Abstract
This study examines associations between an expanded conceptualization of food-related parenting practices, specifically, directive and non-directive control, and child weight (BMI z-score) and dietary outcomes [Healthy Eating Index (HEI) 2010, daily servings fruits/vegetables] within a sample of parent-child dyads (8–12 years old; n=160). Baseline data from the Healthy Home Offerings via the Mealtime Environment (HOME Plus) randomized controlled trial was used to test associations between directive and non-directive control and child dietary outcomes and weight using multiple regression analyses adjusted for parental education. Overall variance explained by directive and non-directive control constructs was also calculated. Markers of directive control included pressure-to-eat and food restriction, assessed using subscales from the Child Feeding Questionnaire; markers of non-directive control were assessed with a parental role modeling scale and a home food availability inventory in which an obesogenic home food environment score was assigned based on the types and number of unhealthful foods available within the child’s home food environment.
Directive control
Food restriction and pressure-to-eat were positively and negatively associated with BMI z-scores, respectively, but not with dietary outcomes.
Non-directive control
An obesogenic home food environment was inversely associated with both dietary outcomes; parental role modeling of healthful eating was positively associated with both dietary outcomes. Neither non-directive behavioral construct was significantly associated with BMI z-scores.
Total Variance
Greater total variance in BMI-z was explained by directive control; greater total variance in dietary outcomes was explained by non-directive control. Including a construct of food-related parenting practices with separate markers for directive and non-directive control should be considered for future research. These concepts address different forms of parental control and, in the present study, yielded unique associations with child dietary and weight outcomes.
In recent years, identification of modifiable determinants of childhood obesity has become a public health priority. Research has highlighted the role of the food environment in the development of obesity, including the food industry, the availability of energy dense foods and a physical environment that has been designed to promote a sedentary lifestyle.1 More recently, researchers have explored the important role of the home food environment; parents have the opportunity to positively influence their children’s weight status and dietary intake by providing healthful foods at home and modeling healthful food choices.2–8 Food-related parenting practices, including encouraging children to eat healthful foods and restricting intake of palatable snack foods, have also been identified as potentially significant determinants of children’s dietary intake and weight status.9–12
Research has shown that parents often adopt controlling food-related parenting practices (e.g., food restriction and pressure-to-eat) in response to concern about their child’s weight status or dietary intake patterns;9,11,12 for example, parents who are worried about their child gaining weight might place restrictions on the amount of sweets consumed by that child, and parents concerned about children’s picky eating patterns might respond by requiring them to eat all of the food on their plate at mealtime. Unfortunately, while parents likely engage in these controlling behaviors in an effort to improve their children’s dietary intake or weight status, the results associated with the impact of these behaviors on child outcomes are mixed. Laboratory, cross-sectional and prospective research suggests children exposed to higher levels of controlling food-related parenting practices (e.g. high food restriction, high pressure-to-eat) are more likely to engage in unhealthful eating behaviors (e.g. emotional eating, eating in the absence of hunger),7,13–17 and have overall less healthful dietary intake (e.g. more frequent consumption of palatable snack foods, less frequent consumption of fruits and vegetables).14,16,18–20 Further, studies have revealed controlling food-related parenting practices are significantly and positively associated with child weight status.10,21–25 Based on these study findings, it would seem that controlling food-related parenting practices have a detrimental effect on child weight and dietary intake patterns. However, several studies have suggested parental control might actually lead to improved dietary intake and reduce unhealthy weight gain over time 9,26–28 and other studies have found no significant associations between food-related parenting practices and child weight and dietary intake outcomes.27,29,30
Thus, while healthcare professionals are generally encouraged to teach parents to avoid controlling food-related parenting practices (pressure to eat, food restriction) to promote healthy dietary intake and weight among children,31–33 the evidence for this recommendation has not been entirely consistent 20,34,35 More recently, it has been suggested that both level (e.g. high vs low) and type (e.g. restriction, pressure, modeling, home food environment) of control, as well as how apparent (e.g. directive vs non-directive) the efforts at control are to the child, may differentially impact child outcomes and that perhaps this previously overlooked nuance might serve to explain inconsistent results to-date.11,34–41 Specifically, it has been posited that perhaps control itself does not lead to poor diet and weight-related outcomes, rather it is the method of control that influences these outcomes. 11,34–41 Several research groups have explored the use and impact of expanded conceptualizations on child outcomes. 11,34–41 For example, in 2006, Ogden and colleagues proposed an expanded conceptualization of food-related parenting practices; their study explored markers of overt control (detectable by the child) and markers of covert control (not detectable by the child).34 Examples of overt control included pressure-to-eat, food restriction, and use of food as a reward; examples of covert control included limiting non-healthful foods within the home environment and avoiding places that serve primarily unhealthful foods when eating out. These two distinct types of control were associated with different eating-related outcomes in children; covert control was associated with less unhealthful snacking while overt control was associated with greater healthful snack food intake. Another, slightly different conceptualization of food-related parenting practices was proposed in a study by Murashima and colleagues; the authors explored directive and non-directive feeding control.35 Pressure-to-eat, food restriction, and use of food as a reward were included in their study as markers of directive control. Markers of non-directive control included role modeling of healthy eating, maintenance of primarily healthy food items within the home, and encouragement to eat healthful food items during meals or as snacks. Study results showed non-directive control was positively associated with consumption of nutrient-dense foods and was negatively associated with energy-dense foods. Several other studies have explored the use and impact of broadened conceptualizations of controlling food-related parenting practices, although terminology (covert vs overt; directive vs. non directive; negative vs positive vs benign; restriction vs structure) and associated measures have differed widely. 11,34–41 It is also worth noting that these studies join, and expand upon, a much larger body of work that has long considered the important impact of the broad home food environment on child weight status and dietary intake.2,42–47
Generally, results from studies utilizing more complex conceptualizations of parental control suggest that perhaps the disparate findings in the child feeding practices literature with regard to control stem, at least in part, from the oversimplification of a multi-dimensional and complex construct. Thus, the goal of the current study is to add to this emerging body of literature by exploring associations between a broader conceptualization of food-related parenting practices, including markers of “non-directive control” and markers of “directive control” and child weight and dietary intake outcomes within a sample of school-aged children. Within this study non-directive control is defined as practices where parents interact with the child or influence the child’s environment with the goal of helping him or her eat a healthy diet by internalizing the goal, and markers include home food availability and parental modeling; directive control is defined as practices where parents put external pressure on the child to eat a healthy diet and markers include food restriction and pressure-to-eat. Findings from this study will help add to this new and ongoing conversation about the different forms of parental food-related control and the potentially different impact these varied forms of control have on child dietary and weight-related outcomes. Further, given that the bulk of research examining expanded conceptualizations of food-related parenting practices has been conducted within toddlers, preschoolers, and early-elementary school aged children,35–38,40,48 examining associations within a sample of late-elementary school aged children and their parents, will yield unique insight into the use and impact of food-related parenting practices within an older, less frequently explored age-group of young people. A better understanding of the impact of different forms of food-related parenting practices on child outcomes may be utilized to inform the anticipatory guidance provided by health care providers who work with parents of school-aged children.
