PEDIATRICS Vol. 107 No. 5 May 2001, pp. 1138-1146

Why Don't Low-Income Mothers Worry About Their Preschoolers Being Overweight?

Anjali Jain, MD^*, Susan N. Sherman, DPA; Leigh A. Chamberlin, MEd, RD, Yvette Carter, Scott W. Powers, PhD^{, §}, and Robert C. Whitaker, MD, MPH^{, §}

From the ^* Department of Pediatrics, University of Chicago, Chicago, Illinois;  Children's Hospital Medical Center, Cincinnati, Ohio; and the ^§ University of Cincinnati College of Medicine, Cincinnati, Ohio.

	ABSTRACT

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Context.  Mothers are in an important position to prevent obesity in their children by shaping early diet and activity patterns. However, many mothers of overweight preschool children are not worried about their child's weight.

Objective.  To explore mothers' perceptions about how they determine when a child is overweight, why children become overweight, and what barriers exist to preventing or managing childhood obesity.

Design.  Three focus groups with 6 participants in each. Participant comments were transcribed and analyzed. Themes were coded independently by the 6 authors who then agreed on common themes.

Setting.  A clinic of the Special Supplemental Nutrition Program for Women, Infants, and Children in Cincinnati, Ohio.

Participants.  Eighteen low-income mothers (13 black, 5 white) of preschool children (mean age of 44 months) who were at-risk for later obesity. All but 1 mother had a body mass index (BMI) 25 kg/m², and 12 mothers had a BMI 30 kg/m². All but 1 child had a BMI 85th percentile for age and sex, and 7 had a BMI 95th percentile.

Results.  Mothers did not define overweight or obese in their children according to how height and weight measurements were plotted on the standard growth charts used by health professionals. Instead, mothers were more likely to consider being teased about weight or developing limitations in physical activity as indicators of their child being overweight. Children were not believed to be overweight if they were active and had a healthy diet and/or a good appetite. Mothers described overweight children as thick or solid. Mothers believed that an inherited tendency to be overweight was likely to be expressed in the child regardless of environmental factors. In trying to shape their children's eating, mothers believed that their control over the child's diet was challenged by other family members. If a child was hungry, despite having just eaten, it was emotionally difficult for mothers to deny additional food.

Conclusions.  Health professionals should not assume that defining overweight according to the growth charts has meaning for all mothers. Despite differing perceptions between mothers and health professionals about the definition of overweight, both groups agree that children should be physically active and have healthy diets. Health professionals may be more effective in preventing childhood obesity by focusing on these goals that they share with mothers, rather than on labeling children as overweight.  Key words:  obesity, body weight, mothers, child, preschool, mother-child relations.

Childhood obesity is difficult to treat¹and is associated with both physical² and emotional³ morbidity. Furthermore, obese children are more likely to become obese adults,^4,5 and the morbidity,⁶ costs,⁷ and mortality⁸ from adult obesity are all enormous. Therefore, obesity prevention that begins early in life^9,10is an important approach to reducing the dramatic upward trends in obesity prevalence.^11,12

Low-income preschool children have historically been regarded as at-risk for undernutrition^13,14; however, the prevalence of overweight in this group has recently also increased.^15,16 These children may be at particular risk for later obesity because their mothers are more likely to be obese,¹⁷ and parental obesity increases the risk for offspring obesity,¹⁸ probably through sharing of both genetic and environmental factors.

Despite the need for obesity prevention efforts in low-income preschoolers, there are multiple barriers to such efforts. For example, we have shown that among mothers without any college education, only 11% of those with an overweight preschool-aged child believed that their child was overweight.¹⁹ Among these same mothers, >90% of those who were obese (body mass index [BMI]  30 kg/m²) considered themselves overweight.

Mothers are critical mediators of obesity prevention efforts with preschoolers because mothers play such a large role in shaping the diet²⁰ and activity²¹ patterns of their young children. For pediatricians and other health professionals working with low-income preschool children, it will be difficult to engage mothers in obesity prevention efforts without first understanding how mothers perceive the problem of obesity.

The objective of this study was to understand the perceptions of low-income mothers about how they determine when a child is overweight, why children become overweight, and what barriers exist to preventing or managing childhood obesity. We used qualitative research methods because they are often useful in exploring complex, multi-faceted questions that may not be readily understood by more direct, closed-ended questioning. The methods are meant to generate a theoretical framework for how low-income mothers perceive the problem of childhood obesity and are not meant to test specific hypotheses.

