Abstract
Parental perception of their child’s weight may influence their feeding practices. However, few studies examined the longitudinal associations and the potential sex differences within it. Considering that parents may perceive and respond differently to boys’ and girls’ weight status due to biological and sociocultural expectations, it is important to investigate potential sex differences. The prospective cohort study aims to examine the associations between parental weight perception and their non-responsive feeding practices in preschool children and explore child sex differences in the association. Parent–child dyads (n = 426, Mage = 3.76, SD = 0.50, 53.6%boys) were surveyed at two time points separated by a 2-year interval in China. Generalized estimating equations (GEE) were conducted to examine longitudinal associations between parental weight perception and non-responsive feeding practices (restrictive feeding, food as a reward, and pressure to eat), adjusting for key confounders, including child age, body mass index-for-age z-score (BAZ), having siblings, primary caregiver identity, and grandparent-parent parenting. Sex-stratified analyses were conducted to examine whether the associations differed between boys and girls. Parental underweight perception was associated with restrictive feeding (B = − 0.260, p = 0.004) and pressure to eat (B = 0.350, p < 0.001), but not with food as rewards (B = 0.015, p = 0.868) in the overall sample. However, parental overweight and obesity (OWOB) perception was not associated with restrictive feeding (B = − 0.029, p = 0.819), food as a reward (B = − 0.228, p = 0.146), and pressure to eat (B = − 0.284, p = 0.054). Among boys, underweight perception was associated with restrictive feeding (B = − 0.205, p = 0.023) and pressure to eat (B = 0.362, p < 0.001); OWOB perception was associated with pressure to eat (B = − 0.325, p = 0.024). While no significant associations were observed among girls for restrictive feeding, food as a reward, and pressure to eat.
Conclusion: Findings in this study suggested that the longitudinal associations between parental weight perception and feeding practices differed by sex among Chinese preschool children. Healthcare providers should consider offering anticipatory guidance to parents who perceive their child’s weight as abnormal, educating them on evidence-based, sex-specific strategies to promote healthy feeding practices.
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What is Known: • Cross-sectional studies suggest that parental weight perception is associated with non-responsive feeding practices and that these associations may differ by child sex. • In China, cultural beliefs such as “a chubby child is a healthy child” may lead parents to underestimate their child’s weight, potentially influencing their feeding behaviors. What is New: • This longitudinal study in urban Chinese preschoolers found that parental underweight perception was associated with increased pressure to eat and reduced restrictive feeding over time. • These associations were observed only among boys, highlighting potential sex-specific mechanisms shaped by cultural norms as early as the preschool years. |
Supplementary Information
The online version contains supplementary material available at 10.1007/s00431-025-06361-9.
Keywords: Preschooler, Parent, Weight perception, Non-responsive feeding practice, Longitudinal
Introduction
Overweight and obesity (OWOB) in early childhood have emerged as significant public health concerns globally. In China, the prevalence of OWOB among children under the age of 6 reached 10.4% in 2019 [1]. Childhood obesity results from wide-ranging and multifaceted factors, with family influences playing a particularly crucial role [2]. Within the family setting, parents serve as the primary caregivers for children, and their feeding practices are key during early developmental stages [3, 4]. Therefore, evidence-based parental feeding practices are essential for the effective prevention and management of OWOB in early childhood.
Drawing on Family Systems Theory [5], which conceptualizes the family as an interconnected system where each member’s behavior influences others, this framework suggests that parental feeding practices are shaped by broader family dynamics. Building on this, some studies [6–8] found that parental feeding practices are influenced by their perceptions of child’s weight. Parental perception of children’s weight (hereafter referred to as parental weight perception) refers to how parents evaluate their child’s body weight, which may differ from objective measures [9]. When parents perceive their child’s weight as unhealthy—whether underweight or OWOB—they often adopt non-responsive feeding practices, such as pressure to eat and restrictive feeding. For example, Wang et al. indicated that maternal weight perception is directly associated with pressure to eat [8], while a Portuguese birth cohort study linked perceived underweight to feeding strategies that encouraged excessive food intake [6]. However, despite increasing interest in this area, longitudinal evidences on the association between parental weight perception and non-responsive feeding practices over time remain scarce.