Methods
Study design
For the present study, data were drawn from the baseline measurement of the Healthy Home Offerings via the Mealtime Environment (HOME) Plus study.49–51 HOME Plus was a randomized controlled trial designed to prevent childhood obesity via a family-focused, community-based program that encouraged families to eat healthy meals and snacks together and limit screen time.49 The main meal-preparing parent and one 8–12-year-old child per household were recruited to participate through events and flyers at Minneapolis Park and Recreation centers where the intervention program was held. Families were ineligible to participate if parents or children did not speak English, children had health conditions that prevented them from participating in the intervention, or children had an age- and gender adjusted body mass index (BMI) below the 50th percentile.51 Baseline surveys were completed by 160 parent–child dyads in their homes during the summers of 2011 and 2012 (two cohorts).50 All adults and children provided written consent and assent, respectively. Families received a $75 gift card for participating in baseline data collection. The study was approved by the University of Minnesota’s Institutional Review Board.
Measures
At baseline, parents and children completed psychosocial surveys, study staff measured height and weight to calculated standardized BMI z-scores, and children completed multiple 24-hour dietary recalls. The psychosocial surveys assessed a variety of topics, including measures of overt and covert control and demographic characteristics. Trained research staff ensured parents and children completed their surveys independently. Cronbach’s alphas described below were calculated using the data collected from Home Plus study participants.
Directive Control
Two separate subscales (i.e., pressure-to-eat and food restriction) from the Child Feeding Questionnaire (CFQ) 52,53 were utilized to assess markers of directive control. Pressure-to-eat was assessed by asking parents to complete the full 4-item CFQ Pressure-to-Eat Subscale, which was designed to measure the degree to which a parent encourages a child to eat more food (Cronbach’s α = 0.72). For example, parents were asked to rate their agreement with this statement, “My child should always eat all of the food on his/her plate” using a 5-point Likert scale, with each point on the scale represented by a word anchor. Food restriction was measured using the 8-item CFQ Restriction Subscale, which was designed to measure a parent’s attempt to control a child’s eating by restricting access to palatable foods (Cronbach’s α = 0.78). For example, parents were asked to rate their agreement with this statement, “I have to be sure that my child does not eat too many sweets” using a 5-point Likert scale, with each point on the scale represented by a word anchor. Overall scale scores were created by averaging responses across each measure (4-item and 8-item, respectively).
Non-directive Control
Two measures were utilized to assess markers of non-directive control; parental role modeling of healthy food intake and an obesogenic home food environment score. Parental role modeling of healthy food intake was assessed on the parent survey using a 6-item parent role modeling scale (Cronbach’s α = 0.67). This measure was designed to expand on two previously well-validated measures of parental role modeling that exist in the literature;54,55 our expanded measure includes specific questions about role modeling in front of the child and captures information on meal- and food-specific role modeling behaviors. Two items on our survey assessed parental role modeling while snacking (“When you eat a snack in front of your child, how often do you:… eat fruit as a snack? … eat vegetables as a snack?”), and four items assessed parenting role modeling while eating dinner (“When you are with your child, how often do you:… eat fruit at dinner? … eat vegetables at dinner? … eat green salad at dinner? … fill ½ your plate with fruits and vegetables at dinner?… drink water? … drink sugar-sweetened beverages, like soda pop?”). Responses for role modeling of healthful foods at both snack and dinner were on a 4-point scale: “Usually/ Always,” “Sometimes,” “Hardly ever,” and “Never.” Responses for individual items were summed to create a parental role modeling score, with higher scores indicating greater positive parental role modeling behaviors (scale range 8–32). Obesogenic home food environment was measured with the Home Food Inventory.56 Parents completed this validated instrument to document foods and beverages available in their homes. The inventory includes 13 major food categories (e.g., fruits, sweetened beverages) and two ready-access categories (i.e., in the kitchen and in refridgerator). The obesogenic score represents a total count of the number of regular-fat versions of cheese, milk, yogurt, other dairy, frozen desserts, prepared desserts, savory snacks, added fats; regular-sugar beverages; processed meat; high-fat quick, microwavable foods; candy; and access to unhealthful foods in refrigerator and kitchen. A higher obesogenic score reflects more readily available unhealthful foods at home.