	METHODS

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In November and December of 1999, we conducted 3 focus groups with mothers whose preschool children were enrolled at a clinic of the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) located at Children's Hospital Medical Center (CHMC) in Cincinnati, Ohio. WIC is a federally funded program that provides supplemental food and nutrition counseling to women and their young children living in low-income households (income below 185% of the federal poverty level). To be certified for WIC, children must meet a nutritional risk criteria to be certified, in addition to the income criteria. At the time of the study, Ohio WIC was using a weight-for-height percentile (WHP) 90th percentile as the cut point for defining overweight as a nutritional risk criteria.

For the focus groups, our aim was to recruit the biological mothers of preschool children (24-60 months old) at-risk for later obesity. We used records from the WIC clinic to identify potential mothers for telephone recruitment. The records contained children's height and weight measurements that were obtained at this clinic, according to standard protocol, during the semiannual WIC certification visits. Standing without shoes, children were measured to the nearest centimeter using a wall-mounted, Harpenden Stadiometer (Holtain Limited, London, England). Wearing only light clothing and no shoes, children were weighed to the nearest 0.1 kilogram using an electronic scale (Scale-Tronix, Model 5005, White Plains, NY). We calculated the age (in months) at the most recent WIC measurement. The 2000 Centers for Disease Control and Prevention (CDC)-US growth charts²² were then used to calculate the child's WHP for sex and the child's body mass index (BMI, kg/m²) percentile for age and sex. WHP was also calculated from the 1977 National Center for Health Statistics growth charts^23,24 because this reference was used by the clinic to classify children as overweight.

There were 174 children 24 to 60 months old enrolled at this WIC clinic, and 31 (18%) had been classified by WIC as overweight (WHP 90th percentile) using the 1977 growth charts. These 31 children all had a BMI 90th percentile according to the 2000 CDC-US growth charts. We used a 2-stage recruitment procedure. In the first stage, we telephoned the 30 mothers of the 31 overweight children (1 pair of overweight siblings). This group of mothers was of primary interest to us because their children had been certified previously for WIC on the basis of meeting the nutritional risk criteria of overweight. Thus, the children had been labeled by WIC as overweight, and the mothers had also received some counseling from WIC about managing the child's weight. Of the 30 mothers of overweight children, 17 agreed to participate and 1 refused; 4 children were not living with their mother; and 8 households could not be reached by phone (phone disconnected or no answer).

Because we anticipated that some of these mothers would not arrive for the focus group, we conducted a second stage of recruitment involving the mothers of children in the clinic who had not been classified by WIC as overweight. From the 143 children who were not overweight, we identified 52 children, by random chart review, whose WHP was 50th percentile. To recruit 5 additional mothers, we telephoned the households of the children in this group with the highest WHP. Among the children of these 5 mothers, 4 had a BMI 85th percentile for age and sex and the mother of the fifth child was obese (BMI 34 kg/m²). Although these children were not overweight, they were at increased risk for later obesity.¹⁸

At the time of our recruitment for the focus groups, each mother answered a brief telephone questionnaire. Mothers reported demographic information, height, and weight (prepregnant weight, if pregnant). They also responded to questions about whether they considered their children overweight, worried that their child was now overweight, or worried that their child would become overweight. In addition, mothers were also asked whether they considered themselves overweight or if their own weight was a problem.¹⁹

Of the 22 total mothers who agreed to participate, 18 arrived for their 1-hour focus group session held at CHMC (6 mothers in each group). Each mother provided written consent before participating in the session and was given $50 as compensation for her time and the expenses of travel, parking, and childcare. The Institutional Review Board at CHMC approved the study.

Two of the authors (S.N.S. and Y.C.), 1 white and 1 black, jointly moderated the focus groups. One (S.N.S.) is an experienced focus group facilitator and the other (Y.C.) is a nutritionist with 16 years of experience in the WIC programs of Kentucky and Mississippi. The prompting questions used in the focus groups were developed during group meetings with all authors. The broad, open-ended (root) questions (Table 1) were followed by more specific (probe) questions to clarify the participants responses and to narrow the discussion. The questions were designed to explore mothers' perceptions about how they determine when a child is overweight (definition), why children become overweight (etiology), and what barriers exist to preventing or managing childhood obesity (management). After each of the first 2 focus groups, the 2 leaders reviewed the questions, reworded them, and added probe questions. There was strong convergence in the responses across the focus groups, and no new ideas were emerging in the third group.

