Search

BACKGROUND Data from the NHANES indicate that BMI has increased in some subgroups of children and adolescents in the United States over the past 20 y; however, BMI is an indirect measure of body fatness. OBJECTIVES We assessed changes in DXA-derived measures of adiposity in a nationally representative population of US children and adolescents aged 8-19 y from 1999-2006 to 2011-2018. METHODS Using data from the NHANES, we compared the means and distributions of DXA-derived percentage body fat (%BF) and fat mass index (FMI; fat mass/height2 in kg/m2) between 1999-2006 (n = 10,231) and 2011-2018 (n = 6923) among males and females by age group, race and Hispanic origin, and BMI categories. Estimates were standardized by age and race and Hispanic origin. RESULTS From 1999-2006 to 2011-2018, mean %BF increased from 25.6% to 26.3% (change in %BF: 0.7%; 95% CI: 0.2%, 1.2%; P

Background Polyphenols are a class of phytochemicals that have antioxidant, anti-inflammatory, anticancer, and antiviral properties. Previous research suggests that dietary polyphenol intake is protective against major chronic diseases. To our knowledge, no data on polyphenol intake for the US adult population are available. Objective This study explored usual dietary polyphenol intake among US adults in 2013-2016 and examined trends in intake during 2007-2016 by demographic characteristics, and identified major dietary sources of polyphenols. Design The National Health and Nutrition Examination Survey is a series of cross-sectional surveys representative of the civilian noninstitutionalized US population. Participants/setting This study included 9,773 adults aged 20 years and older. Main outcome measures Dietary and supplement data were obtained from two 24-hour dietary recalls. Polyphenol intake was estimated using the Phenol Explorer Database and adjusted for total energy intake. Statistical analysis performed Usual intake was estimated both overall and by demographic characteristics using the National Cancer Institute method. Trends in intake on a given day over 10 years were evaluated using regression analysis. The complex survey design was incorporated in all analyses. Results In 2013-2016, the usual intake of dietary polyphenols was a mean (standard error) of 884.1 (20.4) mg per 1,000 kcal/d. Polyphenol intake was higher in adults 40 years and older, women, non-Hispanic White adults, and college graduates. During 2007-2016, the mean daily polyphenol intake did not change significantly over time for overall and demographic groups. Main polyphenol classes consumed were phenolic acids (mean [standard error] of 1,005.6 [34.3] mg/d) and flavonoids (mean [standard error] of 379.1 [10.7] mg/d). Foods and beverages contributed 99.8% of polyphenol intake, with coffee (39.6%), beans (9.8%), and tea (7.6%) as major dietary contributors. Conclusion Findings from this study suggest that polyphenol intake is consistent with the low intake of fruits, vegetables, and whole grains in the US population, and provide more evidence of the need for increased consumption of these food groups.

Background Limited information is available on added sugars consumption in US infants and toddlers. Objectives To present national estimates of added sugars intake among US infants and toddlers by sociodemographic characteristics, to identify top sources of added sugars, and to examine trends in added sugars intake. Design Cross-sectional analysis of 1 day of 24-hour dietary recall data. Participants/setting A nationally representative sample of US infants aged 0 to 11 months and toddlers aged 12 to 23 months (n=1,211) during the period from 2011 through 2016 from the National Health and Nutrition Examination Survey. Trends were assessed from 2005-2006 through 2015-2016 (n=2,795). Main outcome measures Among infants and toddlers, the proportion consuming any added sugars, the average amount of added sugars consumed, percent of total energy from added sugars, and top sources of added sugars intake. Statistical analysis Paired t tests were used to compare differences by age, sex, race/Hispanic origin, family income level, and head of household education level. Trends were tested using orthogonal polynomials. Significance was set at P Results During 2011 to 2016, 84.4% of infants and toddlers consumed added sugars on a given day. A greater proportion of toddlers (98.3%) consumed added sugars than infants (60.6%). The mean amount of added sugars toddlers consumed was also more compared with infants (5.8 vs 0.9 tsp). Non-Hispanic black toddlers (8.2 tsp) consumed more added sugars than non-Hispanic Asian (3.7 tsp), non-Hispanic white (5.3 tsp), and Hispanic (5.9 tsp) toddlers. A similar pattern was observed for percent energy from added sugars. For infants, top sources of added sugars were yogurt, baby food snacks/sweets, and sweet bakery products; top sources among toddlers were fruit drinks, sugars/sweets, and sweet bakery products. The mean amount of added sugars decreased from 2005-2006 through 2015-2016 for both age groups; however, percent energy from added sugars only decreased among infants. Conclusion Added sugars intake was observed among infants/toddlers and varied by age and race and Hispanic origin. Added sugars intake, as a percent of energy, decreased only among infants from 2005 to 2016.

