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. Author manuscript; available in PMC: 2025 Sep 1.
Published in final edited form as: Appetite. 2024 Jun 17;200:107564. doi: 10.1016/j.appet.2024.107564

The effects of parent-child dysfunctional interactions on early childhood weight: A serial mediation model through emotional feeding and child appetite traits

Christina N Kim a,*, Mary Jo Messito a, Carol Duh-Leong a, Michelle Katzow b, Radhika Teli a, Rachel S Gross a
PMCID: PMC11907409  NIHMSID: NIHMS2006009  PMID: 38897417

Abstract

Parent-child dysfunctional interactions (PCDI) are known to contribute to children’s weight status. However, the underlying mechanisms in how dysfunctional interactions between parent and child influence child weight are not clear. This study investigates the impact of PCDI on toddlers’ weight, focusing on the potential serial mediation by maternal emotional feeding and child appetite traits. We conducted a secondary analysis of longitudinal data from a larger intervention trial to prevent childhood obesity in low-income Hispanic families. A total of 241 mother-child dyads were included in these analyses. Measurements were taken at various stages: PCDI at child age 19 months, maternal emotional feeding at 28 months, and both child appetite traits and weight-for-age z-score (WFAz) at 36 months. Serial mediation analyses revealed a significant indirect effect of early PCDI on later child WFAz through maternal emotional feeding and two child food approach traits (food responsiveness, emotional overeating) out of the eight child appetite traits assessed. PCDI at 19 months was associated with increased use of emotional feeding in mothers at 28 months, which was associated with heightened food responsiveness and emotional overeating in children at 36 months, which in turn was linked to greater child WFAz at 36 months. The findings of this study expand the understanding of the mechanisms underlying PCDI and child weight, emphasizing the interplay between maternal feeding practices and child appetite in the context of adverse parent-child interactions during early childhood.

Keywords: Child weight, Childhood obesity, Appetite traits, Maternal emotional feeding, Dysfunctional parent-child interactions

1. Introduction

1.1. Parent-child dysfunctional interactions and child weight

Negative interactions between a parent and child, such as high levels of parental control and low levels of parental support and responsiveness, have been linked to an increased likelihood of childhood obesity (Skouteris et al., 2012). Children who have lower quality interactions with their parents during early childhood have more than two-fold increased likelihood of developing overweight or obesity compared to those who have more positive interactions with their parents (Anderson et al., 2012). While studies have demonstrated a significant link between parent-child dysfunctional interactions (PCDI), or impaired, poor quality interactions between parents and children, and increased weights in older children and adolescents, this association has not yet been firmly established among young children. The existing literature primarily focuses on school-age children and adolescents (Anderson et al., 2012; Rhee et al., 2006; Wu et al., 2011), leaving a gap in our understanding of whether this association extends to young children as well. Given that childhood obesity is more prevalent among Hispanic (26.9%) children compared to non-Hispanic White (16.1%) children (Tsoi et al., 2022), examining how parent-child interactions may influence child weight in Hispanic parent-child dyads poses an important area of study. This study aims to examine the longitudinal impacts of PCDI on child weight during toddlerhood in low-income Hispanic families, with a focus of understanding the underlying mechanisms.

1.2. Emotional feeding as a mediator

One pathway through which PCDI can lead to an increased risk of obesity in young children is through non-responsive feeding practices. Poor quality parent-child relationships can exacerbate parenting stress, which may impair a mother’s ability to provide consistently responsive and sensitive caregiving (Deater-Deckard, 2004). This stress can manifest in the feeding context, leading to maladaptive feeding practices where mothers may not adequately respond to their child’s nutritional needs and hunger cues (Almaatani et al., 2023; Hurley et al., 2008). Previous research has shown that higher levels of parental stress are associated with a greater tendency to engage in emotional feeding, which involves using food to soothe or comfort a child in response to emotional distress rather than to meet their actual nutritional needs. (Rodgers et al., 2014; Wardle et al., 2002). Notably, emotional feeding has been directly linked to an increased risk of excessive weight gain in children (Demir & Bektas, 2017). Collectively, these findings suggest that emotional feeding may serve as a mediator in the relationship between PCDI and childhood obesity, amplifying the likelihood of obesity as mothers use food to cope with the emotional challenges that arise in their interactions with their children.

1.3. Child appetite traits as a mediator

Child appetite is another potential mediator in the linkage between PCDI and childhood obesity and overweight. Child appetite traits describe dispositions toward food and can be characterized as food-approaching traits and food-avoidant traits. (Carnell & Wardle, 2007; Costa & Oliveira, 2023). Food-approach traits demonstrate strong appetite and heightened interest in food and include food responsiveness (desire to eat in response to external food cues), emotional overeating, enjoyment of food, and desire to drink. Food avoidance traits, characterized by lower appetite and tendency to avoid or restrict certain food or food groups, include satiety responsiveness (ability to regulate intake of food in response to feelings of fullness), emotional undereating, food fussiness, and slowness in eating.

