouldgetthere.Ofthosesurveyed,44%said
theydidnotexclusivelyusetheGreenGrocerbecauseofthelimitedoptionsitofferedand36%

saidbecauseitwastooexpensive.ThetownofAldersonhas4fastfoodrestaurantswithinits

borders,buttheydidnotseeanincreaseinsalesaftertheclosingofthegrocerystorenordid

theyseeadecreaseinsalesfollowingtheopeningoftheGreenGrocer.

Theresultsfromthisinterventionindicatedthatopeningacommunitygrocerycoopwas

notafeasiblewaytoincreaseaccessibilitytonutritiousfoods.Familyfoodattainmentpatterns

experiencednosignificantchangeafteropeningit,andlimitedoptionsandhighpricesrestricted

AldersoncitizensfromutilizingtheGreenGrocerexclusively.Interventionswithoutthose

barriersthatincreaseaccessibilityareneeded.Oneadditionalfindingfromthisstudywasthat

43%ofparticipantsreportedrelyingonfoodpantriesmoreaftertheirtownbecameanofficial

fooddesert.Thisfindingidentifiesavenueforintervention.

Increasedrelianceonfoodshelves/pantriesisatrendinfamilieswithchildrenacross

America.36ApilotinterventioninSt.Paul,MNincorporatedacookingandnutritioneducation

classinto4foodpantriesacrossthecity.37Theaimwastogagetheeffectivenesstheclasswould

haveoncookingskillanddietaryqualityoffoodpantryusers.Pre,post,andfollowupsurveys

wereusedtotrackchanges.Betweenthe4sites,63individualsparticipatedin6sessionswhere

12recipesweretaughtbyachef,followedby3040minutesofnutritioneducationviaa

CookingMatterscourse.Ofthosewhoparticipated,62%wereSNAPrecipients.Pre

intervention,dietqualitywasverypoor,averaging50.9/100ontheHealthyEatingIndexscale.

Directlyaftertheintervention,dietaryqualityincreasedto58.5/100(p=.01).Healthycooking

abilitywasalsomeasuredandincreasedfrom33.1%to35.9%throughtheintervention

(measuredviatheparticipantsreportingthattheywereveryconfidentintheircookingskills).
Unfortunately,atfollowup,theimproveddietaryqualityhadnotbeensustained,butperceived

cookingabilitywas.

Whilethisinterventionsuccessfullyimprovedcookingskills,whichcanimprovedietary

qualityinfamilies,directimpactonchildrenoflowincomefamilieswasnotlookedat.

Furthermore,foodpantriesarenotusedbyoravailabletoallAmericans.Interventionsavailable

toalargeraudienceshouldbeconsideredandimplemented.

OnequasiexperimentalstudyinBaltimoreaimedtodothat.38Thepurposeofthestudy

wastodeterminethefeasibilityofstockingandsellinghealthyfoodoptionsincornerstoresinan

urbanareatoincreaseaccessibilitytohealthyfoodsforlowsocioeconomicstatusfamilies.

Thesetypesofstoresarewheremanylowincomefamiliesintheareadotheirfoodshoppingand

healthyoptionsareusuallyfewandfarbetween.Thehopewasthatbyincreasingaccessibility,

dietaryqualityofthecommunitywouldimprove.Sevencornerstoresand2supermarkets

receivedtheinterventionand6cornerstoresand2othersupermarketsservedasthecomparison

controlgroup.Asetof24hourfoodrecallswerepreformedthroughoutthecommunityto

identifythemostcommonlyeatenunhealthyfoods.Healthieralternativestothosefoods(suchas

lowsugarhighfibercerealsinplaceofhighsugarcereals)werepresentedtothestoreowners

alongwithinformationonwheretopurchasethoseitemsinordertostockthemintheirstore.

Overall,12healthyoptionswererecommendedforstockingoverthecourseof10months.Inthe

end,interventionstoreshadanaverageofa7fortheirhealthyfoodstockingscore(onascaleof

110basedonthenumberofhealthyoptionstheyofferedandtheextenttowhichtheywere

stocked),versus5.5inthecomparisonstores,asignificantresult(p=.009).Sixmonthspost

intervention,somehealthyoptions,suchaswholewheatbreads,lowsaltcrackers,andbaked
chips,werestillbeingofferedinthosestores(theyhadnotbeenpreintervention)indicatinga

degreeofsustainability.Overall,thestoreownersperceivedfeasibilityofregularlystocking

healthyfoods(andknowingwhichfoodswerehealthywhenchoosingproducts)wasmoderately

increased,buttheircontinuedstockingofhealthyfoodsindicatesthatthisisavenuewhere

furtherinterventioncouldbesuccessful.Unfortunately,storeownerswerenotwillingtorelease

salesrecords,soinformationaboutthecommunitysacceptabilityofthehealthyoptionsis

unknown.Moreresearchisneededinthisarena.