Besides, sex differences further complicate the relationship between parental weight perception and non-responsive feeding practices, as parental perceptions and responses to children’s weight often vary between boys and girls. On the one hand, parents are more likely to underestimate their sons’ weight, often perceiving OWOB boys as normal weight or even underweight, and normal-weight boys as underweight [10–12]. In contrast, parental perceptions of their daughters’ weight are more accurate. A systematic review included 46 studies that assessed children’s sex and showed that parents of girls were less likely to misperceive (n = 6) or underestimate (n = 18) their weight status than parents of boys [11]. On the other hand, parental feeding practices exhibit sex differences. Compared to girls, parents are more likely to adopt overfeeding or high-calorie dietary strategies for boys, whereas they tend to focus on controlling feeding or selecting low-calorie foods for girls [13, 14]. A study of preschool children in America demonstrated that boys’ meals contained significantly more calories than girls’ meals, driven by less healthy food choices [13]. Similarly, Qiu et al. reported that Chinese parents exerted greater control over their sons’ eating behaviors compared to their daughters’ [14]. These sex differences may reflect culturally embedded expectations from early childhood, where boys are often associated with ideals of strength and robustness, while girls are expected to conform to slender body standards [15–17]. While such patterns have been noted across various cultural settings, studies on potential moderating effects of child sex in the associations between parental weight perception and feeding practices are particularly limited.
Urban Chinese families offer a unique lens through which to explore these associations, as they are shaped by a blend of traditional family values and modern health beliefs. Studying how parental weight perception associates to feeding practices in this setting not only addresses a local public health concern but also contributes to the broader literature by highlighting culturally contingent mechanisms influencing early childhood obesity risk.
Therefore, this study aims to investigate the longitudinal associations between parental weight perception and non-responsive feeding practices among preschool children in urban China and examine sex differences in the associations. Using a prospective longitudinal design, this research seeks to generate robust evidence to support future intervention and implementation studies that develop culturally tailored strategies for promoting healthy feeding practices and reducing the risk of overweight and obesity in early childhood.
Method
Participants and procedure
This prospective cohort study recruited a convenience sample from eight public kindergartens in the Pudong District of Shanghai. The implementation process is detailed in Fig. 1. At baseline (October 2020, T1) and at follow-up (December 2022, T2), all children from the junior classes and their parents were invited to participate, with questionnaires distributed to and collected from parents via the same teacher-mediated home‐return procedure at both time points. Of the 644 parent–child dyads initially recruited, the following exclusions were applied: (i) parents who were not the primary caregivers, (ii) children with nutrition-related conditions (e.g., fever or diarrhea), and (iii) questionnaires with more than 30% missing data. Written informed consent was obtained from all parents at each time point.
Fig. 1.
Procedure of participant recruitment and implementation process
A total of 180 parent–child dyads were lost to follow-up due to the following reasons: absence, transfer schools, and decline to participate in the follow-up investigation. Supplementary Table 1 showed no significant differences in baseline demographic characteristics between parent–child dyads lost to follow-up and those retained in the study. Additionally, 7 dyads were excluded due to missing data > 30%. The analytic samples included 426 parent–child dyads at baseline and follow-up (Fig. 2). In this study, the follow-up rate was 70.6%, and the complete follow-up rate was 69.49%. Ethical approval for this study was obtained from the Ethics Committee of Shanghai Jiao Tong University School of Medicine (registration number: SJUPN-201908).
Fig. 2.