While the association between PCDI and a heightened risk of obesity is becoming more widely acknowledged (Pinquart, 2014), the underlying mechanisms remain poorly understood. To elucidate the potential pathways, research efforts have begun to investigate how the quality of parent-child interactions may shape the development of appetite traits, which are known predictors of childhood obesity (Dubois et al., 2007; Power et al., 2020; Vandyousefi et al., 2021). In a cross-sectional study examining the relationships among parent-child interactions, appetite traits, and child weight in school-aged children, Schuetzmann et al. (2008) found no association between parent-child interactions and child weight. However, they revealed that parent-child interactions were associated with children’s appetite traits, regardless of the children’s weight. Specifically, children who reported experiencing poor-quality interactions with their parents exhibited greater use of eating in response to external food cues (i.e., food responsiveness) and negative emotions (i.e., emotional eating). Although the cross-sectional nature of this study prevents determining a causal relationship between parent-child interactions and appetite traits, the findings suggest that the poor quality parent-child interactions could negatively impact the development of obesogenic appetite traits. Supporting this, a longitudinal study with preadolescents found that poor quality interactions with mothers at baseline significantly predicted an increase in eating pathology development 1 year later (Goossens et al., 2012). However, given the limited research in this area, further studies are needed to establish directionality between PCDI and child appetite traits. Additionally, it is important to examine whether child appetite traits serve as mediators in the relationship between PCDI and child weight.

1.4. Potential serial mediation through emotional feeding and child appetite traits

Although the significant roles of feeding practices and child appetite traits in childhood obesity have been well documented (Demir & Bektas, 2017; Vandyousefi et al., 2021), the combined influence of these factors on child weight during early childhood has not been clearly established. Though it is likely that parenting stress manifests in the feeding context regardless of who is doing the feeding (mother, father, or other caregiver), many empirical studies focus on mothers (Braden et al., 2014; Carnell et al., 2014). Existing literature highlight the robust associations between emotional feeding and child appetite traits (Costa & Oliveira, 2023; Wang et al., 2022). In a cross-sectional study with children aged 2–5 years, emotional feeding was significantly associated with greater child food responsiveness (Carnell et al., 2014). This association has also been documented in school-aged children aged 8–12 years, such that emotional feeding was significantly associated with child emotional eating (Braden et al., 2014). While these cross-sectional studies are limited in establishing causality, recent longitudinal studies provide support for the causal relationship between emotional feeding and appetite traits (Berge et al., 2020; Rodgers et al., 2013). Specifically, these studies found that greater use of emotional feeding practices leads to higher levels of food approach appetite traits – such as food responsiveness, emotional eating, and tendency to overeat – in young children (Berge et al., 2020; Rodgers et al., 2013). Although the causal path between emotional feeding and child appetite traits is yet to be distinctly outlined (Costa & Oliveira, 2023; Wang et al., 2022), it’s plausible that emotional feeding serves as a precursor, setting the stage for the development of appetite traits associated with obesity. To better understand how emotional feeding might serve as a developmental risk factor for obesogenic appetite traits, we investigate both emotional feeding and appetite traits together as potential serial mediators in extending the adverse impacts of PCDI on child weight.

In summary, converging evidence suggest that the PCDI may indirectly contribute to an increased risk of childhood obesity through a sequential path of emotional feeding and food approach traits. It can be thus hypothesized that elevated levels of PCDI result in more frequent usage of emotional feeding practices, which subsequently predicts obesogenic appetite traits, and in turn, leads to greater weight gain in children. However, little is known about the underlying mechanism that links PCDI to child weight, especially among low-income Hispanic families with young children.

1.5. Present study

The aim of the present study is to investigate the longitudinal associations between PCDI and child weight in toddlers from Hispanic families with low-income. Specifically, we test emotional feeding and child appetite traits as possible sequential pathways in explaining the association of PCDI and child weight. We hypothesize that PCDI is positively associated with child weight. We also hypothesize that: a) elevated levels of PCDI at 19 months lead to more frequent use of emotional feeding at 28 months, b) this increased use of emotional feeding at 28 months then predicts appetite traits at 36 months, and c) finally, these appetite traits will result in greater weight gain at 36 months.

2. Method

2.1. Study design

We conducted a secondary data analysis from the Starting Early Program (StEP) randomized controlled trial (RCT), aimed at reducing early childhood obesity. The StEP RCT specifically targets low-income Hispanic families and begins in the third trimester of pregnancy (Gross et al., 2016; Messito et al., 2020). To qualify for the StEP RCT, pregnant people had to be 18 years or older, have a single uncomplicated pregnancy, identify as Hispanic/Latina, plan to receive prenatal and pediatric care at the study sites, and be fluent in English or Spanish. Women who had a history of severe medical or psychiatric illness, or severe fetal anomalies were excluded. Eligible women were offered participation in the study during a prenatal visit in the third trimester. Bilingual research assistants, proficient in both English and Spanish, obtained written consent from all interested women. Initial assessment was conducted at a baseline prenatal visit with subsequent assessments at child ages 3 months, 10 months, 19 months, 28 months, and 36 months. In the present study, our primary study variables are assessed at 19 months, 28 months, and 36 months. This study was approved by the institutional review boards of New York University School of Medicine and New York City Health + Hospitals. This study was registered on clinicaltrials.gov (NCT01541761).