Asresearch,hassuggested,accesstofoodisatleastinpartinfluencedbyneighborhood

environments.39Innercityandurbanareasareoftenoversaturatedwithsmallconveniencestores

andfastfood.Thisoverexposuretounhealthyoptions,withlimitedaccesstonutritious,whole

foods,hasbeenshowntobecorrelatedwithincreasedratesofchildhoodobesity.Community

levelintervention,inthiscase,becomescritical.

Throughthissectionwehaveseenthatinterventionshavebeguntobeimplementedin

lowsocioeconomicareasacrossthecountrytoincreaseaccesstohealthyfoods,andknowledge

abouthowtopreparethem.Unfortunately,thisisanewareaofconsiderationandnoneofthese

interventionswerelongtermorextremelysuccessful.Asthefeasibilityofprogramsliketheones

discussedherearedeterminedfurtherinterventionscanbedesignedandfinetunedtomeet

communityneedsandhelptoincreaseaccesstohealthyfoodsforfamilies.

PolicyIntervention:SNAPImplicationsandFastFoodRegulation

Combatingchildhoodobesityextendsbeyondthescopeofindividualandcommunity

interventions.Policyinterventionscanreachalargeraudienceandwithgreateramountsof

fundingtohaveagreaterimpactonAmericans.Assistanceandeducationprogramsarealready
inplaceandarecontinuingtodevelop.Alookattheimpactthesepolicieshavehadispresented

inthissection.ArticleswereidentifiedbysearchingPubMedforcookingANDpolicyandby

exploringtheFederalDrugAdministrationswebsiteforuptodateinformationonfastfood

labelinglaws,asthisisinaperiodoftransitionrightnow.40

In2010anumberofhealthreformswereproposedbytheObamaadministration.A

relevantonewastheproposedmenulabelinglaw.Underthislaw,chainrestaurantswithmore

than20locationswillberequiredtopostcalorieinformationforallregularmenuitems.41In

addition,informationabouttotalfat,caloriesfromfat,saturatedfat,transfat,cholesterol,

sodium,totalcarbohydrates,fiber,sugars,andproteinmustalsobeavailabletoconsumersupon

request.EnforcementofthislawwillgointoeffectonMay5th,2017.Thehopeswerethatif

consumershadaccesstothisnutritioninformationtheywouldmakebetterchoiceswheneating

FAFH.Theimplementationofthislawhastakensolongduetomixedresultsfromtheresearch

oftheimpactthiswillhave.Inaninterventiontotesttheeffectiveness,106adolescentswere

givenmenusfromthreefastfoodchains(McDonaldsDennysandPandaExpress)andaskedto

decideonamealtheywouldorder.42Theywerethengiventhesamemenus,butwithcalorie

valueslistednexttoeachfooditem.Whenaskedtoreconsiderandreorderfromthemenuwith

calorieinformation71%ofthesampledidnotchangetheirorder.Ofthosewhodidchangetheir

order,only15%madeachoicethatdecreasedtheirtotalcalorieintakefromthemeal.These

resultsindicatethatcaloriepostingdoesnotimpactthemealdecisionsofmostadolescents.

Despitethis,thispolicyisbeingputinplacebecauseithasshowntohavesomepositiveeffect

whilenotimpactingtherevenueofthecompaniesrequiredtolistcalories.Whilethisisastepin
therightdirection,theevidencesuggeststhatnosignificantdecreaseinfastfoodconsumption

willlikelyoccurandfurtherpolicyinterventionisrequired.

Anadditionalaspecttopolicyinterventionisfederallyfundededucationprograms.

SNAPprovidesmonetaryassistancetofamilieswhoarelowincomeandcommonlyfood

insecureinAmerica.Additionally,ithasaSNAPedprogramthatprovidesnutritioneducation

abouthealthyeatingonlimitedbudgets.Theeffectivenessofthisprogramwaslookedatina

parallelarmnutritioneducationinterventionacrossthestateofIndiana.43SNAPeligiblefamilies

withchildrenwererecruitedandrandomlysortedintoeitherinterventionorcontrolgroups.The

controlgroupswereaskednottoparticipateinSNAPedforoneyearduringthecourseofthe

interventionwhiletheothergroupwasrequiredtoattendaminimumof4lessonsfromthe

SNAPedcurriculum.Asurveywasgivenbeforeandafterinterventionthataskedquestionsto

gaugelevelsoffoodinsecurity,whichwasthenquantified.Beforetheintervention40%ofthe

familieswerefoundtobefoodinsecure.Theinterventiongroupwasaskedthesamequestions

duringthepostsurvey,butforthetimeframeof30dayssothattheimpactoftheintervention

couldbemeasured.Atthattime,therewasa25%decreaseinfoodinsecurityforthatgroupin

comparisontothecontrolgroup.Educationtopicsincludethriftyspending,farmersmarket

shopping,andstrategiestoincreasefruitandvegetableconsumptiononabudget.Theevidence