Background Although the prevalence of a body mass index [BMI (in kg/m2)] ≥30 has tripled among US adults since the 1960s, BMI is only moderately correlated with body fatness. Because skinfolds can more accurately estimate body fatness than can BMI, it is possible that skinfolds could be useful in monitoring secular trends in body fatness. Objective We examined whether there were similar secular trends for skinfolds (triceps and subscapular), BMI, and waist circumference between US adults. Design This study was an analysis of 45,754 adults who participated in the NHANES from 1988-1994 through 2009-2010. Approximately 19% of the subjects were missing ≥1 skinfold-thickness measurement. These missing values were imputed from other characteristics. Results Trends in mean levels and in the prevalence of high levels of the 4 body size measures were fairly similar between men, with mean levels increasing by ≥5% from 1988-1994 through 2009-2010. Slightly larger increases were seen in women for BMI and waist circumference (7-8%), but trends in skinfolds were markedly different. The mean triceps skinfold, for example, increased by 2 mm through 2003-2004, but subsequently decreased so that the mean in 2009-2010 did not differ from that in 1988-1994. Compared with obese women in 1988-1994, the mean BMI of obese women in 2009-2010 was 1 higher, but mean levels of both skinfolds were 5-10% lower. Conclusions Although there were fairly similar trends in levels of BMI, waist circumference, and skinfold thicknesses in men in the United States from 1988-1994 through 2009-2010, there were substantial differences in women. Our results indicate that it is unlikely that skinfold thicknesses could be used to monitor trends in obesity.

OBJECTIVES: To describe differences in dietary intake of select foods and nutrients by level of urbanization in U.S. youth ages 2–19 years. METHODS: Data from 8301 youth in the National Health and Nutrition Examination Survey, 2013–2018 were used. Mean ratios were estimated for % of fruit consumed as whole fruit (WF) and grains as whole grains (WG), % of energy from added sugars (AS) and saturated fats (SF), and mean intake of fiber, potassium, and sodium on a given day. Proportions consuming >50% (fruit as WF and grains as WG), 50% of fruit as WF increased significantly from 43.7% in non-MSAs to 51.0% in large MSAs, and a significant increase was seen among males. The % of energy from AS decreased significantly from 15.5% in non-MSAs to 13.2% in large MSAs, and significant declines were also seen among males and among lower income youth, and the percentage of males who consumed 50% of fruit as WF

Background: Consuming seafood has health benefits, but seafood can also contain methylmercury, a neurotoxicant. Exposure to methylmercury affects children at different stages of brain development, including during adolescence. Objective: The objective was to examine seafood consumption and blood mercury concentrations in US youth. Methods: In the 2009‐2012 NHANES, a cross-sectional nationally representative sample of the US population, seafood consumption in the past 30 d and blood mercury concentrations on the day of examination were collected from 5656 youth aged 1‐19 y. Log-linear regression was used to examine the association between frequency of specific seafood consumption and blood mercury concentration, adjusting for race/Hispanic origin, sex, and age. Results: In 2009‐2012, 62.4% 6 1.4% (percent 6 SE) of youth consumed any seafood in the preceding month; 38.4% 6 1.4% and 48.5% 6 1.5% reported consuming shellfish and fish, respectively. In 2009‐2012, the geometric mean blood mercury concentration was 0.50 6 0.02 mg/L among seafood consumers and 0.27 6 0.01 mg/L among those who did not consume seafood. Less than 0.5% of youth had blood mercury concentrations $5.8 mg/L. In adjusted log-linear regression analysis, no significant associations were observed between frequency of breaded fish or catfish consumption and blood mercury concentrations, but frequency of consuming certain seafood types had significant positive association with blood mercury concentrations: high-mercury fish (swordfish and shark) [exponentiated b coefficient (expb): 2.40; 95% CI: 1.23, 4.68]; salmon (expb: 1.41; 95% CI: 1.26, 1.55); tuna (expb: 1.38; 95% CI: 1.29, 1.45); crabs (expb: 1.35; 95% CI: 1.17, 1.55); shrimp (expb: 1.12; 95% CI: 1.05, 1.20), and all other seafood (expb: 1.23; 95% CI: 1.17, 1.32). Age-stratified loglinear regression analyses produced similar results. Conclusion: Few US youth have blood mercury concentrations $5.8 mg/L, although more than half of US youth consumed seafood in the past month. JN utrdoi: 10.3945/jn.114.203786.