2.2. Participants

Of the original sample of 533 mother-child dyads, 241 (45%) mother-child dyads who have complete data on the variables of interest were included in the analysis. Mother’s age ranged from 18 to 47 years (M = 29.8 years, SD = 5.6). Most mothers were married or living as married (76%), primarily non-US born (88%), completed high school or higher degree (63%), and WIC participants (91%). About one fifth of the mothers reported clinically significant levels of depressive (12%) and anxiety (13%) symptoms. Compared with those without complete data, and thus not included in the current study, the analytic sample included higher percentage of mother who were single, born outside of the US, and completed high school or less. The proportions of children’s weight categories did not differ between the analytic sample and non-analytic sample. PCDI, emotional feeding, and child weight did not differ between the analytic sample and the sample with missing data. However, compared to the children in the analytic sample, children with missing data exhibit higher levels of food responsiveness, enjoyment of food, and desire to drink.

Of the total children, boys made up half (50%). About two-thirds (68%) had a healthy weight, while around one-third fell into the categories of either overweight (15%) or obese (16%).

2.3. Measures

Parent-Child Dysfunctional Interactions.

Parent-child interaction quality was assessed using the 12-item Parent-Child Dysfunctional Interactions (PCDI) subscale from the Parenting Stress Index Short Form (Abidin, 1995,Abidin, 1995) at child age 19 months. The PSI-SF has been validated for parents of young children (Barroso et al., 2016) and for use with Spanish-speaking mothers of young children (Gabriela et al., 2020). The P-CDI measures mothers’ perception of the emotional quality of their relationships with their children, including aspects such as feelings of disappointment, rejection, or estrangement experienced by parents towards or from their children. Example items include “Most times I feel that my child does not like me and does not want to be close to me” and “My child rarely does things for me that make me feel good”. The response options ranged from 1 (strongly disagree) to 5 (strongly agree). The items were summed, with higher scores reflecting greater dissatisfaction in parents’ interaction with their children. Cronbach’s alpha value for the P-CDI scale with the current sample was 0.74.

Emotional feeding.

Mothers’ emotional feeding practices were assessed using the 3-item Emotion Regulation (ER) subscale from the Comprehensive Feeding Practices Questionnaire (CFPQ; Musher-Eizenman & Holub, 2007) at child age 28 months. Mothers responded to items such as “Do you give this child something to eat or drink if s/he is upset even if you think s/he is not hungry?” on a 5-point scale with response options ranging from 1 (never) to 5 (always). An average score was created with higher scores indicating greater use of food to regulate their children’s emotions. Cronbach’s alpha value for the ER scale with the current sample was 0.72.

Child appetite traits.

Mothers reported on their children’s appetite traits using the Child Appetite Traits Questionnaire (CEBQ; Wardle et al., 2001) at child age 36 months. The CEBQ measures parental perception of children’s appetitive traits across four food approach traits (i.e., Food responsiveness, Emotional overeating, Enjoyment of food, Desire to drink) and four food avoidance traits (i.e., Satiety responsiveness, Emotional undereating, Food fussiness, Slowness in eating). Response options range from 1 (never) to 5 (agree). For each subscale, average scores are calculated, with higher scores indicating more frequent reports of children demonstrating the particular characteristics. In the current sample, the Cronbach’s alpha values for Satiety Responsiveness, Slowness in Eating, and Emotional Undereating were 0.57, 0.52, and 0.26, respectively. To optimize Cronbach’s alpha and improve the reliability of the instrument, a single item was deleted from each subscale (i.e., “My child has a big appetite” in Satiety Responsiveness; “My child finishes his/her meal quickly” in Slowness in Eating; “My child eats more when she is happy” in Emotional Undereating). The updated Cronbach’s alpha values ranged from 0.68 to 0.79.

Anthropometric measures.

Child weight data at 36 months were acquired through the examination of medical records, which contained measurements taken by medical assistants during clinical visits (Howe et al., 2009). Although the original intention for the StEP trial was to utilize BMI-for-age and weight-for-length/height z-scores, the study switched to using weight-for-age z-scores (WFAz) due to the detection of biologically implausible variability in the clinically measured lengths/heights (Refer to Messito et al., 2020 for detailed information). Weight-for-age z-scores were calculated according to the U.S. Center for Disease Control and Prevention (CDC) national reference guidelines (Flegal & Cole, 2013).

Maternal characteristics.