Flow chart of the study participants
Measurement
Parental perception of children’s weight
Parental weight perception was evaluated using the question [18], “How would you describe your child’s weight?” Responses were recorded on a 5-point Likert scale, ranging from 1 (very underweight) to 5 (very overweight). For analysis, the responses were recategorized into three groups: underweight (≤ 2), normal weight (= 3), and OWOB (≥ 4). This recoding was necessary due to the very small number of participants selecting the extreme options (e.g., “very underweight,” n = 10; “very overweight,” n = 0), which limited the feasibility of using all five original categories.
Parental non-responsive feeding practices
Parental non-responsive feeding practices over the past month were evaluated using the Chinese Preschooler’s Caregivers’ Feeding Behavior Scale (CPCFBS) [19] and the Chinese version of the Child Feeding Questionnaire (C-CFQ) [20]. The two scales were utilized to evaluate three non-responsive feeding practices: restrictive feeding, food as a reward, and pressure to eat. Restrictive feeding was assessed using four items that measured strict limitations on children’s access to or consumption of unhealthy foods. Food as a reward was evaluated with two items addressing the use of desired foods to regulate children’s eating or behavior. Pressure to eat was captured by four items focusing on insistence, demands, or physical struggles to encourage children to consume more food. Each item was framed to reflect the frequency of the practice, with response options ranging from 1 (never) to 5 (always). Subscale scores were calculated as the mean of all items within each respective subscale. In this study, Cronbach’s alpha for restrictive feeding, food as a reward, and pressure to eat was 0.752, 0.628, and 0.727 at baseline (T1) and 0.807, 0.561, and 0.773 at follow-up (T2), respectively.
Children’s actual weight
The child’s weight (kg) and height (cm) were measured by trained healthcare professionals at the community hospital’s child health unit. Based on WHO guidelines [21], the BMI-for-age z-score (BAZ) was calculated using WHO Anthro software for children aged 2 to 5 years and the Young Growth Curve for those aged 5 to 6 years. BAZ values were classified into three categories: underweight (z-score < –2), normal weight (–2 ≤ z-score ≤ 1), and OWOB (z-score > 1).
Demographic and family-related variables
Demographic and family-related variables were collected through a self-reported questionnaire, which included the child’s birth date, sex, main caregiver identity, parental age, weight, height, education level, grandparent-parent parenting, number of children, and annual household income. Parental body mass index (BMI) was calculated as weight (kg) divided by height squared (m2).
Statistical method
Analyses were conducted separately for boys and girls because previous research has found sex differences in parental weight perception and non-responsive feeding practices [7]. All statistical analyses were conducted using SPSS Statistical software version 24.0. Statistical significance was set at α = 0.05 (two-tailed).
The multiple imputation with chained equations (MICE) was used to impute missing values. The Harman single-factor test assessed common method bias, revealing six factors with eigenvalues greater than 1. The first factor accounted for 28.1% of the variance, below the 40% threshold, indicating no significant common method bias in the data.
Continuous variables were assessed for normality using histograms and Q-Q plots and were described using mean and standard deviation (SD). Categorical variables were summarized as counts and percentages. Independent samples t-tests and Chi-square tests were used to compare continuous and categorical variables, respectively, between boys and girls.
Generalized estimating equations (GEE) were used to examine the longitudinal associations between parental weight perception at baseline and non-responsive feeding practices at follow-up. Parental weight perception was included in the model as dummy variables, using “normal weight perception” as the reference category. Sex, parental weight perception, and their interaction terms (sex × parental weight perception) were simultaneously entered into the models to test whether child sex moderated the associations.
To test whether these associations varied by child sex, we created an interaction term between parental weight perception and sex and included it in the GEE models based on the total sample. Additionally, multicollinearity was assessed for all independent variables before model fitting. If the interaction term was not statistically significant, we also performed sex-stratified analyses to explore potential sex-specific trends.
Result
Participants’ characteristics
Table 1 presents the descriptive characteristics of the parent–child dyads, separately for boy and girl respondents. The mean baseline age of children was 3.76 years (SD = 0.30), and 53.8% were boys. At baseline, most children (85.4%) were normal weight, while 13.4% were classified as OWOB. Mothers constituted the primary caregivers for most children (76.3%), with grandparents participating in childcare across 82.2% of families.