Data Management and Analysis

Each focus group session was audio taped and transcribed. We considered a comment by a participant as any uninterrupted utterance in response to a question. All the transcribed data were placed into a computerized transcript database. Each of the 1072 participant comments was assigned a unique comment number. Each author read the transcripts2 general pediatricians (A.J., R.C.W.), 1 clinical psychologist (S.W.P.), 2 nutritionists (L.A.C., Y.C.), and the focus group facilitator (S.N.S.). Each reader independently identified recurrent themes and selected comments, by comment number, as examples of each theme. Each reader's list of recurrent themes and comment numbers were coded into the transcript database and discussed at a group meeting of all readers. Twenty-two themes were identified by group consensus and a total of 366 unique supporting comments corroborated these themes. Each theme was assigned a number and a descriptive name. All supporting comments identified by the readers were then coded in the transcript database with the corresponding theme number and theme name. The 22 themes were then collapsed into 10 major themes that were also named by the group.

After this process, an additional reader independently reviewed the transcripts and recorded a set of themes. This reader was a nutritionist with 22 years of experience in Kentucky WIC and was not involved in planning or executing the focus groups. All of the themes identified by the outside reader were among the 22 themes identified by the 6 primary readers during their group consensus. Finally, using the transcript database, the authors generated a list of all comments supporting each of the 10 major themes and together selected the most representative comments for presentation here (n = 84).

	RESULTS

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Anthropometrics and Telephone Questionnaire Responses

The mean age of the mothers who participated in the focus groups was 25 years (range: 17-38 years) and the mean age of their children was 44 months (range: 26-56 months). Thirteen of 18 mothers were black, and 5 were non-Hispanic whites. Twelve of the mothers were obese (BMI 30 kg/m²), and 4 others were overweight (BMI 25 kg/m²). All 12 of the obese mothers accurately perceived themselves as overweight, and all but 1 of them also believed that their own weight was a problem. We did not specifically aim to enroll overweight mothers. The fact that all but 2 mothers were overweight reflects both the high prevalence of overweight in the mothers of children in WIC²⁵ and the recruitment of mothers of overweight children.

Seven of the 18 children were boys. All but 1 child had a BMI >85th percentile for age and sex. Of these, 14 had a BMI >95th percentile, of whom 7 had a BMI >97th percentile. Fifteen of the 18 children met the WIC definition of overweight (WHP 90th percentile) using the 2000 growth chart, and 13 met the definition using the 1977 growth chart. Among the mothers of these 15 overweight children, 10 labeled the child as either a little or very overweight, but only 2 of these 15 mothers worried about their child's present weight, and only 5 worried about their child's weight in the future.

The 10 major themes we identified in the focus groups are presented in Table 2, 3, and 4, along with representative comments supporting each theme. Each of these tables is devoted to 1 of the 3 major target areas of discussiondefinition, etiology, and management.

Definition

Mothers in our focus groups did not accept the health professional's classification of children as overweight according to the chart's parameters. There was a shared dislike and distrust of the growth charts, along with the claim that the charts were not relevant to their children (comments 1.1-1.7).

In describing children and adults, mothers used terms such as thick, solid, strong, or big-boned to indicate increased size. These terms were not being used euphemistically to really mean fat or overweight (comments 2.1-2.8). Being big boned or having a large frame was culturally acceptable to these moms and, perhaps, even desirable (comments 2.9-2.11). Some mothers stated they would be concerned about their child's weight if clothing had to be purchased too frequently, indicating overly rapid growth (comments 2.12-2.15).

Although these mothers did not worry about a child's percentile on the growth chart or large frame size, per se, they would become concerned about a child's weight if the child became inactive or was being teased by peers. For these mothers, inactivity and low self-esteem were the 2 most critical aspects of weight-related functional impairment in children. If a child ceased to run and play with other children, mothers would be worried (comments 3.1-3.4 and 4.1-4.3). There was a strong suggestion that being overweight caused inactivity in children rather than the other way around. Although few of these mothers responded in the telephone survey that they were worried about their child's current or future weight, they frequently discussed the social and emotional consequences of being overweight and the potential damage to a child's self-esteem (comments 3.8-3.10).