Dietary outcomes
The two dietary outcomes used for analysis were average daily servings of fruits and vegetables and Healthy Eating Index (HEI) - 2010 score. Dietary data were collected with dietary recalls, which are considered valid for collecting food intake data with children 57,58 and were completed with all children at baseline. Daily servings of fruits and vegetables consumed were averaged over the nonconsecutive day recalls (two weekdays and one weekend day). The first recall was completed in-person during the baseline data collection and the other two were completed over the phone with trained research staff within two weeks. Of note, of the 160 participants, 133 completed all three recalls (83%), 22 completed only two recalls (14%) and five only complete one recall (3%). For the current study we averaged all completed recalls to create our dietary intake variables. Fried vegetables (e.g. French fries) were not included as a serving of fruit or vegetable while 100% fruit/vegetable juice was included. Dietary recalls were collected using Nutrition Data System for Research (NDSR) software version 2011 and 2012 and analyzed with version 2012 (Nutrition Coordinating Center University of Minnesota). The Healthy Eating Index (HEI)-2010 total dietary quality scores compare diet quality to the 2010 Dietary Guidelines for Americans.59,60 Each child’s diet quality score was calculated using dietary recall data by summing 12 dietary component scores: nine assessing meeting adequate intake and three assessing intake moderation. Higher dietary quality scores indicate more healthful dietary intake.
Anthropometric Measures
Trained study staff utilized standardized procedures to measure the heights and weights of all study participants.61 Using these numbers, Body Mass Index (BMI; weight (kg) / height (cm)2 was calculated for study participants, and age- and gender-adjusted BMI z-scores were calculated using the CDC’s growth charts parameters.
Demographic Characteristics
Parents completed demographic items including information about their birth date (to assess age), ethnicity/race (American Indian/Alaskan Native, Asian, African American, White, or more than one race), gender and receipt of economic assistance (e.g., free- or reduced-price lunch, Supplemental Nutrition Assistance Program benefits), as well as their child’s birth date and race. Children reported on their own gender. Parent participants were primarily white (77%) and mothers (95%) with a mean age of 41.4 years (SD = 7.70). Of the parent sample, 59% had completed at least a four-year college degree. Thirty-eight percent of parents reported that their family received some form of economic assistance (i.e., public assistance or free/reduced lunch). Child participants were split almost evenly between male and female with a mean age of 10.4 years (SD = 1.40). Table 1 provides further information regarding participant demographic characteristics.
Table 1.
Participant Characteristics | Total | |
---|---|---|
% | n | |
Parent gender | ||
Male | 5% | 8 |
Female | 95% | 152 |
Child Gender | ||
Male | 53% | 85 |
Female | 47% | 75 |
Parent race | ||
Other a | 3% | 5 |
White | 77% | 123 |
Child race | ||
Othera | 9% | 15 |
White | 68% | 109 |
Parent Education | ||
Less than a bachelor’s degree | 41% | 64 |
Bachelor’s degree or higher | 59% | 91 |
Income | ||
Less than $35,000 | 31% | 49 |
$35,000 to $74,000 | 23% | 36 |
$75,000 or more | 47% | 74 |
Receives Economic Assistanceb | ||
Yes | 39 | 62 |
No | 61 | 98 |
Mean (SD) | ||
Age of adults | 41.38 (7.71) | |
Age of children | 10.37 (1.40) |
American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, Other, or More than one race.
Examples of economic assistance include free- or reduced-price lunch, Supplemental Nutrition Assistance Program benefits, etc.
Statistical Analysis
Multiple linear regression models were used to test the associations between markers of directive control (pressure-to-eat, food restriction) and non-directive control (parental role modeling of healthful eating, home food availability) and each of our research outcomes of interest (fruit and vegetable intake, HEI-2010 dietary quality score, child BMI z-scores). Because level of parental education is known to be associated with predictor variables as well as the research outcomes of interest, we included parental education as a covariate in all models. Beta values, standard errors and associated p-values are reported. Finally, to address our aims, overall variance explained by directive and non-directive control constructs was also calculated, both with and without parental education in the models. R2 and 95% confidence intervals are reported. A p-value of 0.05 or less was considered to be statistically significant. All analyses were performed in Stata v13 (College Station, TX: StataCorp LP).
Results
Directive control
Pressure-to-eat was inversely associated with child BMI z-scores (β=-0.04; SE=0.02; p<0.01) while food restriction was positively associated with child BMI z-scores (β=0.02; SE=0.01; p=0.01). Neither pressure-to-eat nor food restriction were significantly associated with the assessed child dietary outcomes (HEI-2010 diet quality score and daily fruit and vegetable consumption) (Table 2).
Table 2.