BACKGROUND Seafood is part of a healthy diet, but seafood can also contain methyl mercury-a neurotoxin. OBJECTIVE The objective was to describe seafood consumption in US adults and to explore the relation between seafood consumption and blood mercury. DESIGN Seafood consumption, obtained from a food-frequency questionnaire, and blood mercury data were available for 10,673 adults who participated in the 2007-2010 NHANES-a cross-sectional nationally representative sample of the US population. Seafood consumption was categorized by type (fish or shellfish) and by frequency of consumption (0, 1-2, 3-4, or ≥5 times/mo). Linear trends in geometric mean blood mercury concentrations by frequency of seafood consumption were tested. Logistic regression analyses examined the odds of blood mercury concentrations ≥5.8 μg/L (as identified by the National Research Council) based on frequency of the specific type of seafood consumed (included in the model as continuous variables) adjusted for sex, age, and race/Hispanic origin. RESULTS In 2007-2010, 83.0% ± 0.7% (±SE) of adults consumed seafood in the preceding month. In adults consuming seafood, the blood mercury concentration increased as the frequency of seafood consumption increased (P < 0.001). In 2007-2010, 4.6% ± 0.39% of adults had blood mercury concentrations ≥5.8 μg/L. Results of the logistic regression on blood mercury concentrations ≥5.8 μg/L showed no association with shrimp (P = 0.21) or crab (P = 0.48) consumption and a highly significant positive association with consumption of high-mercury fish (adjusted OR per unit monthly consumption: 4.58; 95% CI: 2.44, 8.62; P < 0.001), tuna (adjusted OR: 1.14; 95% CI: 1.10, 1.17; P < 0.001), salmon (adjusted OR: 1.14; 95% CI: 1.09, 1.20; P < 0.001), and other seafood (adjusted OR: 1.12; 95% CI: 1.08, 1.15; P < 0.001). CONCLUSION Most US adults consume seafood, and the blood mercury concentration is associated with the consumption of tuna, salmon, high-mercury fish, and other seafood.

OBJECTIVES: Rural populations are generally older, sicker, and poorer than their urban counterparts. Few studies have examined differences in dietary patterns by urbanization that may mirror differences in health by urbanization. Our objective is provide national estimates of dietary patterns among adults by urbanization level. METHODS: Using a single 24 hour recall from NHANES 2013–2016, we estimated the mean consumption of fruits, vegetables, % of calories from added sugars and % of calories from saturated fats, by age, sex, education, race and Hispanic origin, and urbanization level among US adults aged 20 and over (n = 9939). We used SUDAAN to conduct all analyses and we evaluated differences between groups using a t statistic and tests of trend across ordinal variables using orthogonal contrast matrices. RESULTS: During 2013–2016, the average fruit intake (cup equivalence) was 0.9 (SE 0.03) for both men and women. After adjustment by age, education level, and race and Hispanic origin, fruit intake increased with higher level of urbanization, from 0.6 (SE 0.07) in rural areas, to 0.9 (SE 0.05) in medium or small urban areas, to 1.0 (SE 0.04) in large urban areas among men. After adjustment, differences by urbanization were not significant for women. The average % of calories from added sugars on a given day was 12% (SE 0.2) for both men and women. After adjustment, added sugars intake decreased with higher level of urbanization, from 14.0% (SE 0.9) in rural areas, to 12.6% (SE 0.3) in medium to small urban areas, to 12.0% (SE 0.2) in large urban areas among women. A similar pattern was also observed among men. There were no differences in vegetable consumption or % of energy from saturated fat by level of urbanization. CONCLUSIONS: Disparities in dietary patterns exist by urbanization. Additional research may show how these differences impact health and identify opportunities to improve health in rural communities. FUNDING SOURCES: The National Center for Health Statistics and the US Centers for Disease Control and Prevention funded this study.