When questioned specifically about the meaning of the word obesity, mothers described it as a condition that caused severe functional impairment, specifically, compromised mobility (comments 3.5-3.7). None of the mothers had ever known a young child they considered obese.

These mothers would not worry about a child's weight if the child had a good appetite and ate healthy foods. Mothers implied that eating healthy foods compensated for eating junk foods. If a child ate certain foods, such as fruits and vegetables, then his/her diet and weight were considered healthy, regardless of the amount and nutritional quality of the other foods in the diet (comments 4.4-4.7).

Etiology (Table 3)

The dominant belief was that a child's size and growth pattern was fixed or predestined and was attributable to an inherited metabolism or body type. Most mothers believed that it was nearly impossible to alter a child's weight if there was a familial predisposition to be large (comments 5.1-5.8). Some mothers, however, would acknowledge that parental diet and activity habits could influence children's habits (comments 6.1-6.4). Also supporting the notion that a child's size was naturally programmed was the belief that children would grow into their weight, or that the fat of a younger child would disappear as the child became taller, older, and more active (comments 5.9-5.12).

Management (Table 4)

Mothers described difficulties limiting or structuring their children's eating. These mothers spoke about a lack of control over the family diet and felt either powerless to remedy the situation or unwilling to take charge of it (comments 7.1-7.4). They especially struggled with children whose appetites seemed boundless and who were perpetually hungry. Mothers voiced an inability to say no if a child claimed to be hungry, and they believed that saying no would be starving the child. Providing ample nourishment to their children was an important and emotionally rewarding part of parenting that mothers seemed unwilling to relinquish (comments 7.5-7.9). The inability to limit a child's eating may have been related to the use of food as a parenting tool or to reward children (comments 8.1-8.3). Some mothers were also reluctant to withhold food or limit certain foods because they were proud to be able to afford "treats" (comments 8.4-8.5). There was a suggestion that the inclination to treat children with food was related to other times, in the recent or remote past, when the food supply was more insecure.

Mothers described scenarios where their authority over the child's dietary habits was challenged by other caretakers, commonly the child's father or grandparents. The children, aware of the conflicting views of their caretakers, would naturally seek approval from the more permissive adult (comments 9.1-9.10).

When explaining their attitudes and behaviors regarding children's weight, mothers consistently intermingled anecdotes about their own weight histories, both as children and adults. It was often difficult to discern the mothers' own stories from those about their children. Mothers described feeling ambivalent about their own weight status and whether being overweight was a problem in their lives. Alternately they expressed both contentment and dissatisfaction with their own weight. Some mothers emphasized the need to strengthen a child's self-esteem to buffer the effects of being teased about weight in the future. They often proposed this approach rather than trying to prevent obesity itself (comments 10.1-10.5).

	DISCUSSION

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Mothers in our study did not find it meaningful to use pediatric growth charts to define their children as overweight. Instead, these mothers of overweight preschoolers in WIC considered their children at a healthy weight as long as their children's activity and social functioning were unimpaired. Mothers believed they were unlikely to affect a child's biological predisposition to be overweight. In addition, they described difficulties structuring their young children's eating habits. Other caretakers often interfered with the mother's sense of control and mothers themselves found it emotionally difficult to deny food to a hungry child.

This study has several limitations. First, the findings were from a small sample of urban, mostly black, low-income mothers with young children who were overweight, and all but 2 mothers were overweight. Perspectives and practices may or may not differ in normal weight mothers, mothers from other socioeconomic or cultural backgrounds, or mothers who have normal weight children. Qualitative research is intended to generate an explanation or theory of a phenomena that is not well understood.²⁶ In this case, what was not well understood was why low-income mothers are not more concerned about their preschool children being overweight. Using focus groups, we probed, in-depth, the perspectives of a small number of mothers. Interpretations of the mothers' statements were made by consensus of a group of readers with varying perspectives. Together, the authors developed an explanation of why low-income mothers may not worry about their preschoolers being overweight. This research methodology produced testable hypotheses for future study in larger samples. The study was not meant to produce any conclusion about the phenomenon under study that could be generalized to all mothers or even to all low-income black mothers.