Markers of Directive Control | Markers of Non-Directive Control | ||||||||
---|---|---|---|---|---|---|---|---|---|
Pressure-to-Eat (Range: 4–20) |
Food Restriction (Range: 9–40) |
Positive Parental Role Modeling (Range: 12–35) |
Obesogenic Home Food Environment (Range: 5–51) |
||||||
Mean Score (SD) | 8.84 (3.85) | 26.97 (6.88) | 27.4 (3.43) | 22.23 (7.77) | |||||
B (SE) | P-value | B (SE) | P-value | B (SE) | P-value | B (SE) | P-value | ||
Average daily servings of Fruits/Vegetables |
−0.04 (0.04) |
0.31 | −0.02 (0.02) |
0.29 | Average daily servings of Fruits/Vegetables |
0.11 (0.04) | 0.01 | −0.04 (0.02) |
0.05 |
Total R2 for Directive Control |
0.06 (−0.02, 0.14) | Total R2 for Non- directive Control |
0.11 (0.02, 0.21) | ||||||
HEI-2010 diet quality scores |
0.03 (0.23) |
0.91 | −0.11 (0.13) |
0.39 | HEI-2010 diet quality scores |
0.60 (0.26) | 0.02 | −0.23 (0.11) |
0.05 |
Total R2 for Directive Control |
0.07 (−0.01, 0.15) | Total R2 for Non- directive Control |
0.14 (0.04, 0.24) | ||||||
BMI z-score | −0.04 (0.02) |
<0.01 |
0.02 (0.01) |
0.01 | BMI z-score | −0.02 (0.02) |
0.15 | −0.01 (0.01) |
0.10 |
Total R2 for Directive Control |
0.15 (0.05, 0.25) | Total R2 for Non- directive Control |
0.08 (−0.01, 0.17) |
Notes: 1) All models (including Total R2) include adjustment for level of parent educational attainment; 2) Bolding indicates significance at p≤0.05.
Together, markers of directive control (pressure-to-eat and food restriction) explained 2% (95% CI= −0.03, 0.07) and 1% (95% CI= −0.03, 0.05) of the total variance in average daily fruit and vegetable consumption and HEI-2010 diet quality scores, respectively. Markers of directive control explained 6% (95% CI = −0.02, −0.15) of the total variance in child BMI z-score. Total variance explained increased with the addition of parental education to models: directive control and parental education explained 6% (95% CI= −0.02, 0.14) and 7% (95% CI= 0=0.01, 0.15) of the total variance in average daily fruit and vegetable consumption and HEI-2010 diet quality scores, respectively. Markers of directive control and parental education explained 15% (95% CI = 0.05, 0.25) of the total variance in child BMI z-score.
Non-directive control
Positive parental role modeling of healthful food intake was positively associated with average daily servings of fruits and vegetables and HEI-2010 diet quality scores (β=0.11; SE=0.04; p<0.01 and β=0.60; SE=0.26; p=0.02, respectively). An obesogenic home food environment was inversely associated with average daily servings of fruits and vegetables and HEI-2010 diet quality scores (β = −0.04; SE=0.02; p=0.05 and β =−0.23; SE=0.11; p=0.05, respectively; Table 2). No associations were observed between positive parental modeling or an obesogenic home food environment and child BMI z-score.
Together, markers of non-directive control (positive parental modeling and obesogenic home food environment) explained 8 percent (95% CI = −0.00, 0.16) and 8 percent (95% CI= 0.01, 0.16) of the total variance in average daily fruit and vegetable consumption and HEI-2010 diet quality scores, respectively. Markers of non-directive control explained 3 percent (95% CI=-0.02, 0.09) of the total variance in child BMI z-score. Total variance explained increased with the addition of parental education to models: non-directive control and parental education explained 11 percent (95% CI = 0.02, 0.21) and 14 percent (95% CI= 0.04, 0.24) of the total variance in average daily fruit and vegetable consumption and HEI-2010 diet quality scores, respectively. Markers of non-directive control and parental education explained 8 percent (95% CI=−0.01, 0.17) of the total variance in child BMI z-score.
Discussion
The present study aimed to explore associations between a broad conceptualization of food-related parenting practices, including markers of non-directive control (i.e. home food availability and parental role modeling) and markers of directive control (i.e. food restriction and pressure-to-eat) and child dietary intake and weight outcomes. This study joins a small number of previously published papers that attempted to examine food-related parenting practices and markers of the home food environment together in a way that paints a more comprehensive picture of parental influence. 20,34,35 It has been suggested that both level (e.g. high vs low) and type (e.g. restriction, pressure, modeling) of control, as well as how apparent (e.g. directive vs non-directive) the efforts at control are to the child, may differentially impact child outcomes and that perhaps this previously overlooked nuance might serve to explain inconsistent results to-date.11,34–41 The present study explored this hypothesis by separately examining associations between level and type of control, as well as by how apparent the efforts of control are to the child, and child dietary intake and weight outcomes.
In the present study, markers of directive control (food restriction and pressure-to-eat) were found to be significantly associated with child BMI z-score, but not with child dietary outcomes. Study findings reveal pressure-to-eat food-related parenting practices were significantly and inversely associated with BMI z-scores, whereas food restriction practices were found to be significantly and positively associated with BMI z-scores. These cross-sectional findings, align with previously conducted cross-sectional and prospective research.9 Unfortunately, there is accumulating evidence for the detrimental effects of pressure-to-eat and food restriction food-related parenting practices on children’s food preferences and ability to self-regulate energy intake.9 For example, laboratory studies have shown that a child, who is pressured to consume a particular food (e.g. vegetables) at meals, shows a decrease in preference for and intake of that particular food item long-term.18,62 With regard to food restriction, both laboratory and prospective studies have demonstrated that children whose parents restrict or limit the consumption of particular food items, are more likely to seek out and overconsume the restricted food item when given the opportunity (e.g. at school or a friend’s home).13–16,63–69 Further, the present study demonstrated no cross-sectional associations with food restriction or pressure-to-eat and better dietary intake outcomes. Thus, while parents likely adopt directive forms of control with the goal of improving their child’s dietary intake or weight status, findings from the present study, in combination with previous studies exploring the impact of food restriction and pressure-to-eat on child outcomes,9,10 suggest these forms of control might yield unintended results.