Table 1.
Participants’ characteristics
| Total (n = 426) | Boy (n = 229) | Girl (n = 197) | t/χ2 (p) | |
|---|---|---|---|---|
| Age (years) | 3.76 ± 0.30 | 3.77 ± 0.31 | 3.75 ± 0.28 | 0.47a (p = 0.64) |
| BAZ | 0.11 ± 0.89 | 0.15 ± 0.88 | 0.06 ± 0.91 | 1.10a (p = 0.27) |
| Actual weight categories | 3.67 (p = 0.89) | |||
| Underweight | 5 (1.25%) | 3 (1.3%) | 2 (1.0%) | |
| Normal weight | 364 (85.4%) | 194 (84.7%) | 170 (86.3%) | |
| Overweight/obesity | 57 (13.4%) | 32 (14.0%) | 25 (12.7%) | |
| Parental weight perceptions | 3.67 (p = 0.16) | |||
| Underweight | 117 (27.5%) | 66 (28.8%) | 51 (25.9%) | |
| Normal weight | 254 (59.6%) | 140 (61.1%) | 114 (57.9%) | |
| Overweight | 55 (12.9%) | 23 (10.0%) | 32 (16.2%) | |
| Presence of siblings | 0.38 (p = 0.54) | |||
| Yes | 163 (38.3%) | 84 (36.7%) | 78 (39.6%) | |
| No | 263 (61.7%) | 145 (63.3%) | 119 (60.4%) | |
| Breastfeeding time (months) | 0.68 (p = 0.71) | |||
| < 6 months | 107 (25.1%) | 56 (24.5%) | 51 (25.9%) | |
| 6 ~ 12 months | 208 (48.8%) | 116 (50.7%) | 92 (46.7%) | |
| > 12 months | 111 (26.1%) | 57 (24.9%) | 54 (27.4%) | |
| Main caregiver | 1.46 (p = 0.23) | |||
| Mother | 325 (76.3%) | 180 (78.6%) | 145 (73.6%) | |
| Father | 101 (23.7%) | 49 (21.4%) | 52 (26.4%) | |
| Restrictive feeding | 3.65 ± 0.74 | 3.67 ± 0.73 | 3.62 ± 0.75 | 0.71a (p = 0.48) |
| Food as a reward | 3.38 ± 0.79 | 3.38 ± 0.79 | 3.39 ± 0.80 | − 0.14a (p = 0.89) |
| Pressure to eat | 3.10 ± 0.81 | 3.11 ± 0.81 | 3.09 ± 0.80 | 0.31a (p = 0.76) |
| Grandparent-parent parenting | 0.30 (p = 0.59) | |||
| Yes | 350 (82.2%) | 186 (81.2%) | 164 (83.2%) | |
| No | 76 (17.8%) | 43 (18.8%) | 33 (16.8%) | |
| Father’s age (years) | 36.54 ± 4.80 | 36.35 ± 4.65 | 34.77 ± 4.12 | − 0.86a (p = 0.39) |
| Mother’s age (years) | 34.52 ± 3.91 | 34.29 ± 3.75 | 34.77 ± 4.12 | − 1.25a (p = 0.21) |
| Father’s BMI | 24.32 ± 2.98 | 24.39 ± 3.06 | 24.24 ± 2.90 | 0.50a (p = 0.61) |
| Mother’s BMI | 21.50 ± 2.79 | 21.42 ± 2.70 | 21.60 ± 2.90 | − 0.67a (p = 0.50) |
| Father’s education level | 0.70 (p = 0.40) | |||
| Senior high school or below | 40 (9.4%) | 19 (8.3%) | 21 (10.7%) | |
| Advanced degree | 386 (90.6%) | 210 (91.7%) | 176 (89.3%) | |
| Mother’s education level | 0.12 (p = 0.73) | |||
| Senior high school or below | 41 (9.6%) | 21 (9.2%) | 20 (10.2%) | |
| Advanced degree | 385 (90.4%) | 208 (90.8%) | 177 (89.8%) | |
| Annual household income | 0.44 (p = 0.51) | |||
| < CNY 300,000 | 183 (43.0%) | 95 (41.5%) | 88 (44.7%) | |
| ≥ CNY 300,000 | 243 (57.0%) | 134 (58.5%) | 109 (55.3%) |
Data are presented as mean (SD) for continuous measures, and n (%) for categorical measures. BAZ, body mass index-for-age z-score; BMI, body mass index
at value
In our sample, 61.1% of boys and 57.9% of girls were perceived as normal weight by their parents. Overweight perceptions were more common for girls (16.2%) than boys (10.0%), while underweight perceptions were more frequent for boys (28.8%) than girls (25.9%). Among three non-responsive feeding practices, restrictive feeding had the highest score (M = 3.65, SD = 0.74), while pressure to eat had the lowest score (M = 3.10, SD = 0.81). At baseline, no significant sex differences were observed in parental weight perception or non-responsive feeding practices (p > 0.05).
