In the wise words of the Harvard psychologist Jerome Kagan, precisely how a parent feeds an infant or disciplines a teenager is less important than "the melody those actions comprise." The feelings that parents bring to the role-their pleasure in parenting, their respect for the child-are extremely important. But most important is ensuring adequate time for the role...at the heart of the matter is time, huge amounts of it, freely given. Whatever the child-raising technique, a child simply does better with loving, committed, long-term attention from both mom and dad.
Hewlett and West 1
A 1995 Carnegie Corporation report 2 describes the depth and reach of our child-related problems: "Altogether, nearly half of American adolescents are at high or moderate risk of seriously damaging their life chances. The damage may be near-term and vivid, or it may be delayed, like a time bomb set in youth."(2p10) Obesity is but one of the "time bombs" that affects the health and longevity of youth, but unlike other threatening factors, such as drug and alcohol use, the consequences of smoking and obesity can take many years to develop. As with individuals who smoke, many individuals who are obese appear to be left relatively unscathed by adverse social or health consequences. This may lead to a false sense of security among parents that childhood obesity is a relatively benign condition that cannot and should not be a high priority of beleaguered parents who are rightfully concerned about drug and alcohol use, violence, precocious sex, and other seemingly more urgent problems.
What needs to be examined carefully is whether committed parenting can prevent these more obvious threats to the health and well-being of children and at the same time yield the added dividend of preventing childhood obesity. If that can be convincingly demonstrated, it argues for a more comprehensive and coordinated approach to addressing the threats to children's health and well-being. It is critically important, therefore, to define the elements of engaged parenting and how it operates within families to promote or prevent childhood obesity. Wherever possible, we should quantify the extent to which effective parenting strategies for obesity prevention may yield other child health protective effects as well. In the meantime, in the absence of data to guide us, many healthcare professionals, researchers, and educators have extrapolated from the meager obesity prevention literature that does exist and from their own experience to identify strategies that hold promise. One such report appears in this issue of Nutrition Today. This report examines 4 environmental factors that the authors reasonably argue can help prevent childhood obesity. The factors they have chosen to focus on are portion control, fruit and vegetable consumption, television viewing, and vending machines. The authors argue that parents can become teachers, guides, advocates, and role models with respect to these factors, and we would agree. However, the barriers and challenges faced by parents have never been greater. The benefit of this report is that much of it can be implemented by parents (this term is used throughout in the broadest sense of "caregivers") who are, after all, the policy makers in the family. Of course, this is easier said than done.
The Benefits of Engaged Parenting
Parental love and parental attention and guidance are nearly without parallel in determining the fate of children. Genes may dictate eye color and disease predisposition and, to a significant degree, raw intelligence, but whether a child acquires discipline and self-esteem and becomes a well-adjusted productive person is largely a function of parental input and how well both parent and child are supported by the wider community. 1 In their remarkable book, The War Against Parents, Hewlett and West make the case that committed parenting is a key factor that can prevent a whole host of problems that besiege American youth, including obesity. 1 These authors paint a depressing and vivid picture of the myriad ways in which parents are under siege: of fatherless families, extreme pressures on single mothers, the necessity for both parents to work in otherwise intact families, few social and economic policies that value parenting and that support parents in meaningful ways, and the absence of enlightened family leave policies. Instead, in many instances, the stress is so great that parenting "breaks down and becomes inconsistent and erratically punitive." 1 It is children in these families who are in greater danger of not succeeding in school, experimenting with drugs, and becoming clinically depressed and seriously self-destructive compared to children in other industrialized countries.
Dr Laurence Steinberg of Temple University has studied adolescent academic performance and other behaviors. He has described 4 parenting styles 3 (authoritative, which is the most preferred style; authoritarian; permissive; and uninvolved, which is the least preferred) and identified at least 5 ways in which parents influence their children's health behaviors (L. Steinberg, verbal communication, August 10, 2003):
[black small square] Parents are a source of genetic transmission of vulnerability
[black small square] Parents serve as models of health behavior
[black small square] Parents permit access to various foods (food type, quantity, and frequency at home and outside the home) or products that foster either activity (bikes and sporting equipment) or a sedentary lifestyle (television or telephone in bedroom, etc)
[black small square] Parents provide direct socialization of relevant behaviors (eg, what they tell their children they can and cannot eat, rule making, grooming, setting appearance standards, how they support or reward a child's activity through dance or soccer lessons, and attending a child's basketball games)
[black small square] Parents are a source of indirect socialization of health behavior through general parenting practices (eg, harsh parenting or neglect may lead to depression, which may lead to overeating and inactivity; balanced parenting based on respect for the child and the encouragement of self-expression may lead to self-esteem and confidence)
How does all of this relate to a consideration of how eating and activity get transmitted from parents to children? With respect to child-feeding practices, children's food preferences and food selection, Birch and Fisher 4 have summarized the multitude of factors that are involved:
[black small square] Parents choose an infant-feeding method (eg, breast vs bottle).