It is possible that the focus group setting may have inhibited some of the participants from expressing their views. There was, however, considerable agreement among the 3 focus groups, and the themes highlighted here were found in all 3 groups. Despite these limitations, this study suggests that there are major differences in the way parents and health professionals view the definition, etiology, and management of overweight preschoolers. In short, these low-income mothers, whose children are at-risk for later obesity, have a different textbook of childhood obesity than physicians, nurses, or nutritionists.

In contrast to our previous study¹⁹ and to 1 other,²⁷ in the telephone survey, the majority of our focus group mothers who had overweight preschoolers did describe their children as overweight. As in our previous study, however, very few of these mothers were worried about the child's current or future weight. Asking mothers about their child's weight status with a telephone interview may have elicited a different reply than when the same questions were asked in a self-administered paper survey. It is also possible that these mothers were acknowledging that their children may be considered overweight by health professionals or by medical definitions. As our focus group discussion revealed, however, these mothers did not truly believe their children were overweight, and, thus, were unconcerned.

Previous investigators^28,29 have documented ethnic differences in weight acceptance among women, and these differences may extend to children. However, the 12 obese mothers in the focus groups considered themselves overweight, and all but 1 believed their own weight was a problem. Because these mostly black mothers were not accepting of their own weight, we do not know to what extent their acceptance of their children's weight is related to ethnicity.

In its recent revisions of the growth charts for children,²² the US Department of Health and Human Services included BMI charts for children 24 months old and older and also suggested BMI levels for classifying children as overweight or at risk of overweight. In releasing the 2000 growth charts, the federal government emphasized the potential importance of the charts as a tool for teaching parents about their children's growth and for encouraging parents to prevent obesity in their children.³⁰ The low-income mothers that participated in our study clearly did not accept the use of standardized, statistically-based definitions of a normal or healthy weight. This study suggests that the new charts, especially the new BMI charts, may not be meaningful or comprehensible for certain populations.

Our previous qualitative research also suggested parents' interpretations of the growth chart may depart from that of health professionals'.³¹ We indicated that parents may consider an infant's placement on the growth chart as a sign of parental competence. If parents consider a larger size desirable for infants, use of the growth charts by health professionals to indicate excess weight during the preschool years may confuse parents and de-emphasize the relevance of growth charts. Health professionals may be unaware of how the growth chart information is being perceived and understood by parents. It is likely that some unintended messages are being conveyed. One important possibility is that parents may implicitly receive a message that their parenting skills are being judged. Mothers in this study complained that the health professional looked at the percentile on the chart instead of assessing the individual child or family. Thus, the advice given in response to the child's growth pattern might then be considered irrelevant.

Feeding is an essential part of parenting young children. Indeed, eating habits are so closely woven into the day that they impact patterns of play and activity, sleep, and social interactions for both the parent and the child. Likewise, to establish healthy eating patterns in children requires a variety of parenting skills that also improve overall child well-being. These skills include the ability to set limits, establish consistent routines, anticipate a child's needs, read nonverbal cues, provide physical and emotional closeness, and encourage and model desirable behaviors. Developing and maintaining these parenting skills is a challenge for any parent, even those with multiple resources.

These mothers voiced difficulties in establishing and maintaining the healthy eating routines for their children that are necessary to prevent obesity. The study revealed several possible explanations for these difficulties. Although we did not assess what was meant by a healthy diet, there seemed to be a greater problem with consistent implementation of a healthy diet than with knowledge of which foods were healthy. These mothers believed that obesity and becoming overweight could not be prevented in children because of the overriding influence of heredity. This belief may decrease motivation to change eating habits of a young child. Instead, it may be more attractive to implement the nonnutritive uses of food as a parenting tool, to set limits, reward behavior, and provide nurturing. Food may be helping mothers to maintain their sense of competence and control, despite contributing to a child's risk of obesity. Other qualitative research with black adolescent mothers suggests a strong role of grandmothers in deciding what infants should eat^32,33 and in shaping the young mothers' overall parenting style.³⁴ Our data suggest that maternal attempts to structure eating habits in their preschool children may be influenced not only by grandmothers but also by fathers and grandfathers.