Figure 3 illustrates the positive association between children’s actual weight and parental weight perception for boys and girls. The horizontal axis displays the three parental weight perception categories, while the vertical axis represents the children’s BAZ. The figure demonstrates that among children perceived as underweight, girls typically display a lower BAZ concentration than boys. Conversely, among those perceived as OWOB, boys tend to show a higher concentration of BAZ than girls.
Fig. 3.
Violin plot about the distribution of children’s BAZ over parental weight perception
Bivariate associations between parental weight perception and follow-up non-responsive feeding practices
Table 2 presents differences in non-responsive feeding practices scores across parental weight perception categories. Restrictive feeding scores differed significantly among boys (p = 0.008) but showed no significant differences in the total sample (p = 0.094) and girls’ group (p = 0.058). Scores for food as a reward were consistent across parental weight perception categories in both the total sample (p = 0.108) and sex-specific subsamples (p = 0.468, and 0.741, respectively). While pressure to eat scores varied significantly across parental weight perception categories in the total sample (p < 0.001) but showed no significant differences in boys and girls (p = 0.334, and p = 0.462, respectively).
Table 2.
Average of non-responsive feeding practices across parental weight perception
| Parental weight perception T1 | |||||
|---|---|---|---|---|---|
| Underweight | Normal weight | Overweight | p | ||
| Restrictive feeding T2 | Total | 3.53 ± 0.77 | 3.71 ± 0.72 | 3.64 ± 0.74 | 0.094 |
| Boy | 3.47 ± 0.79 | 3.72 ± 0.71 | 3.98 ± 0.49 | 0.008 | |
| Girl | 4.88 ± 0.18 | 3.61 ± 0.72 | 3.63 ± 0.89 | 0.058 | |
| Food as reward T2 | Total | 3.46 ± 0.73 | 3.39 ± 0.81 | 3.19 ± 0.84 | 0.108 |
| Boy | 3.40 ± 0.87 | 3.40 ± 0.76 | 3.19 ± 0.72 | 0.468 | |
| Girl | 3.75 ± 0.35 | 3.40 ± 0.80 | 3.32 ± 0.82 | 0.741 | |
| Pressure to eat T2 | Total | 3.35 ± 0.71 | 3.06 ± 0.84 | 2.76 ± 0.74 | < 0.001 |
| Boy | 3.10 ± 0.80 | 3.15 ± 0.83 | 2.88 ± 0.77 | 0.334 | |
| Girl | 3.63 ± 1.24 | 3.10 ± 0.79 | 2.96 ± 0.90 | 0.462 | |
Data are presented as mean (SD) for continuous measures. T1, at baseline; T2, at the follow-up after 2 years
Generalized estimating equations of parental weight perception on follow-up non-responsive feeding practices
Table 3 shows the association between parental weight perception (T1) and their non-responsive feeding practices (T2) in longitudinal analyses and sex subgroup analyses, after adjusting for sociodemographic characteristics. In the total sample, the underweight perception was negatively associated with restrictive feeding (B = − 0.260, p = 0.004) and positively associated with pressure to eat (B = 0.350, p < 0.001), but not with food as a reward (B = 0.015, p = 0.868). However, parental overweight and obesity (OWOB) perception was not associated with restrictive feeding (B = − 0.029, p = 0.819), food as a reward (B = − 0.228, p = 0.146), and pressure to eat (B = − 0.284, p = 0.054).