When interpreting the present study’s cross-sectional findings, temporal direction of these observed relationships remains unclear. In fact, research suggests the relationship between parental food restriction and pressure-to-eat and child weight-related outcomes is likely to be bidirectional;9 for example, whereas high levels of food restriction have been shown to lead to an increase in child weight, parents of overweight and obese children are more likely to adopt restrictive parenting practices in an effort to help curb their child’s food intake. Results from a small number of studies indicate that parental restriction often precedes excess weight in young children, 7,14,15 suggesting that the bidirectional path begins with parental use of controlling feeding practices; this exposure then leads to a child’s weight gain over time and creates a feedback cycle in which both food-related parenting practices and the child’s excess weight gain persist across time.
Although more research is necessary to establish whether it is parental restriction or pressure-to-eat that initiates what is likely a complex, lifelong interaction between food-related parenting practices and child weight-related outcomes, it is recommended that parents engage in behaviors known to promote child healthful eating behaviors and weight management, including making nutritious food items readily available within the home, and modeling healthful food choices. In the expanded conceptualization of food-related parenting practices explored within the present paper, we defined these types of parenting behaviors (positive parental role modeling and provision of a healthy home food environment) as markers of non-directive control; non-directive control reflects a form of parental behavior that does not utilize external pressure, but rather relies upon the parent making changes to the behaviors they are modeling or child’s home or social environment. Consistent with previous research findings, positive parent modeling was found to be positively associated with average daily servings of fruits and vegetables consumed by children, as well as HEI-2010 diet quality scores;70 an obesogenic home food environment was found to be negatively associated with average daily servings of fruits and vegetables consumed by children, as well as HEI-2010 diet quality scores. These cross-sectional findings, lend support to the idea that parents can promote their children’s healthful dietary intake through the provision of a physical (home food availability) and social (parental modeling) environment conducive to making healthy choices. However, in the present study these non-directive behaviors were not associated with BMI z-scores. These nonsignificant associations with BMI z-scores could indicate the associations between non-directive behaviors and improved eating patterns are not strong enough to yield improved weight outcomes in young people. Conversely, it might be that these non-directive behaviors associated with improved eating patterns in the short term, overtime may also be associated improved weight status. Future, longitudinal, research is needed to understand the long-term impact of these non-directive forms of parental control on both child dietary intake and weight outcomes.
This study has limitations and strengths and all results presented should be interpreted with these in mind. A primary limitation includes the lack of a validated tool via parental report that captures parental role modeling of specific foods and at specific eating events (meals versus snacks). However, without validated measures in the literature, we adapted validated questions from Cullen et al.71 for parent self-report of role modeling for these specific foods and eating behaviors. Further research should be conducted to validate questionnaires on parent self-report of role modeling. Another potential limitation stems from our exclusion of children with an age-and gender matched BMI below the 50th percentile; by excluding children in the lower half of the BMI percentiles (which includes both normal and underweight children) it is possible we biased the direction and/or magnitude of our study findings, as well as limiting the generalizability of study findings to only children with an age- and gender-matched BMI at or above the 50th percentile. Nevertheless, our findings may apply to many youth given the current prevalence of overweight/obesity. Finally, the current sample utilized was fairly homogenous with regard to ethnicity as well as level of parental education. Given that several studies to date have illuminated the influence of parental culture on feeding,9,11,72–74 the homogeneity of this sample should be considered a limitation.
This study is also marked by several notable strengths. The measures of dietary intake were obtained via the gold standard approach of 24-hour dietary recalls collected by NDSR software and trained staff. Use of the well-validated CFQ subscales and Healthy Eating Index-2010 scales as well as measured heights and weights to calculate child BMI z-score, strengthen the validity of study findings. Finally, although our sample was not particularly large, it was adequate for the analyses conducted and allowed for examination of associations within an under-explored age group. Previous work exploring food-related parenting practices has been conducted primarily in samples of toddlers, preschoolers, and early-elementary school aged children,35–38,40,48 with some more recent work exploring the impact of these practices on adolescents;10,20,25,74,75 thus we were able to fill a gap in the literature by examining associations within a population of late-elementary school children.
Conclusions
The present study aimed to add to the literature by exploring associations between a broadened conceptualization of food-related parenting practices and child dietary intake and weight outcomes within a sample of late-elementary school children and their parents. This study aimed to complement and add to the body of literature that has considered broadened conceptualizations of food-related parental control among younger children, and may provide some clarity for the confusing and contradictory results in the existing literature. Results of the present indicate that future research in this area should include a construct of food-related parenting practices with separate markers for directive and non-directive control behaviors. These concepts address distinct forms of parental control and appear to yield unique associations with child dietary and weight outcomes. Future, longitudinal, studies are needed to help establish long-term associations with child dietary and weight-related outcomes.
Acknowledgments
Funding source: This study was supported by Grant R01 DK08400 by the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK) at the National Institutes of Health (NIH) (J. Fulkerson, PI). Software support was also provided by the University of Minnesota’s Clinical and Translational Science Institute (Grant Number 1UL1RR033183 from the National Center for Research Resources (NCRR) of the NIH.