Background: Reducing sugar-sweetened beverage (SSB) consumption is a recommended strategy to promote optimal health. Objective: The objective was to describe trends in SSB consumption among youth and adults in the United States. Design: We analyzed energy intake from SSBs among 22,367 youth aged 2–19 y and 29,133 adults aged $20 y who participated in a 24-h dietary recall as part of NHANES, a nationally representative sample of the US population with a cross-sectional design, between 1999 and 2010. SSBs included soda, fruit drinks, sports and energy drinks, sweetened coffee and tea, and other sweetened beverages. Patterns of SSB consumption, including location of consumption and meal occasion associated with consumption, were also examined. Results: In 2009–2010, youth consumed a mean (6SE) of 155 6 7 kcal/d from SSBs and adults consumed an age-adjusted mean (6SE) of 151 6 5 kcal/d from SSBs—a decrease from 1999 to 2000 of 68 kcal/d and 45 kcal/d, respectively (P-trend , 0.001 for each). In 2009–2010, SSBs contributed 8.0% 6 0.4% and 6.9% 6 0.2% of daily energy intake among youth and adults, respectively, which reflected a decrease compared with 1999–2000 (P-trend , 0.001 for both). Decreases in SSB consumption, both in the home and away from home and also with both meals and snacks, occurred over the 12-y study duration (P-trend , 0.01 for each). Conclusion: A decrease in SSB consumption among youth and adults in the United States was observed between 1999 and 2010. Am J Clin Nutr doi: 10.3945/ajcn.112.057943.

Article Title And Bibliographic Information Is there a relationship between birth weight and subsequent growth on the development of dental caries at 5 years of age? A cohort study. Kay EJ, Northstone K, Ness A, Duncan K, Crean SJ. Community Dent Oral Epidemiol 2010;38:408-14. Reviewers Bruce A. Dye, DDS, MPH, Cynthia L. Ogden, PhD, MRP Purpose/Question Do height and weight at birth and subsequent growth affect caries development? Source of Funding Partial support through Avon Longitudinal Study of Parents and Children from the UK Medical Research Council, the Wellcome Trust, and the University of Bristol Type of Study/Design Cohort study Level of Evidence Level 2: Limited-quality, patient-oriented evidence Strength of Recommendation Grade Not applicable

Terminology and measures used in studies of weight and adiposity in children can be complex and confusing. Differences arise in metrics, terminology, reference values, and reference levels. Most studies depend on body mass index (BMI) calculated from weight and height, rather than on more direct measures of body fatness. Definitions of overweight and obesity are generally statistical rather than risk-based and use a variety of different reference data sets for BMI. As a result, different definitions often do not give the same results. A basic problem is the lack of strong evidence for any one particular definition. Rather than formulate the question as being one of how to define obesity, it might be useful to consider what BMI cut-points best predict future health risks and how efficiently to screen for such risks. The answers may be different for different populations. In addition, rather than depending solely on BMI to make screening decisions, it is likely to be useful to also consider other factors, including not only race-ethnicity, sex and age, but also factors such as family history. Despite their limitations, BMI-based definitions of overweight and obesity provide working practical definitions that are valuable for general public health surveillance and screening.

Background: The 2000 Centers for Disease Control and Prevention (CDC) growth charts included lambda-mu-sigma (LMS) parameters intended to calculate smoothed percentiles from only the 3rd to the 97th percentile. Objective: The objective was to evaluate different approaches to describing more extreme values of BMI-for-age by using simple functions of the CDC growth charts. Design: Empirical data for the 99th and the 1st percentiles of body mass index (BMI)-for-age were calculated from the data set used to construct the growth charts and were compared with estimates extrapolated from the CDC-supplied LMS parameters and to various functions of other smoothed percentiles. A set of reestimated LMS parameters that incorporated a smoothed 99th percentile were also evaluated. Results: Extreme percentiles extrapolated from the CDC-supplied LMS parameters did not match well to the empirical data for the 99th percentile. A better fit to the empirical data was obtained by using 120% of the smoothed 95th percentile. The empirical first percentile was reasonably well approximated by extrapolations from the LMS values. The reestimated LMS parameters had several drawbacks and no clear advantages. Conclusions: Several approximations can be used to describe extreme high values of BMI-for-age with the use of the CDC growth charts. Extrapolation from the CDC-supplied LMS parameters does not provide a good fit to the empirical 99th percentile values. Simple approximations to high values as percentages of the existing smoothed percentiles have some practical advantages over imputation of very high percentiles. The expression of high BMI values as a percentage of the 95th percentile can provide a flexible approach to describing and tracking heavier children. Am J Clin Nutr doi: 10.3945/ajcn.2009.28335.