Table 3.
Sex-stratified associations between parental weight perception at baseline and non-responsive feeding practices at follow-up
| Total (n = 426) | Boy (n = 229) | Girl (n = 197) | ||||
|---|---|---|---|---|---|---|
| B (95%CI) | p | B (95%CI) | p | B (95%CI) | p | |
| Restrictive feeding T2 | ||||||
| Underweight | − 0.260 (− 0.435, − 0.085) | 0.004 | − 0.205 (− 0.382, − 0.028) | 0.023 | 0.085 (− 0.131, 0.302) | 0.440 |
| Overweight | − 0.029 (− 0.282, 0.223) | 0.819 | − 0.111 (− 0.383, 0.161) | 0.423 | − 0.187 (− 0.409, 0.035) | 0.100 |
| Underweightsex | 0.197 (− 0.075, 0.469) | 0.156 | ||||
| Overweightsex | 0.172 (− 0.160, 0.504) | 0.311 | ||||
| Food as rewards T2 | ||||||
| Underweight | 0.015 (− 0.160, 0.190) | 0.868 | − 0.002 (− 0.173, 0.170) | 0.986 | − 0.032(− 0.239, 0.175) | 0.762 |
| Overweight | − 0.228 (− 0.535, 0.079) | 0.146 | − 0.209(− 0.530, 0.112) | 0.202 | 0.189 (− 0.059, 0.437) | 0.135 |
| Underweightsex | 0.047 (− 0.218, 0.313) | 0.727 | ||||
| Overweightsex | 0.017 (− 0.379, 0.414) | 0.933 | ||||
| Pressure to eat T2 | ||||||
| Underweight | 0.350 (0.172, 0.529) | < 0.001 | 0.362 (0.174, 0.550) | < 0.001 | − 0.226(− 0.462, 0.010) | 0.061 |
| Overweight | − 0.284 (− 0.572, 0.005) | 0.054 | − 0.325 (− 0.607, − 0.042) | 0.024 | 0.265 (− 0.019, 0.550) | 0.067 |
| Underweightsex | − 0.163 (− 0.441, 0.114) | 0.249 | ||||
| Overweightsex | 0.030 (− 0.370, 0.429) | 0.885 | ||||
Parental weight perception (T1) was treated as a dummy variable, with perceived normal weight as the reference category. Child age, body mass index-for-age z-score (BAZ), main caregiver, parental age, body mass index (BMI), parental education, annual household income, having siblings, and grandparent-parent parenting were additionally controlled for in all statistical models, but corresponding coefficients were not reported. Sex, parental weight perception, and their interaction terms were tested in the total samples model. T1, at baseline; T2, at the follow-up after 2 years
Sex-specific analyses showed that among boys, underweight perception was negatively associated with restrictive feeding (B = − 0.205, p = 0.023) and positively associated with pressure to eat (B = 0.362, p < 0.001). Accordingly, OWOB perception was negatively associated with pressure to eat (B = − 0.325, p = 0.024). However, no significant associations were observed among girls for restrictive feeding, food as a reward, and pressure to eat.