Mothers provided information on their demographic characteristics including education, marital status, country of birth, and receipt of public aid/assistance. For the current analyses, demographic characteristics were dichotomized. Education was dichotomized as either less than high school degree or high school graduate or higher; marital status was dichotomized as single or married/living as married; country of birth was dichotomized as US born or non-US born; and receipt of public aid/assistance was dichotomized as participation in any public aid/assistance, including WIC and SNAP, or non-participation in any of these programs. Mothers’ anxiety and depression symptoms were assessed using the General Anxiety Scale 7-Item (GAD-7; Spitzer et al., 2006) and Patient Health Questionnaire 9-Item (PHQ-9; Kroenke et al., 2001), respectively. The GAD-7 and PHQ-9 scores were dichotomized using a clinical cutoff score of 5. In the current sample, 13% and 12% of mothers displayed clinically significant levels of anxiety and depression symptoms, respectively. Maternal pre-pregnancy BMI were calculated using weight and height from medical record review (Holland et al., 2013).

2.4. Plan of analysis

All analyses were performed using SPSS 26.0 (IBM Corp). Pearson correlation analysis was conducted between the variables of interest. Adjusted and unadjusted regression analyses were used to determine the association between PCDI and child weight.

Serial mediation analyses were conducted using PROCESS macro (version 3.4; model 6) to determine whether the emotional feeding (M1) and child appetite traits (M2) mediated the relationship between PCDI (X) and child weight (Y). Eight serial mediation models were examined in total, with each model representing one of the eight domains of child appetite traits. The serial mediation model enabled the exploration of multiple pathways. The first pathway examined the indirect effects of PCDI on child weight through emotional feeding (M1). The second pathway examined the indirect effects of PCDI on child weight through child appetite traits (M2). The third pathway examined the indirect effects of PCDI on child weight as mediated through the serial mediation of emotional feeding (M1) and child appetite traits (M2). The significance of all pathways was determined by a 95% bias-corrected bootstrap confidence intervals (CI) that are considered significant when the upper and lower bound does not contain zero. Bootstrapping with 5000 samples was used.

All analyses adjusted for sociodemographic factors and covariates known to be related to child obesity including child sex, maternal education, marital status, foreign-born status, receipt of public aid/assistance, pre-pregnancy BMI, and 19-months depression and anxiety symptoms at baseline. Additionally, we controlled for the intervention status (StEP intervention vs. control) (see Table 1).

Table 1.

Baseline Maternal and child characteristics.

mean ± SD, n (%)
Child
 Male sex 121 (50)
 Birth weight (kg, mean ± SD) 3.4 ± 0.5
 Premature <37 wk Gestational age 5 (2)
Intervention group status 122 (51)
Mothers’ socio-demographic factors
 Age (mean ± SD) 29.8 ± 5.6
 Primiparous 70 (29)
 Married or living as married 186 (76)
 Born outside of United States 211 (88)
 Completed high school or higher 151 (63)
Mothers’ psychosocial factors
 Dysfunctional-parent child interactions 15.2 ± 5.6
 Depressive symptoms 30 (12)
 Anxiety symptoms 32 (13)
 Number of public assistance programs received 1.6 ± 0.8
 WIC participation 219 (91)
 SNAP participation 104 (43)
Mothers’ weight-related factors
 Gestational weight gain (kg, mean ± SD) 9.7 ± 4.8
 Pre-pregnancy BMI (mean ± SD) 27.6 ± 5.1
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Note. N = 241.

a

Values are n(%) unless otherwise states.

Abbreviations: SNAP = Supplemental Nutrition Assistance program; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.

3. Results

3.1. Bivariate analysis

Means, SDs, and correlations for variables of interest are presented in Table 2. PCDI was significantly positively correlated with emotional feeding and child appetite traits, except for child enjoyment of food (r = −0.027, p = 0.634). PCDI at 19 months was not correlated with child WFAz at 36 months (r = 0.109, p = 0.068). Child WFAz at 36 months was significantly negatively correlated with emotional feeding at 28 months (r = −0.148, p = 0.010). Among appetite traits, child WFAz at 36 months was positively correlated with child enjoyment of food (r = 0.145, p = 0.013) at 36 months, but not with other traits.

Table 2.

Pearson correlations of main study variables.

Variables M(SD) 1 2 3 4 5 6 7 8 9 10 11
1. PCDI 15.17 (5.57) –
2. Emotional feeding 1.51 (0.71) 0.21** –
3. Child food responsiveness 2.03 (0.91) 0.33** 0.26** –
4. Child emotional overeating 1.41 (0.56) 0.38** 0.28** 0.51** –
5. Child enjoyment of food 3.87 (0.85) −0.03 −0.06 0.22** 0.01 –
6. Child desire to drink 3.16 (1.21) 0.19** 0.11* 0.46** 0.28** 0.04 –
7. Child satiety responsiveness 2.75 (0.81) 0.12* 0.14** 0.10* 0.27** −0.16** 0.16** –
8. Child emotional undereating 2.47 (1.00) 0.14* 0.16** 0.12* 0.33** −0.22** 0.17** 0.41** –
9. Child slowness in eating 2.80 (0.96) 0.15* 0.13* 0.04 0.19** −0.28** 0.15** 0.44** 0.31** –
10. Child food fussiness 2.84 (0.83) 0.15* 0.10 −0.01 0.13* −0.45** 0.10* 0.31** 0.37** 0.31** –
11. Child WFAz 0.55 (1.15) 0.11 −0.15* 0.06 0.02 0.15* 0.00 −0.06 −0.06 −0.10 −0.04 –
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Note.