Footnotes
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References
- 1.Granot E. Preventive Nutrition. Springer; 2015. [Accessed June 23, 2016]. Childhood Obesity: New Paradigms on Susceptibility, Co-morbidities, and Interventions; pp. 321–334. http://link.springer.com/chapter/10.1007/978-3-319-22431-2_18. [Google Scholar]
- 2.Arcan C, Neumark-Sztainer D, Hannan P, van den Berg P, Story M, Larson N. Parental Eating Behaviours, Home Food Environment and Adolescent Intakes of Fruits, Vegetables and Dairy Foods: Longitudinal Findings from Project EAT. Public Health Nutr. 2007;10(11):1257–1265. doi: 10.1017/S1368980007687151. [DOI] [PubMed] [Google Scholar]
- 3.Birch LL. Does parenting affect children’s eating and weight status? Int J Behav Nutr Phys Act. :5. doi: 10.1186/1479-5868-5-15. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Cromley T, Neumark-Sztainer D, Story M, Boutelle KN. Parent and Family Associations With Weight-Related Behaviors and Cognitions Among Overweight Adolescents. J Adolesc Health. 2010;47(3):263–269. doi: 10.1016/j.jadohealth.2010.02.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Cullen KW, Baranowski T, Rittenberry L, Olvera N. Social-environmental influences on children’s diets: results from focus groups with African-, Euro-and Mexican-American children and their parents. Health Educ Res. 2000;15(5):581. doi: 10.1093/her/15.5.581. [DOI] [PubMed] [Google Scholar]
- 6.Davison KK, Birch LL. Child and parent characteristics as predictors of change in girls’ body mass index. Int J Obes Relat Metab Disord J Int Assoc Study Obes. 2001;25(12):1834. doi: 10.1038/sj.ijo.0801835. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Birch LL, Fisher JO. Development of eating behaviors among children and adolescents. Pediatrics. 1998;101(3):539. [PubMed] [Google Scholar]
- 8.O’Connor TM, Hughes SO, Watson KB, et al. Parenting practices are associated with fruit and vegetable consumption in pre-school children. Public Health Nutr. 2010;13:91–101. doi: 10.1017/S1368980009005916. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Faith MS, Scanlon KS, Birch LL, Francis LA, Sherry B. Parent-Child Feeding Strategies and Their Relationships to Child Eating and Weight Status. Obesity. 2004;12(11):1711–1722. doi: 10.1038/oby.2004.212. [DOI] [PubMed] [Google Scholar]
- 10.Loth K, Fulkerson JA, Neumark-Sztainer D. Food-related parenting practices and child and adolescent weight and weight-related behaviors. Clin Pract Lond Engl. 2014;11(2):207–220. doi: 10.2217/cpr.14.5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Rollins BY, Savage JS, Fisher JO, Birch LL. Alternatives to restrictive feeding practices to promote self-regulation in childhood: a developmental perspective. [Accessed June 23, 2016];Pediatr Obes. 2015 doi: 10.1111/ijpo.12071. http://onlinelibrary.wiley.com/doi/10.1111/ijpo.12071/pdf. [DOI] [PubMed] [Google Scholar]
- 12.Ek A, Sorjonen K, Eli K, et al. Associations between Parental Concerns about Preschoolers’ Weight and Eating and Parental Feeding Practices: Results from Analyses of the Child Eating Behavior Questionnaire, the Child Feeding Questionnaire, and the Lifestyle Behavior Checklist. PLOS ONE. 2016;11(1):e0147257. doi: 10.1371/journal.pone.0147257. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Carper JL, Orlet Fisher JO, Birch LL. Young girls’ emerging dietary restraint and disinhibition are related to parental control in child feeding. Appetite. 2000;35(2):121–129. doi: 10.1006/appe.2000.0343. [DOI] [PubMed] [Google Scholar]
- 14.Fisher JO, Birch LL. Restricting access to palatable foods affects children’s behavioral response, food selection, and intake. Am J Clin Nutr. 1999;69(6):1264. doi: 10.1093/ajcn/69.6.1264. [DOI] [PubMed] [Google Scholar]
- 15.Fisher JO, Birch LL. Restricting Access to Foods and Children’s Eating. Appetite. 1999;32(3):405–419. doi: 10.1006/appe.1999.0231. [DOI] [PubMed] [Google Scholar]
- 16.Birch LL, Fisher JO, Davison KK. Learning to overeat: maternal use of restrictive feeding practices promotes girls eating in the absence of hunger. Am J Clin Nutr. 2003;78(2):215–220. doi: 10.1093/ajcn/78.2.215. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Loth KA, MacLehose RF, Fulkerson JA, Crow S, Neumark-Sztainer D. Are food restriction and pressure-to-eat parenting practices associated with adolescent disordered eating behaviors? Int J Eat Disord. 2014;47(3):310–314. doi: 10.1002/eat.22189. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Galloway AT, Fiorito LM, Francis LA, Birch LL. [] Finish your soup’: Counterproductive effects of pressuring children to eat on intake and affect. Appetite. 2006;46(3):318–323. doi: 10.1016/j.appet.2006.01.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Gregory JE, Paxton SJ, Brozovic AM. Pressure to eat and restriction are associated with child eating behaviours and maternal concern about child weight, but not child body mass index, in 2-to 4-year-old children. Appetite. 2010;54(3):550–556. doi: 10.1016/j.appet.2010.02.013. [DOI] [PubMed] [Google Scholar]
- 20.Loth KA, MacLehose RF, Larson N, Berge JM, Neumark-Sztainer D. Food availability, modeling and restriction: How are these different aspects of the family eating environment related to adolescent dietary intake? Appetite. 2016;96:80–86. doi: 10.1016/j.appet.2015.08.026. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Joyce JL, Zimmer-Gembeck MJ. Parent feeding restriction and child weight. The mediating role of child disinhibited eating and the moderating role of the parenting context. Appetite. 2009;52(3):726–734. doi: 10.1016/j.appet.2009.03.015. [DOI] [PubMed] [Google Scholar]