Discussion
The study comprehensively investigated the longitudinal associations between parental weight perception at baseline and non-responsive feeding practices at follow-up among preschool children in urban China and further explored the sex differences in observed relationships. Our findings support (i) parental perception of their child’s weight represented sex differences; (ii) the potential association between parental weight perception and subsequent restrictive feeding and pressure to eat; and (iii) the longitudinal associations between parental weight perception and their non-responsive feeding practices differ by sex, with stronger and more pronounced patterns observed among boys than girls.
When comparing the distribution of parental weight perception categories by child sex, underweight perceptions were more prevalent in boys, while OWOB perceptions were more common in girls. These results are consistent with previous research [22–24], including a cross-European analysis showing that parents tend to assign lower weight ratings to boys [23]. In our sample, among children perceived as underweight, girls had lower BAZ scores than boys, and boys perceived as OWOB had higher BAZ than girls—indicating possible misperceptions influenced by gendered expectations in young children. Similar findings were also observed among adolescents in mainland China [25]. These findings suggest potential misperceptions driven by culturally shaped expectations—parents may perceive thinness as more concerning in boys and overweight as more problematic in girls, reflecting societal ideals that associate thinness with femininity and robustness with masculinity.
We observed that parental underweight perception at baseline was significantly associated with both increased restrictive feeding and increased pressure to eat at follow-up, even after adjusting for child BAZ, parental BMI, grandparental involvement in child-rearing, and other covariates. This suggests that when parents perceive their child as underweight, they may simultaneously attempt to both restrict and encourage food intake, possibly reflecting complex parental strategies to manage perceived nutritional inadequacy. These findings align with previous literature indicating that parental perception of child weight is an important driver of non-responsive feeding practices [26–28]. The positive association between underweight perception and pressure to eat is consistent with a systematic review reporting that parental concerns about low child weight often led to pressuring feeding behaviors [26]. Similarly, the link between underweight perception and restrictive feeding suggests that parents may attempt to regulate food quality or types rather than simply increasing quantity, possibly out of concern for promoting “healthy” weight gain [28].
In contrast, we did not find significant associations between parental OWOB perception and subsequent non-responsive feeding practices, which is in line with prior research [29, 30]. This may reflect culturally ingrained beliefs where underweight is viewed as a more immediate health concern, while OWOB may not elicit the same urgency for behavioral adjustment [31]. In some Chinese families, larger body sizes in young children are still culturally tolerated or even valued, which may explain the limited response to OWOB perceptions.
Sex-stratified analyses revealed that these associations were primarily evident among boys. Specifically, parental underweight perception was associated with both restrictive feeding and pressure to eat in boys, while OWOB perception was linked to decreased pressure to eat. These associations were not observed among girls. This sex-specific pattern is consistent with previous studies from both Chinese and Western contexts, which have reported that parents of boys are more likely to adopt controlling feeding practices in response to weight concerns [7, 32]. For example, an American study found that parents applied more food restriction and pressure to eat when they perceived their sons to be over or underweight, compared to daughters [7]. Similarly, a Chinese study noted that pressure to eat remained high for boys regardless of their perceived weight status [32].
These sex differences may be shaped by cultural body ideals that emerge in the preschool years, with thinness socially preferred for girls and strength valued for boys [13, 16, 17]. Consequently, parents may exert greater control over boys’ eating behaviors to encourage larger body sizes [14, 15]. Evidence from Chinese school-aged children also suggests that parents are more likely to adopt controlling feeding strategies for boys compared to girls [14]. However, some studies in Western populations have reported no significant sex differences in parental feeding practices [33, 34]. This disparity highlights the profound influence of cultural context on parental practices and attitudes [35, 36] and reflects differences in cultural normativeness and beliefs about the legitimacy of parental authority [37]. This cultural context should be considered when designing sex-sensitive interventions.