We suggest that the lack of maternal concern about her overweight preschooler is not necessarily some complex form of denial³⁵ that needs to be penetrated by health professionals with discussions about the long-term medical complications of obesity. Health professionals may be more helpful to families by trying to understand how the pathways to energy imbalance in children reflect the more complex and emotionally-laden task of parenting and by exploring the intergenerational influences on parenting practices. The WIC program, for example, may need to consider ways to increase parenting capacity to make its nutritional messages more effective.³⁶

Just how should mothers be parenting their preschool children to prevent obesity? An increasing body of scientific literature suggests that a child's obesity risk may be increased when parents exert a high degree of control over the feeding interaction.^37-39 This control has been conceptualized in the form of restricting children from eating and is thought to arise from excessive parental concern about a child being or becoming overweight.³⁶ This is especially true between mothers and their daughters. In studies primarily conducted with white, educated, and married parents, it has been shown both that using food as a reward⁴⁰ and restricting access to food^41,42 may lead to a child overeating. These studies have also shown that the relative weight of preschool children is greater when parents report more restriction of children's access to snack foods.

However, the causal direction between controlling parenting practices and increased weight in children has not been clearly established in these cross-sectional studies. It is very possible that controlling behaviors of parents leads to appetite dysregulation in some children and to subsequent overeating. Alternately, parents may become more controlling over their children's diet when those children most genetically susceptible to obesity begin to overeat (exhibit poor self-control over intake) or to become overweight. These contrasting mechanisms lead to different conclusions about what advice is most appropriate to give parents to prevent obesity in their preschoolers. If excess maternal concern about preschoolers being overweight is thought to initiate a cascade of interactions that worsens energy balance in a child, then a complete lack of concern about weight and no limit setting in the diet cannot, at the same time, also be in the child's best interest. The current scientific literature has not identified the happy medium of maternal concern and, thus, does not inform practitioners about some common and seemingly straightforward questions. For example, should a parent restrict access to food in an overweight 3.5 year old who says she is hungry between meals? Prospective studies with sociodemographically diverse families may be required to resolve such questions.

Based on this qualitative study, we hypothesize that a lack of parental control and unrestricted eating may contribute to obesity in the low-income population we studied. Indeed, whether parents are able to restrict or structure their child's eating, in the face of an obesity-promoting environment, may be a measure of parenting abilityan ability that may be particularly lacking in families with limited resources.

This qualitative study was meant to be hypothesis-generating rather than confirming. We hypothesize that the continued use of growth charts to define and emphasize childhood obesity, at least with low-income, black mothers who have overweight children, is unlikely to enhance parental efforts to prevent excessive weight gain and may even limit the effectiveness of nutritional counseling that is given. We believe that the categorization of children as overweight, using the new growth reference, is an important part of health supervision. However, we also believe that there should be a reexamination of if and how these growth charts should be used in counseling for obesity prevention.

Finally, we hypothesize that low-income mothers whose parenting skills allow them to impose more structure and control on their children's eating and activity patterns are more likely to prevent obesity in their children. Despite differing perceptions between mothers and health professionals about the definition of overweight, mothers aspire to have active children with healthy diets. We postulate that the best approach to preventing obesity may be to focus more on improving general parenting skills and less on discussing the child's growth.

	ACKNOWLEDGMENTS

This work was supported by a grant by federal funds from the US Department of Agriculture, Food and Nutrition Service, Cooperative Agreement 59-3198-8-500.

This study was part of the Fit WIC Project, a multistate project to examine how WIC can be more responsive to the problem of childhood obesity. The participating state WIC agencies include California, Virginia, Kentucky, Vermont, and the Inter-Tribal Council of Arizona. The 5 grantees are working collaboratively with the US Department of Agriculture's Food and Nutrition Service and with the CDC.

We would like to give special thanks to the mothers who participated in this study. We would also like to extend our gratitude to Nancy Merk, RD, for her willingness to assist us with participant recruitment; Dianna Colson, MS, CN, nutrition consultant for the Kentucky Department for Public Health and WIC coordinator in Kentucky's Marshall County Health Department, for serving as outside reader of the focus group transcripts; Fran Hawkins, MS, RD, manager of the Nutrition Services Branch at the Kentucky Department for Public Health, for her support of Kentucky's Fit WIC Project; and to Jeffrey A. Wright, MD, and Amy Baughcum for their careful review of this manuscript.