- 22.Costanzo PR, Woody EZ. Domain-specific parenting styles and their impact on the child’s development of particular deviance: the example of obesity proneness. J Soc Clin Psychol. 1985;3(4):425–445. [Google Scholar]
- 23.Birch LL, Fisher JO. Mothers’ child-feeding practices influence daughters’ eating and weight. Am J Clin Nutr. 2000;71(5):1054–1061. doi: 10.1093/ajcn/71.5.1054. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Fisher JO, Birch LL. Eating in the absence of hunger and overweight in girls from 5 to 7 y of age. Am J Clin Nutr. 2002;76(1):226–231. doi: 10.1093/ajcn/76.1.226. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Loth KA, MacLehose RF, Fulkerson JA, Crow S, Neumark-Sztainer D. Food-Related Parenting Practices and Adolescent Weight Status: A Population-Based Study. Pediatrics. 2013;131(5):e1443–e1450. doi: 10.1542/peds.2012-3073. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Farrow CV, Blissett J. Controlling Feeding Practices: Cause or Consequence of Early Child Weight? Pediatrics. 2008;121(1):e164–e169. doi: 10.1542/peds.2006-3437. [DOI] [PubMed] [Google Scholar]
- 27.Campbell K, Andrianopoulos N, Hesketh K, et al. Parental use of restrictive feeding practices and child BMI z-score. A 3-year prospective cohort study. Appetite. 2010;55(1):84–88. doi: 10.1016/j.appet.2010.04.006. [DOI] [PubMed] [Google Scholar]
- 28.Sud S, Tamayo NC, Faith MS, Keller KL. Increased restrictive feeding practices are associated with reduced energy density in 4–6-year-old, multi-ethnic children at ad libitum laboratory test-meals. Appetite. 2010;55(2):201–207. doi: 10.1016/j.appet.2010.05.089. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Spruijt-Metz D, Li C, Cohen E, Birch LL, Goran M. Longitudinal influence of mother’s child-feeding practices on adiposity in children. J Pediatr. 2006;148(3):314–320. doi: 10.1016/j.jpeds.2005.10.035. [DOI] [PubMed] [Google Scholar]
- 30.Spruijt-Metz D, Lindquist CH, Birch LL, Fisher JO, Goran MI. Relation between mothers’ child-feeding practices and children’s adiposity. Am J Clin Nutr. 2002;75(3):581. doi: 10.1093/ajcn/75.3.581. [DOI] [PubMed] [Google Scholar]
- 31.Dietz WH, Stern L. American Academy of Pediatrics Guide to Your Child’s Nutrition: Feeding Children of All Ages. Villard Books; 1999. [Accessed August 28, 2012]. http://www.getcited.org/pub/100328669. [Google Scholar]
- 32.Holt, Wooldridge, Story, Sofka. Bright Futures: Nutrition. 3rd. American Academy of Pediatrics; [Google Scholar]
- 33.Spiegel AM, Alving BM. Executive summary of the Strategic Plan for National Institutes of Health Obesity Research. Am J Clin Nutr. 2005;82(1):211S–214S. doi: 10.1093/ajcn/82.1.221S. [DOI] [PubMed] [Google Scholar]
- 34.Ogden J, Reynolds R, Smith A. Expanding the concept of parental control: A role for overt and covert control in children’s snacking behaviour? Appetite. 2006;47(1):100–106. doi: 10.1016/j.appet.2006.03.330. [DOI] [PubMed] [Google Scholar]
- 35.Murashima M, Hoerr SL, Hughes SO, Kaplowitz SA. Feeding behaviors of low-income mothers: directive control relates to a lower BMI in children, and a nondirective control relates to a healthier diet in preschoolers. Am J Clin Nutr. 2012;95(5):1031–1037. doi: 10.3945/ajcn.111.024257. [DOI] [PubMed] [Google Scholar]
- 36.Rodgers RF, Paxton SJ, Massey R, et al. Maternal feeding practices predict weight gain and obesogenic eating behaviors in young children: a prospective study. Int J Behav Nutr Phys Act. 2013;10:24. doi: 10.1186/1479-5868-10-24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Brown KA, Ogden J, Vögele C, Gibson EL. The role of parental control practices in explaining children’s diet and BMI. Appetite. 2008;50(2):252–259. doi: 10.1016/j.appet.2007.07.010. [DOI] [PubMed] [Google Scholar]
- 38.Corsini N, Danthiir V, Kettler L, Wilson C. Factor structure and psychometric properties of the Child Feeding Questionnaire in Australian preschool children. Appetite. 2008;51(3):474–481. doi: 10.1016/j.appet.2008.02.013. [DOI] [PubMed] [Google Scholar]
- 39.Mitchell S, Brennan L, Hayes L, Miles CL. Maternal psychosocial predictors of controlling parental feeding styles and practices. Appetite. 2009;53(3):384–389. doi: 10.1016/j.appet.2009.08.001. [DOI] [PubMed] [Google Scholar]
- 40.Nowicka P, Flodmark C-E, Hales D, Faith MS. Assessment of parental overt and covert control of child’s food intake: A population-based validation study with mothers of preschoolers. Eat Behav. 2014;15(4):673–678. doi: 10.1016/j.eatbeh.2014.10.001. [DOI] [PubMed] [Google Scholar]
- 41.Rodenburg G, Kremers SP, Oenema A, van de Mheen D. Associations of parental feeding styles with child snacking behaviour and weight in the context of general parenting. Public Health Nutr. 2014;17(5):960–969. doi: 10.1017/S1368980013000712. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Birch LL, Davison KK. Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatr Clin North Am. 2001;48(4):893–907. doi: 10.1016/s0031-3955(05)70347-3. [DOI] [PubMed] [Google Scholar]