This study contributes to the existing literature by providing longitudinal evidence on the influence of parental weight perception on non-responsive feeding practices among preschool children in urban China. Additionally, the study specifically explored child sex differences in the observed associations. However, this research has several limitations. First, the sample comes from urban areas of a city in China, and the participating families were generally characterized by higher education levels and higher household income. Thus, caution is needed when generalizing these findings to the broader population. Further studies using more socioeconomically and geographically diverse samples of children and their caregivers are necessary to validate these findings and enhance their generalizability. Second, non-responsive feeding practices and other related factors were self-reported, which may introduce social desirability bias. Additionally, the weight perception measure relied on a single-item Likert scale that was collapsed into three categories due to the sparse distribution of extreme responses. While this recoding was necessary for analysis, it may have reduced the sensitivity to detect subtle differences in perception and introduced potential misclassification. Moreover, the CPCFBS is culturally tailored and has not been internationally validated, which may affect cross-cultural applicability. The reliability of the “using food as reward” subscale at follow-up was relatively low, possibly due to the small number of items in this dimension (two items). This may have limited the accuracy in capturing this specific feeding practice. Future studies should consider using more detailed and validated measures. Besides, the 2-year time interval between the assessment of parental weight perception and subsequent non-responsive feeding practices may not fully capture the true dynamic relationship between these variables. It is possible that a longer follow-up period or multiple time points would be necessary to more accurately reflect the causal and temporal effects of parental weight perception on non-responsive feeding practices. Future research should seek to include an even wider range of factors, including the primary caregiver identity (e.g., mother; father; or grandparents), parenting styles, and child temperament.
Conclusion
The current study provides novel insights into the longitudinal associations between parental weight perception and non-responsive feeding practices among preschool children in urban China, with a particular focus on sex differences. Our results indicated the significant role of parental weight perception in shaping feeding practices, particularly the restrictive feeding and pressure to eat among boys while highlighting the absence of such associations among girls. These findings suggest that future intervention and implementation research is needed to explore effective, child sex-specific strategies that can help parents develop accurate weight perceptions and adopt responsive feeding practices. This evidence will be critical in informing the design of culturally sensitive public health initiatives and educational programs aimed at promoting healthy child development.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We would like to acknowledge all the participants for their participation and cooperation during data collection. In addition, we would like to express our gratitude to all the child healthcare professionals at Jinyang Community Health Service Center in the study area for their contributions to data collection.
Abbreviations
- C-CFQ
Chinese version of the Child Feeding Questionnaire
- CPCFBS
Chinese Preschooler’s Caregivers’ Feeding Behavior Scale
- BAZ
Body mass index-for-age z-score
- BMI
Body mass index
- GEE
Generalized estimating equations
- MICE
Multiple imputation by chained equations
- OWOB
Overweight and obesity
Author contributions
Conceptualization: Y.Chen, and D.Z.; data curation: Y.Chen, F.Q. and X.S.; formal analysis: Y.C hen; funding acquisition: D.Z.; investigation: Y.Chen, F.Q., X.W., X.S., R.W., and J.W.; methodology: D.Z., and Y.Chen; project administration: D.Z. and X.T.; resources: D.Z. and X.T.; supervision: D.Z., Y.Cao, and W.H.; visualization: Y.Chen; writing—original draft: Y.Chen; writing—review and editing: Y.Chen, F.Q., D.Z., W.H. and Y.Cao. All authors have read and agreed to the published version of the manuscript.
Funding
It was supported by a grant from the National Social Science Foundation of China (No. 19BSH070).
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the principles of the Declaration of Helsinki and the Ethical Review Measures for Biomedical Research Involving Humans issued by the National Health and Family Planning Commission of China. Ethical approval was obtained from the Ethics Committee of Shanghai Jiao Tong University School of Medicine (registration number: SJUPN-201908, Approval Date: 3 Dec 2019). No identifying participant information was collected, and informed consent was obtained from all participants prior to their participation in the study.
Consent for publication
Obtained.
Competing interests
The authors declare no competing interests.
Footnotes
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
No datasets were generated or analysed during the current study.