[black small square] Parents make certain foods available and accessible in the home.
[black small square] Parents model certain eating behaviors that their children emulate.
[black small square] Parents influence the extent of media exposure in the home.
[black small square] Parents interpret media messages for their children.
[black small square] Parents set the tone and interact with children in the eating context.
[black small square] Parents often believe that certain foods are "good" and others are "bad" and do not believe or understand that there are quantities in which all foods can be enjoyed and safely consumed.
[black small square] Parents use foods to manipulate their children's behavior (rewarding behavior with certain foods or withholding certain foods as a punishment).
[black small square] Parents believe that consumption of certain foods (such as vegetables) should be encouraged and do not realize that this can lead to dislike of those foods.
[black small square] Parents believe that consumption of certain foods should be discouraged and do not realize that this can lead to increased liking of those foods.
Regarding physical activity the connection is less clear. Kohl and Hobbs 5 have described the strong influence of parents who can directly provide a "supportive, nurturing environment." Parents can also influence their children through modeling the active lifestyle they wish their children to adopt. Kohl and Hobbs report a relationship between the physical activity of parents and that of their children and assert that there is "reasonable evidence" of a dose-response between the number of active parents (0,1,2) and the activity levels of children. The effect of parental behavior on children may be greater than the effect on adolescents and may differ according to the gender of the child. These authors acknowledge that peer pressure and professional athletes may also affect the physical activity levels of children but do not develop the concept that parents can modulate or filter this influence.
Barriers to Engaged Parenting
Hewlett and West identify a cross-cutting factor that affects parents in all walks of life in contemporary America: they are suffering from a "time famine"-all parents report that they are unable to devote sufficient time and attention to their children. One Stanford economist, Victor Fuchs, has argued that the amount of parental time available to children decreased in the 1970s and the 1980s with the result that "white children lost ten hours a week of parental time, while black children lost twelve hours." 6 A similar argument has been advanced by another economist, Edward Wolff. 7 More recently, James Surowiecki has described escalating costs of raising children-primarily a function of rising costs of housing and education-and has pointed to the economic perils of middle-class couples who face higher rates of bankruptcy and late bill payments "in large part because they have kids." 8 Parents are facing these economic challenges by working ever harder and longer hours. They often earn a living in an environment that is hostile or indifferent to their plight, in which there is an absence of family leave policies, especially in companies with fewer than 50 employees.
The average worker is now at work 163 hours (an extra month) a year more as compared to 1969. 9 Thus, the overall drift of society is toward more parents working longer hours than ever, leaving "millions of youngsters fending for themselves, coping more or less badly with the difficult business of growing up." 1 Indeed, an important 2004 report from the US Department of Agriculture 10 demonstrated that mothers working full-time is associated with a negative effect on their children's nutritional status. Contemporary America is populated by overworked stressed-out parents who are increasingly unable to be available for their children and whose lifestyles scarcely permit them to model healthy eating and exercise behaviors that are needed to prevent the development of obesity. Many of these parents are forced to place their children in day-care facilities that may or may not provide adequate care or emphasize the importance of healthy eating and physical activity. The cost, quality, and availability of day care for their children are constant concerns for contemporary parents. Coping with a child's illness that may keep a child at home is yet another source of stress.
Summary
In discussions of obesity etiology, it has been argued that genetics "loads the gun" but environment "pulls the trigger." In their examination of factors contributing to childhood obesity, Birch and Fisher 4 have rightfully pointed out that "parents provide both genes and environment for children." We can readily accept that parents play a critical role in fostering educational achievement in their children by reading to them, listening to them carefully, correcting their grammar and pronunciation, teaching the ABCs, drilling on multiplication tables, encouraging children to speak for themselves, and teaching them how to reason and frame an argument. Likewise, parents play a critical role in preventing childhood obesity by fostering healthy eating and exercise habits and by nurturing a healthy and confident self-image in their children. This cannot be accomplished without a large ongoing investment of parental time and attention, yet the parental time famine may represent an enormous barrier that must be faced and overcome to prevent obesity in our nation's children.
Not only is parenting and parental behaviors a delicate topic because of family privacy issues, but also there is a body of evidence suggesting that parental attempts to restrict and control children's eating and weight may backfire-producing the problem that they are intended to avoid. 4 Other qualitative research 11 has highlighted the defensiveness of parents regarding their own weight status and their parenting skills and priorities. Our responsibility, therefore, is to tread carefully and to demarcate those parenting practices that are demonstrably helpful from those that carry potential for harm. Policy changes designed to help parents in ways that parents themselves would welcome are urgently needed. Just as urgently needed are methods of converting policies into practice on a national scale that will positively affect the lives of children throughout this land. It is our hope that these policies will be carefully crafted to leave no parent behind.
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