Background: Body mass index (BMI), waist circumference (WC), and the waist-stature ratio (WSR) are considered to be possible proxies for adiposity. Objective: The objective was to investigate the relations between BMI, WC, WSR, and percentage body fat (measured by dual-energy X-ray absorptiometry) in adults in a large nationally representative US population sample from the National Health and Nutrition Examination Survey (NHANES). Design: BMI, WC, and WSR were compared with percentage body fat in a sample of 12,901 adults. Results: WC, WSR, and BMI were significantly more correlated with each other than with percentage body fat (P < 0.0001 for all sex-age groups). Percentage body fat tended to be significantly more correlated with WC than with BMI in men but significantly more correlated with BMI than with WC in women (P < 0.0001 except in the oldest age group). WSR tended to be slightly more correlated with percentage body fat than was WC. Percentile values of BMI, WC, and WSR are shown that correspond to percentiles of percentage body fat increments of 5 percentage points. More than 90% of the sample could be categorized to within one category of percentage body fat by each measure. Conclusions: BMI, WC, and WSR perform similarly as indicators of body fatness and are more closely related to each other than with percentage body fat. These variables may be an inaccurate measure of percentage body fat for an individual, but they correspond fairly well overall with percentage body fat within sex-age groups and distinguish categories of percentage body fat.

To compare the prevalence of shortness, underweight, and overweight by using the Centers for Disease Control and Prevention (CDC) 2000 and the World Health Organization (WHO) 2006 growth charts. These comparisons are undertaken with 2 sets of cutoff values.Data from the National Health and Nutrition Examination Survey 1999-2004 were used to calculate the prevalence estimates in US children aged 0 to 59 months (n = 3920). Cutoff values commonly used in the United States, on the basis of the 5th percentile of height-for-age to define shortness, the 5th percentile of weight-for-height or weight-for-age to define underweight, and the 95th percentile of weight-for-height or body mass index-for-age to define overweight were compared with the cutoff values recommended by WHO, which use-2 z-score (equivalent to 2.3rd percentile) to define shortness and underweight andor=2 z-score (equivalent to 97.7th percentile) to define overweight. A comparison with the same cutoff values (5th and 95th) in the 2 charts was also performed.Applying the 5th or 95th percentile, we observed a higher prevalence of shortness and overweight for all the age groups when the WHO 2006 growth charts were used than when the CDC 2000 growth charts were used. Applying the 5th percentile to the WHO 2006 charts produced lower rates of underweight than did the CDC 2000 charts. However, applying the 5th or 95th percentiles to the CDC 2000 charts and the WHO-recommended cutoff values of -2 or +2 z-score to the WHO charts produced smaller differences in the prevalence of shortness and overweight than were seen when the 5th and 95th percentiles were applied to both the CDC and WHO charts.Estimates of the prevalence of key descriptors of growth in children aged 0 to 59 months vary by the chart used and the cutoff values applied. The use of the 5th and 95th percentiles for the CDC growth charts and the 2.3rd and 97.7th percentiles for the WHO growth charts appear comparable in the prevalence of shortness and overweight, but not underweight. If practitioners were to use the WHO growth charts, it might be more appropriate to adopt the WHO recommended cutoff values as well, but this would be a change for office practice.