suggeststhatSNAPedissuccessfulinincreasingfoodsecurity,andduetothenatureofthe

program,athomecooking(SNAPprovidesmoneytopurchasegroceriesthatcannotbeusedon

fastfood).ExpandingtheSNAPedprogramandallowingittoreachmorefamiliesmaybea

usefultoolinincreasingtheprevalenceofhealthyathomecookingtocombatchildhoodobesity.
 Proposingpolicylevelinterventionscanonlygosofariftheyarenotsupportedbythe

governmentandpublic.Arecentstudycompiledquantitativedataonpublicsupportforcooking

andnutritionrelatedpolicies,asthiscanbeaturbulentissue,especiallyinthecurrentpolitical

climate.44A7pointLikertscalewasdesignedtoquantifyparticipantssupportforpoliciessuch

asSNAPed,requirednutritioneducationinschools,andhomeeconomicclassesthatfocuson

shoppingforhealthyfoods.Oftheparticipants,64%agreedthatschoolsshouldberequiredto

teachcookingtochildrentoimprovetheirnutrition,67%supportedofferingclassestoteachkids

howtoshopforandcookhealthyfoods,butonly45%supportedanincreaseinfundingfor

cookingclassesforSNAPparticipants.Nonotabledifferencesbetweengender,age,ethnicityor

politicalaffiliation,werenotedforsupportfortheclassesinschoolbutgapsinlevelof

education,age,andpoliticalaffiliationwereseenforthesuggestionofanincreaseofSNAP

funding.

SNAP,WIC,andanumberofstateandfederallevelprogramsareinplacetohelp

supportfoodinsecurefamiliesinmakinghealthydecisionsandcookingathomeinplaceof

eatingfrequentFAFH.Regulationsonfastfoodindustriesareinplace,butonlytoasmalldegree

anddiscussionsabouttaxationandmarketingregulationareinplacetofurtheraddressthehealth

impacttheycanhaveonAmericanchildren.Whilecommunityandindividualinterventionshave

showntobesuccessfulinaddressingchildhoodobesity,majorchangeswillnotbeseenuntil

publicpolicycatchesup.Moreresearchandinterventionsareneededtoaddresstheissueat

hand.

Conclusions
 IthasbeenmadeclearthatchildhoodobesityisapresentproblemacrossAmerica,but

especiallyinlowsocioeconomiccommunities.Anumberoffactorscontributetothisproblem

includinggenetics,parentingstyles,schoolenvironments,and,asdiscussed,theproportionof

fastfoodtomealseatenathome.Obesity,often,istheresultofoverconsumptionofenergy

densefoods,muchlikethefoodsfoundinfastfoodrestaurantsandconveniencestores.In

comparison,mealspreparedathome,withhelpfromchildren,promotehealthierdietary

behaviorandpatterns,suchasgreatervegetableconsumptionanddecreasedsaturatedfatand

sodiumconsumption.18

Thepresentpaperreviewedanumberofrecentstudies,mostlyofobservationaldesign,to

examinewhyfamiliesareeatingfastfood,howfastfoodiscontributingtotheproblemof

childhoodobesity,whatisstoppingfamiliesfromeatinghealthymealsathome,andwhatis

beingdoneontheindividual,community,andpolicylevelstoaddresstheseissues.

Theevidenceavailableatthistimesupportsthatfastfooddoescontributetochildhood

obesity,butfallsshortinsuggestingwhatinterventionscansuccessfullybeputinplaceto

increasefoodeatenathomeonalargescale.Nearlyalloftheinterventionsthathavebeendone

atthispointhavebeenofanobservationalnatureandonasmallscale.Furtherrandomized

controltrialsoflargersamplesizesareneededtoincreasethelevelofevidenceavailableonthis

subject.Anongoingstudyiscurrentlyworkingtodeterminewhattypesofinterventionsarebest

toencouragehealthyeatinginfamilies.Thisresearchwilllikelybeusefulindesigningfuture

programs.45Oneadvantagetotheinformationthatisavailableisthatamajorityoftheresearch

hasbeendoneinlowsocioeconomiccommunities,avulnerablepopulationthatismostaffected
byfoodinsecurityandlackofinformationabouthowtomakehealthyeatingchoicesevenwhen

eatingfastfood.

Childhoodobesityhasnoonecauseandbroadereffortsthataddressthosemultiple

factorsareneededthatgobeyondthecontextofthispaper.Interventionsdonotneedtobe

isolated,butshouldinfactaddressmultipleissuesatoncetobethemosteffective.Childhood

obesityisaproblemthatimpactsthehealthofournationasawhole,andneedstocontinuetobe

researchedandaddressedonmultiplelevels.
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