	FOOTNOTES

The contents of this publication do not necessarily reflect the views or policies of the US Department of Agriculture, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.

Received for publication Jul 26, 2000; accepted Nov 4, 2000.

Reprint requests to (R.C.W.) Children's Hospital Medical Center, Division of General and Community Pediatrics, CH-1S, 3333 Burnet Ave, Cincinnati, OH 45229-3039.

Address correspondence to Anjali Jain, MD, Department of Pediatrics, Section of General Pediatrics, University of Chicago Children's Hospital, 5841 S Maryland Ave, MC 6082; Chicago, IL 60637. E-mail: ajain{at}peds.bsd.uchicago.edu

	ABBREVIATIONS

WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; BMI, body mass index; CHMC, Children's Hospital Medical Center; WHP, weight-for-height percentile; CDC, Centers for Disease Control and Prevention.

	REFERENCES

Top Abstract Methods Results Discussion References

1. Jelalian E, Saelens BE. Empirically supported treatments in pediatric psychology: pediatric obesity. J Pediatr Psychol. 1999;223-248
2. Freedman DS, Dietz WH, Srinivasan SR, Berenson GS The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics 1999; 103:1175-1182 [Abstract/Free Full Text]
3. Strauss RS. Childhood obesity and self-esteem. Pediatrics. 2000;105(1). URL: http://www.pediatrics.org/cgi/content/full/105/1/e15
4. Power C, Lake JK, Cole TJ Measurement and long-term health risks of child and adolescent fatness. Int J Obes Relat Metab Disord 1997; 21:507-526 [CrossRef][Medline]
5. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T Do obese children become obese adults? A review of the literature. Prev Med 1993; 22:167-177 [CrossRef][Medline]
6. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH The disease burden associated with overweight and obesity. JAMA 1999; 282:1523-1529 [Abstract/Free Full Text]
7. Wolf AM, Colditz GA Current estimates of the economic cost of obesity in the United States. Obes Res 1998; 6:97-106 [Medline]
8. Allison DB, Fontaine KR, Manson JE, Stevens J, VanItallie TB Annual deaths attributable to obesity in the United States. JAMA 1999; 282:1530-1538 [Abstract/Free Full Text]
9. Hill JO, Trowbridge FL Childhood obesity: future directions and research priorities. Pediatrics 1998; 101:570-574 [Abstract/Free Full Text]
10. The National Task Force on Prevention and Treatment of Obesity. Towards prevention of obesity: research directions. Obes Res. 1994;571-584
11. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP The spread of the obesity epidemic in the United States, 1991-1998. JAMA. 1999; 282:1519-1522 [Abstract/Free Full Text]
12. Troiano RP, Flegal KM Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics 1998; 101:497-504 [Abstract/Free Full Text]
13. Owen GM, Kram KM, Garry PJ, Lowe JE, Lubin AH A study of nutritional status of preschool children in the United States, 1968-1970. Pediatrics. 1974; 53:597-646 [Abstract/Free Full Text]
14. Miller JE, Korenman S Poverty and children's nutritional status in the United States. Am J Epidemiol 1994; 140:233-43 [Abstract/Free Full Text]
15. Mei Z, Scanlon KS, Grummer-Strawn LM, Freedman DS, Yip R, Trowbridge FL. Increasing prevalence of overweight among US low-income preschool children. The Centers for Disease Control and Prevention Pediatric Nutrition Surveillance, 1983-1995. Pediatrics. 1998;101(1). URL: http//www.pediatrics.org/cgi/content/full/101/1/e12
16. Wiecha JL, Casey VA High prevalence of overweight and short stature among Head Start children in Massachusetts. Public Health Rep 1994; 109:767-773 [Medline]
17. Flegal KM, Harlan WR, Landis JR Secular trends in body mass index and skinfold thickness with socioeconomic factors in young adult women. Am J Clin Nutr 1988; 48:535-543 [Abstract/Free Full Text]
18. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997; 337:869-873 [Abstract/Free Full Text]
19. Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC Maternal perceptions of overweight preschool children. Pediatrics 2000; 6:1380-1386