*

p <. 05,

**

p < 0.01.

PCDI = Parent-Child Dysfunctional Interactions. WFAz = Weight-for-age Z-scores. PCDI is measured at 19 months, emotional feeding at 28 months, and child appetite traits at 36 months, Child WFAz is measured at 36 months.

3.2. Regression analyses

Associations between PCDI and standardized child WFAz at 36 months are shown in Table 3. In the unadjusted bivariate analysis, PCDI at 19 months was not directly associated with child WAFz at 36 months (B = 0.021, SE = 0.012, p = 0.068, 95% CI = [−0.002, 0.044]). However, after adjusting for covariates, PCDI at 19 months was significantly associated with higher child weight at 36 months (B = 0.024, SE = 0.012, p = 0.050, 95% CI = [0.000, 0.048]).

Table 3.

Unadjusted and adjusted association between parent-child dysfunctional interactions at 19 months and child WFAz at 36 months.

DV = Child WFAz at 36 months
Unadjusted model Adjusted model
B 95% CI p-value B 95% CI p-value
IV = PCDI at 19 months 0.021 −0.002, 0.044 0.068 0.24 0.001, 0.048 0.050
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Note. The adjusted model controlled for child sex, maternal pre-pregnancy BMI, education, marital status, foreign-born status, public aid/assistance, depression and anxiety symptoms, and intervention conditions.

3.3. Serial mediation

Fig. 1 and Table 3 present the path coefficients from the bootstrapped mediation analyses. We explored eight serial mediation models corresponding to the eight appetite traits. Among these eight models, only two showed significant serial mediation effects: food responsiveness and emotional overeating. The remaining six appetite traits, including enjoyment of food, desire to drink, satiety responsiveness, emotional undereating, slowness in eating, and food fussiness, did not demonstrate significant serial mediation effects.

Fig. 1.

Fig. 1.

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Longitudinal serial mediation of emotional feeding at 28 months and child eating behaviors at 36 months in the association between parent-child dysfunctional interactions at 19 months and child WFAz at 36 months

Note. Unstandardized coefficients are presented. Bias-corrected bootstrap 95% confidence intervals are presented in parentheses. The models are adjusted for child sex, maternal pre-pregnancy BMI, education, marital status, foreign-born status, public aid/assistance, depression and anxiety symptoms, and intervention conditions. See Table 3 For the indirect effects of dysfunctional parent-child interactions on child weight. *p < 0.05, **p < 0.01, ***p < 0.001.

3.3.1. Indirect effect through emotional feeding (M1) and child food responsiveness (M2)

Fig. 1A displays the first model, where we tested for the indirect effects of PCDI at 19 months on child WFAz at 36 months through a sequential path of emotional feeding at 28 months and child food responsiveness at 36 months. The overall model was statistically significant, F (12, 228) = 2.231, R2 = 0.105, p = 0.011. After including all covariates, PCDI at 19 months positively predicted emotional feeding at 28 months (B = 0.020, SE = 0.008, p = 0.016). When controlling for PCDI at 19 months, the effect of emotional feeding at 28 months on child food responsiveness at 36 months was significant (B = 0.284, SE = 0.071, p < 0.001); and, the effect of PCDI at 19 months on child food responsiveness at 36 months remained significant (B = 0.040, SE = 0.009, p < 0.001). When controlling for PCDI at 19 months and emotional feeding at 28 months, there was a significant effect of child food responsiveness at 36 months on child WFAz at 36 months (B = 0.228, SE = 0.096, p = 0.018); after including both serial mediators in the model, the direct effect of PCDI at 19 months on child WFAz at 36 months was no longer significant (B = 0.016, SE = 0.013, p = 0.217). The result suggests a significant indirect effect of PCDI at 19 months on child WFAz at 36 months through the serial mediation pathway of emotional feeding at 28 months (M1) and child food responsiveness at 36 months (M2) (B = 0.001, SE = 0.001, 95% CI = [0.001, 0.004]), although the effect was small. The serial mediation explained 4.5% of the variance of the total effect.

In addition to the serial pathway, a significant indirect effect of PCDI at 19 months on child WFAz at 36 months through child food responsiveness at 36 months (M2) was found (B = 0.009, SE = 0.005, 95% CI = [0.002, 0.020]). The mediation through food responsiveness accounted 40.9% of the total effect. However, indirect effects through emotional feeding at 28 months (M1) was not found (B = −0.005, SE = 0.003, 95% CI = [−0.012, 0.000]), as seen in Table 4.

Table 4.

Indirect effect of dysfunctional parent-child interactions on child weight.