Background: Several different sets of reference body mass index (BMI) values are available to define overweight in children. Objective: The objective of this study was to compare the prevalence of overweight in US children calculated with 3 sets of reference BMI values: the revised growth charts of the Centers for Disease Control and Prevention (CDC-US growth charts), international standards proposed by Cole et al, and values developed by Must et al. Design: Data for children and adolescents came from cross-sectional nationally representative US surveys: cycles II and III of the National Health Examination Survey (1963-1965 and 1966-1970) and the first, second, and third National Health and Nutrition Examination Surveys: NHANES I (1971-1974), II (1976-1980), and III (1988-1994). The reference values of Cole et al equivalent to a BMI of 25 were compared with the 85th percentiles from the other 2 methods; the values equivalent to a BMI of 30 were compared with the 95th percentiles. Results: The 3 methods gave similar but not identical results. The reference values of Cole et al gave lower estimates than did the CDC-US growth charts for young children but higher estimates for older children. The reference values of Must et al gave much higher prevalences for younger girls than did the other 2 methods. Conclusions: Differences between methods were related to differences in data sets, smoothing methods, and theoretical approaches. All 3 methods are based on statistical criteria and incorporate arbitrary assumptions. These methods should be used cautiously, with awareness of the possible limitations.

The BMI distribution shifted upward in the United States between the 1960s and the 1990s, but little is known about secular trends in the pattern of BMI growth, particularly earlier in the century and early in childhood.The objective was to examine differences in BMI growth in children born in 1929-1999.BMI curves from ages 2 to 18 y were produced for 855 European-American children in the Fels Longitudinal Study born in 1929-1953, 1954-1972, and 1973-1999. Age (A(min)) and BMI (BMI(min)) at adiposity rebound and age (AV(max)), BMI (BMIV(max)), and velocity (V(max)) at maximum velocity were derived; multivariable regression was used to examine whether maternal BMI, infant weight gain, and other covariates mediated the cohort effects on these traits.BMI curves showed that children born in 1973-1999 had the lowest BMI values until age 5 y but had the largest values from age 8 y onward. In adjusted models, boys and girls born in 1973-1999 had a 0.15-kg/m(2) per year faster V(max) and a 1-kg/m(2) higher BMIV(max) than did children of the same sex born in 1929-1953, and girls had a 0.8-y earlier A(min) (P0.01). Maternal BMI and infant weight gain were associated with an obesity-prone pattern of BMI growth but did not account for the observed trends.Shifts in the BMI growth rate around the time of pubertal initiation were apparent starting after 1973. The BMI growth curve did not increase monotonically over time; rather, children born during the obesity epidemic were characterized by lower BMI values before the adiposity rebound and by rapid subsequent BMI gain.

Background: In the United States, black women are at much greater risk of obesity than are black men. Little is known about the factors underlying this disparity.

Objective To examine the accuracies of body mass index (BMI) and skinfold thicknesses in classifying the body fatness of 7365 8- to 19-year-old subjects in a national sample. Study design We used percent body fat determined by dual-energy x-ray absorptiometry (PBF DXA ) between 1999 and 2004. Categories of PBF DXA and the skinfold sum (triceps plus subscapular) were constructed so that that numbers of children in each category were similar to the number in each of 5 BMI categories based on the Centers for Disease Control and Prevention growth charts. Results Approximately 75% of the children and adolescents who had a BMI-for-age ≥ 95th percentile (considered obese) had elevated body fatness, but PBF DXA levels were more variable at lower BMIs. For example, only 41% of the boys who had a BMI DXA . The use of the skinfold sum, rather than BMI, slightly improved the identification of elevated levels of body fatness among boys ( P = .03), but not among girls ( P > .10). A low sum of the triceps and subscapular skinfold thicknesses was a better indicator of low PBF DXA than was a low BMI, but differences were smaller among children with greater levels of body fatness. Among girls who had a PBF DXA above the median, for example, BMI and the skinfold sum were correlated similarly (r = 0.77-0.79) with body fatness. Conclusions Both BMI and skinfold thicknesses are fairly accurate in identifying children who have excess body fatness. In contrast, if the goal is to identify children who have low body fatness, skinfold thicknesses would be preferred.

gramme. Teachers commended the utility and usability of the HH syllabus, reporting that the packaged set of teaching resources developed for the programme attributed to the ease of delivery and uptake by students. Activities involving walking were identified by children, parents, and teachers as being the most fun and achievable. It was perceived that enhanced relationships with family and friends contributed to the sustainability of the programme. Parents reported an increase in activity in the home, while an interest in food preparation and an increased understanding in healthy food options both at school and in the home environment were observed by parents and teachers. Teachers advocated the integration of the HH programme into the school curriculum on a biannual basis. Conclusions: We conclude that compulsory homework designed to teach children to be active and eat well at home is a promising method for promoting healthy lifestyles in children and their families.