20. Birch LL, Fischer JO Development of eating behaviors among children and adolescents. Pediatrics 1998; 101:539-549 [Abstract/Free Full Text]
21. Moore LL, Lombardi DA, White MJ, Campbell JL, Olivera SA, Ellison RC Influence of parents' physical activity levels on activity levels of young children. J Pediatr 1991; 118:215-219 [CrossRef][Medline]
22. Kuczmarski R, Ogden C, Grummer-Strawn L, et al. Centers for Disease Control Growth Charts: United States. Advance Data From Vital and Health Statistics. Hyattsville, MD: National Center for Health Statistics; 2000
23. Hamill PVV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr 1979; 32:607-629 [Abstract/Free Full Text]
24. Dibley MJ, Goldsby JB, Staehling NW, Trowbridge FL Development of normalized curves for the international growth reference: historical and technical considerations. Am J Clin Nutr 1987; 46:736-748 [Abstract/Free Full Text]
25. Randall B, Boast L, Holst L. Study of WIC Participant and Program Characteristics, 1994. Cambridge, MA: Abt Associates, Inc; 1995
26. Giacomini M, Cook D Users' guides to the medical literature: XXIII. Qualitative research in health care, B. What are the results and how do they help me care for my patients? JAMA 2000; 284:478-482 [Abstract/Free Full Text]
27. Jackson J, Strauss CC, Lee AA, Hunter K Parents' accuracy in estimating child weight status. Am J Clin Nutr 1990; 15:65-68
28. Kumanyika S, Wilson J, Guilford-Davenport M Weight-related attitudes and behaviors of black women. J Am Diet Assoc 1993; 93:416-422 [CrossRef][Medline]
29. Wilson DB, Sargent R, Dias J Racial differences in selection of ideal body size by adolescent females. Obes Res 1994; 2:38-43 [Medline]
30. Centers for Disease Control and Prevention NCHS, Division of Data Services. New Pediatric Growth Charts Provide Tool to Ward Off Future Weight Problems. Last accessed March 16, 2001. URL: http://www.cdc.gov/nchs/releases/00news/growchart.htm
31. Baughcum AE, Burklow KA, Deeks CM, Powers SW, Whitaker RC Maternal feeding practices and childhood obesity: a focus group study of low-income mothers. Arch Pediatr Adolesc Med 1998; 152:1010-1014 [Abstract/Free Full Text]
32. Hannon P, Willis S, Bishop-Townsend V, Martinez I, Scrimshaw S African American and Latina adolescent mothers' infant feeding decisions and breastfeeding practices: a qualitative study. J Adolesc Health 2000; 26:399-407 [CrossRef][Medline]
33. Bentley M, Gavin L, Black MM, Teti L Infant feeding practices of low-income, African-American adolescent mothers: an ecological, multigenerational perspective. Soc Sci Med 1999; 49:1085-1100
34. Black MM, Nitz K Grandmother co-residence, parenting, and child development among low income, urban teen mothers. J Adolesc Health 1996; 18:218-226 [CrossRef][Medline]
35. Ness DE, Ende J Denial in the medical interview: recognition and management. JAMA 1994; 272:1777-1181 [Abstract/Free Full Text]
36. Bronner YL, Gross SM, Caulfield L, Early introduction of solid foods among urban African-American participants in WIC. J Am Diet Assoc 1999; 99:457-461 [CrossRef][Medline]
37. Satter EM Internal regulation and the evolution of normal growth as the basis for prevention of obesity in children. J Am Diet Assoc 1996; 96:860-864 [CrossRef][Medline]
38. Birch LL, Fisher JO Development of eating behaviors among children and adolescents. Pediatrics 1998; 101:539-549
39. Costanzo PR, Woody EZ Domain-specific parenting styles and their impact on the child's development of particular deviance: the example of obesity proneness. J Soc Clin Psychol 1985; 3:425-445
40. Birch LL, Zimmerman SI, Hind H The influence of social-affective context on the formation of children's food preferences. Child Dev 1980; 51:856-861 [CrossRef]
41. Fisher JO, Birch LL Restricting access to foods and children's eating. Appetite 1999; 32:405-419 [CrossRef][Medline]
42. Fisher JO, Birch LL Restricting access to palatable foods affects children's behavioral response, food selection, and intake. Am J Clin Nutr 1999; 69:1264-1272 [Abstract/Free Full Text]