Unstandardized Standardized
B SE 95% CI β SE 95% CI
Mediators: Emotional feeding and child food responsiveness
 PCDI → EF → WFAz −0.005 0.003 −0.012 0.000 −0.025 0.016 −0.063 −0.001
 PCDI → FR → WFAz 0.009 0.005 0.002 0.020 0.047 0.025 0.008 0.102
 PCDI → EF→ FR → WFAz 0.001 0.001 0.000 0.004 0.007 0.006 0.001 0.020
Mediators: Emotional feeding and child emotional overeating
 PCDI → EF → WFAz −0.005 0.003 −0.011 0.000 −0.023 0.015 −0.056 0.001
 PCDI → EO → WFAz 0.010 0.005 0.001 0.022 0.053 0.028 0.004 0.113
 PCDI → EF → EO → WFAz 0.001 0.001 0.000 0.003 0.004 0.004 −0.000 0.014
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Note. Unstandardized and standardized coefficients are presented. Statistically significant paths are in bold. Abbreviations: PCDI = Parent-child dysfunctional interactions at 19 months (X); EF = Emotional feeding at 28 months (M1); FR = Child food responsiveness at 36 months (M2); EO = Child emotional overeating at 36 months (M2); WAFz = child Weight-for-age Z-score at 36 months (Y).

Finally, to explore the directionality of the relationships, we tested the reverse model (child WFAz at 36 months → child food responsiveness at 36 months → emotional feeding at 28 months → PCDI at 19 months). Although the reversed model was significant, F (12, 228) = 28.192, R2 = 0.213, p < 0.001, there was no significant indirect effect of child WFAz at 36 months through the serial mediation pathway of child food responsiveness at 36 months and emotional feeding at 28 months (B = 0.020, SE = 0.019, 95% CI = [−0.010, 0.065]). In addition, the individual indirect effects through child food responsiveness (B = 0.206, SE = 0.117, 95% CI = [−0.029, 0.476]) and emotional feeding (B = −0.060, SE = 0.055, 95% CI = [−0.186, 0.029]) were also not significant.

3.3.2. Indirect effect through emotional feeding (M1) and child emotional overeating (M2)

Fig. 1B displays the second model, where we tested for the indirect effects of PCDI at 19 months on child WFAz at 36 months through a sequential path of emotional feeding at 28 months followed by child emotional overeating at 36 months. The pattern of results from the second model matched that of the first. The overall model was statistically significant, F (12, 228) = 2.091, R2 = 0.099, p = 0.018. After including all covariates, PCDI at 19 months positively predicted emotional feeding at 28 months (B = 0.020, SE = 0.008, p = 0.016). When controlling for PCDI at 19 months, the effect of emotional feeding at 28 months on child emotional overeating at 36 months was significant (B = 0.146, SE = 0.048, p = 0.002); and, the effect of PCDI at 19 months on child emotional overeating at 36 months remained significant (B = 0.035, SE = 0.006, p < 0.001). When controlling for PCDI at 19 months and emotional feeding at 28 months, there was a significant effect of child emotional overeating at 36 months on child WFAz at 36 months (B = 0.291, SE = 0.144, p = 0.045); after including both serial mediators in the model, the direct effect of PCDI at 19 months on child WFAz at 36 months was no longer significant (B = 0.015, SE = 0.014, p = 0.264). The result suggests a significant indirect effect of PCDI at 19 months on child WFAz at 36 month through the serial mediation pathway of emotional feeding at 28 months (M1) and child emotional overeating at 36 months (M2) (B = 0.001, SE = 0.001, 95% CI = [0.000, 0.003]), although the effect was small. This serial mediation also explained 4.5% of the variance of the total effect.

In addition to the serial pathway, a significant indirect effect of PCDI at 19 months on child WFAz at 36 months through child emotional overeating at 36 months (M2) was found (B = 0.010, SE = 0.005, 95% CI = [0.001, 0.022]). The mediation through emotional overeating accounted 45.4% of the total effect. However, indirect effects through emotional feeding at 28 months (M1) was not found (B = −0.005, SE = 0.003, 95% CI = [−0.011, 0.001]), as seen in Table 4.

In the exploration of the directionality of the relationships, while the reverse model (child WFAz at 36 months → child emotional overeating at 36 months → emotional feeding at 28 months → PCDI at 19 months) was significant, F (12, 228) = 26.659, R2 = 0.226, p < 0.00, there was no significant indirect effect of child WFAz at 36 months through the serial mediation pathway of child emotional overeating at 36 months and emotional feeding at 28 months (B = 0.014, SE = 0.015, 95% CI = [−0.009, 0.050]). In addition, individual indirect effects through child emotional overeating (B = 0.250, SE = 0.141, 95% CI = [−0.032, 0.570]) and emotional feeding (B = −0.051, SE = 0.050, 95% CI = [−0.166, 0.031]) were also not significant.

4. Discussion

The present study investigated the association between early PCDI and later child weight and its underlying mechanisms in a sample of Hispanic families with low-income participating in a child obesity prevention program. Regression analysis revealed that PCDI in early toddlerhood is associated with increased child WFAz at age 3 years. To enhance understanding of the underlying mechanism of this association, longitudinal serial mediation models were examined in which emotional feeding and child appetite traits serve as mediators. Serial mediation analysis revealed that PCDI predict higher child WFAz through a serial mediation of emotional feeding and child food approach appetite traits, specifically food responsiveness and emotional overeating. The analyses also revealed that the association between PCDI and child weight was not individually mediated by emotional feeding. On the other hand, child food responsiveness and emotional overeating individually served as mediators in this association. The findings of this study highlight interrelations between mothers’ feeding practices and child appetite traits in linking the influence of adverse parent-child interactions on child weight during toddlerhood.

The results from the regression analysis extend existing knowledge about the link between the quality of parent-child interactions and child weight into toddlerhood. Specifically, our findings provide some support for the longitudinal association between the PCDI and child weight, highlighting the adverse impact of poor parent-child interactions on early childhood obesity. Parent-child interactions play a crucial role in influencing children’s health outcomes, such as obesity, particularly in high-risk, low-income families. High-quality interactions promote adaptive social, emotional, and cognitive development in children, which can buffer the negative impact of environmental stressors on their health (Morris et al., 2017). According to the Pathways to Appetite Self-Regulation Model proposed by Saltzman et al. (2017), secure parent-child relationships foster appetite self-regulation in children both directly and indirectly through parents’ responsive feeding practices. In the context of poverty, poor parent-child interactions can exacerbate environmental stressors linked to low-income households and hinder the development of healthy appetite traits in children by impairing their self-regulation skills. Additionally, these negative interactions can hinder parents’ responsive feeding practices, potentially elevating the risk of obesity in children. Taken together, promoting positive parent-child interactions may serve as an effective intervention strategy to mitigate the risk of obesity among children in low-income families.

The serial mediation analyses revealed that the association between PCDI and child weight was mediated through a sequential series of emotional feeding practices and child appetite traits, although the effects were small. Specifically, two of the child food approach appetite traits (i.e., food responsiveness and emotional overeating) serve as a risk pathway in extending the adverse effects of the PCDI on increased child weight. PCDI in early toddlerhood (at 19 months) predicted more frequent use of emotional feeding in mothers six months later. This, in turn, lead to a greater tendency in children to respond to external food cues and overeat in response to negative emotions about a year later, which then predicted greater WFAz at age 3. The findings lend empirical support to the Pathways to Appetite Self-Regulation Model (Saltzman et al., 2017), which posits that the quality of the parent-child relationship is linked to childhood obesity through mechanisms of responsive feeding and child appetite self-regulation. Given that parental feeding practices are a key modifiable factor in young children’s food environment (Daniels, 2019), our finding emphasized the importance of targeting emotional feeding in childhood obesity prevention strategies, particularly in families with children who show higher tendencies towards food responsiveness and emotional overeating. To our knowledge, this is the first study to examine the underlying mechanism linking PCDI to child weight among young children in low-income Hispanic families. Future studies are needed to determine whether the mediation effects observed through emotional feeding and food approach appetite traits are consistent across different age groups.

The serial mediation analyses also revealed significant individual indirect pathways operating through child food responsiveness and emotional overeating, but not through emotional feeding. These findings enhance our understanding of how emotional feeding and child food approach traits individually contribute to the association between PCDI and child weight. A possible explanation for why emotional feeding does not serve as a mediator in the association between PCDI and child weight can be attributed to the cultural values and practices concerning food in Hispanic families. In the U.S., studies have shown that some Hispanic families describe food as an expression of love (Gomel & Zamora, 2007). They often equate sufficient eating with good health and view a lack of hunger as worrisome (Sherry et al., 2004). Hispanic parents also tend to be highly responsive of their children’s emotional state and are less demanding during food interactions with their children (Hughes et al., 2011; Power et al., 2015). Researchers speculate that these feeding tendencies among Hispanic parents stems from a goal of prioritizing children’s happiness during mealtimes (Arlinghaus et al., 2019; Gomel & Zamora, 2007). It may be possible that feeding in response to a child’s emotions in Hispanic families serves as a way to share positive interactions with a child, thereby mitigating the adverse impact of PCDI on the development of obesity. On the other hand, both food responsiveness and emotional overeating individually mediated the association between PCDI and child weight. Previous cross-sectional studies have established associations between poor parent-child interactions and food approach traits (Chao & Chang, 2017; Schuetzmann et al., 2008) as well as the association between food approach traits and child weight (Boswell et al., 2018; Power et al., 2020). Our findings suggest that these associations may also apply to young children in low-income Hispanic families and provide preliminary support for the potential mediating effect of food approach traits.

It is important to interpret these individual indirect effects in relation to the results of the serial mediation. Although emotional feeding did not individually mediate the association between PCDI and child weight, it served as the first mediator in the serial mediation chain. In other words, our study demonstrated that emotional feeding serves as a risk pathway that extends the detrimental effect of PCDI on child weight, especially when a child demonstrates appetite traits such as food responsiveness and emotional overeating. To effectively disrupt this risk pathway, intervention strategies should take a holistic approach in supporting mothers of young children. This should involve enhancing positive parent-child interactions, developing healthy feeding practices, and offering needed parenting support (Morris et al., 2017). In addition, findings from this study suggest that interventions should aim to address parents’ perceptions of their children’s appetite traits, as parents of children who display high food responsiveness and tendencies to overeat may be more susceptible to engaging in emotional feeding, thereby activating this risk pathway.

Furthermore, our study also provided some support for the causal relationship between emotional feeding and obesogenic child appetite traits. Specifically, mothers’ greater use of emotional feeding at 28 months predicted both higher levels of food responsiveness and emotional overeating in children at 36 months. Prior cross-sectional studies have demonstrated a strong association between parental feeding practices and child appetite traits during early childhood (Braden et al., 2014; Carnell et al., 2014; Rodgers et al., 2013). Recently, an increasing number of studies use longitudinal approaches to discern the directionality of causation between the two constructs. However, the findings have revealed mixed results. While some research suggests that feeding practices influence child appetite traits (Rodgers et al., 2013; Steinsbekk et al., 2016), others demonstrate that child appetite traits guide feeding practices (Burnett et al., 2022; Zhou et al., 2020). Yet, some studies point to a reciprocal relationship between feeding practices and appetite traits (Berge et al., 2020; Kininmonth et al., 2023). Our findings add to the current body of literature suggesting that emotional feeding is a developmental risk factor of food approach appetite traits during toddlerhood in low-income Hispanic families.

There are several limitations to this study. First, in the post hoc analysis, the reverse model proved to be non-significant, which provides some support for the direction of causality in our hypothesized model. However, due to the lack of control for prior levels of the variables in the current analyses, the causal relationship of this study should be interpreted with caution. Given that feeding practices and appetite traits can change over time (Jansen et al., 2023; Morales et al., 2024; Vandyousefi et al., 2021), and considering the relationship between these factors (Costa, Oliveira, & Severo, 2021; Kininmonth, 2023), it is also plausible that children who are more food responsive may evoke more emotional feeding from their parents, potentially leading to poorer quality interactions between parents and children. Future studies should consider using a more robust design to determine the directionality among PCDI, emotional feeding, child appetite traits, and child weight. Second, the findings of this study may not be generalizable to other populations, as participants were exclusively low-income Hispanic families with young children from New York City. Future research involving more diverse families is needed to determine whether our serial mediation pathways would be generalizable to young children from different socioeconomic and racial/ethnic groups. Finally, child appetite traits were based on maternal reports, which may be influence by mothers’ beliefs and perception about eating behaviors, appetite, and the weight of their child (Fernandez et al., 2018). Although the validity of maternal reports of child eating behaviors have been reported by independent observations (Powell et al., 2018), future research may benefit from using observational measures of child appetite traits.

5. Conclusion

The present study found that in low-income Hispanic families, PCDI in early toddlerhood predicts higher child weight at age 3 years. This association is further elucidated through a serial mediation of emotional feeding and child food approach appetite traits. Specifically, we found that emotional feeding serves as a risk pathway that extends the detrimental effect of PCDI on child weight, especially when a child demonstrates appetite traits such as food responsiveness and emotional overeating. Feeding practices are modifiable parenting behaviors (Daniels, 2019) that can either promote or attenuate the expression of appetite traits in children (Kininmonth et al., 2023). Culturally-sensitive, family-centered preventive interventions that target obesity-related feeding practices, such as the Starting Early Program (StEP), may support the development of healthy appetite traits in young children. Moreover, providing mothers with the needed support to better navigate the challenges of early childhood parenting is crucial to avert the initiation of risk pathways and reduce the risk of childhood obesity.

Funding

This work is supported by the National Institute of Food and Agriculture, U.S. Department of Agriculture, under award number 2011-68001-30207 and by the National Institute of Health/National Institute of Child Health and Human Development (NIH/NICHD) through a K23 Mentored Patient-Oriented Research Career Development Award (K23HD081077; PI: Rachel S. Gross). The study team also acknowledges support from the National Institutes of Health/NHLBI (K23HL159326, PI: Katzow) and NIEHS (K23ES035461, PI: Duh-Leong).

This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award, T32HP22238, totaling $501,135.00 with 6 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.

We acknowledge the editorial assistance of the NYU-H + H Clinical and Translational Science Institute (CTSI), which is supported by the National Center for Advancing Translational Sciences (NCATS, National Institutes of Health, through Grant Award Number UL1TR001445.

Footnotes

Ethical statement

Ethical approval was granted by institutional review boards of New York University Grossman School of Medicine and New York City Health + Hospitals. Written informed consent was provided by all participants.

CRediT authorship contribution statement

Christina N. Kim: Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization. Mary Jo Messito: Writing – review & editing, Supervision, Methodology, Investigation, Funding acquisition, Data curation, Conceptualization. Carol Duh-Leong: Writing – review & editing, Methodology. Michelle Katzow: Writing – review & editing, Methodology. Radhika Teli: Writing – review & editing, Methodology. Rachel S. Gross: Writing – review & editing, Supervision, Investigation, Funding acquisition, Data curation, Conceptualization.

Declaration of competing interest

The authors declare that they have no competing interests.

Data availability

Data will be made available on request.

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Data Availability Statement

Data will be made available on request.

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