- 43.Couch SC, Glanz K, Zhou C, Sallis JF, Saelens BE. Home Food Environment in Relation to Children’s Diet Quality and Weight Status. J Acad Nutr Diet. 2014;114(10):1569–1579. doi: 10.1016/j.jand.2014.05.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Hanson NI, Neumark-Sztainer D, Eisenberg ME, Story M, Wall M others. Associations between parental report of the home food environment and adolescent intakes of fruits, vegetables and dairy foods. Public Health Nutr. 2005;8(1):77–85. doi: 10.1079/phn2005661. [DOI] [PubMed] [Google Scholar]
- 45.Rosenkranz RR, Dzewaltowski DA. Model of the home food environment pertaining to childhood obesity. Nutr Rev. 2008;66(3):123–140. doi: 10.1111/j.1753-4887.2008.00017.x. [DOI] [PubMed] [Google Scholar]
- 46.Wang L, Dalton WT, 3rd, Schetzina KE, et al. Home food environment, dietary intake, and weight among overweight and obese children in Southern Appalachia. South Med J. 2013;106(10):550–557. doi: 10.1097/SMJ.0000000000000008. [DOI] [PubMed] [Google Scholar]
- 47.Wyse R, Campbell E, Nathan N, Wolfenden L. Associations between characteristics of the home food environment and fruit and vegetable intake in preschool children: a cross-sectional study. BMC Public Health. 2011;11(1):938. doi: 10.1186/1471-2458-11-938. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Mitchell S, Brennan L, Hayes L, Miles CL. Maternal psychosocial predictors of controlling parental feeding styles and practices. Appetite. 2009;53(3):384–389. doi: 10.1016/j.appet.2009.08.001. [DOI] [PubMed] [Google Scholar]
- 49.Flattum C, Draxten M, Horning M, et al. HOME Plus: Program design and implementation of a family-focused, community-based intervention to promote the frequency and healthfulness of family meals, reduce children’s sedentary behavior, and prevent obesity. Int J Behav Nutr Phys Act. 2015;12(53.10):1186. doi: 10.1186/s12966-015-0211-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Fulkerson JA, Friend S, Flattum C, et al. Promoting healthful family meals to prevent obesity: HOME Plus, a randomized controlled trial. Int J Behav Nutr Phys Act. 2015;12(1):154. doi: 10.1186/s12966-015-0320-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Fulkerson JA, Neumark-Sztainer D, Story M, et al. The healthy home offerings via the mealtime environment (HOME) plus study: design and methods. Contemp Clin Trials. 2014;38(1):59–68. doi: 10.1016/j.cct.2014.01.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Musher-Eizenman D, Holub S. Comprehensive Feeding Practices Questionnaire: validation of a new measure of parental feeding practices. J Pediatr Psychol. 2007;32(8):960–972. doi: 10.1093/jpepsy/jsm037. [DOI] [PubMed] [Google Scholar]
- 53.Birch LL, Fisher JO, Grimm-Thomas K, Markey CN, Sawyer R, Johnson SL. Confirmatory factor analysis of the Child Feeding Questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite. 2001;36(3):201–210. doi: 10.1006/appe.2001.0398. [DOI] [PubMed] [Google Scholar]
- 54.Hendy HM, Williams KE, Camise TS, Eckman N, Hedemann A. The Parent Mealtime Action Scale (PMAS). Development and association with children’s diet and weight. Appetite. 2009;52(2):328–339. doi: 10.1016/j.appet.2008.11.003. [DOI] [PubMed] [Google Scholar]
- 55.Musher-Eizenman DR, Holub SC, Hauser JC, Young KM. The Relationship Between Parents’ Anti-fat Attitudes and Restrictive Feeding. Obesity. 2007;15(8):2095–2102. doi: 10.1038/oby.2007.249. [DOI] [PubMed] [Google Scholar]
- 56.Fulkerson JA, Nelson MC, Lytle L, Moe S, Heitzler C, Pasch KE. The validation of a home food inventory. Int J Behav Nutr Phys Act. 2008;5(1):55. doi: 10.1186/1479-5868-5-55. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Lytle LA, Nichaman MZ, Obarzanek E, et al. Validation of 24-hour recalls assisted by food records in third-grade children. J Am Diet Assoc. 1993;93(12):1431–1436. doi: 10.1016/0002-8223(93)92247-u. [DOI] [PubMed] [Google Scholar]
- 58.McPherson RS, Hoelscher DM, Alexander M, Scanlon KS, Serdula MK. Dietary assessment methods among school-aged children: validity and reliability. Prev Med. 2000;31(2):S11–S33. [Google Scholar]
- 59.Guenther PM, Casavale KO, Reedy J, et al. Update of the healthy eating index: HEI-2010. J Acad Nutr Diet. 2013;113(4):569–580. doi: 10.1016/j.jand.2012.12.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60.Guenther PM, Kirkpatrick SI, Reedy J, et al. The Healthy Eating Index-2010 is a valid and reliable measure of diet quality according to the 2010 Dietary Guidelines for Americans. J Nutr. 2014:jn-113. doi: 10.3945/jn.113.183079. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61.Lohman T, Roche A, Martorel R. Standardization of anthropometric measurements. Champaign IL Hum Kinet. 1988:39–80. [Google Scholar]
- 62.Lee H, Keller KL. Children who are pressured to eat at home consume fewer high-fat foods in laboratory test meals. J Acad Nutr Diet. 2012;112(2):271–275. doi: 10.1016/j.jada.2011.10.021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 63.Rollins BY, Loken E, Savage JS, Birch LL. Effects of restriction on children’s intake differ by child temperament, food reinforcement, and parent’s chronic use of restriction. Appetite. 2014;73:31–39. doi: 10.1016/j.appet.2013.10.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64.Fisher JO, Birch LL. Parents’ restrictive feeding practices are associated with young girls’ negative self-evaluation of eating. J Am Diet Assoc. 2000;100(11):1341–1346. doi: 10.1016/S0002-8223(00)00378-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 65.Jansen E, Mulkens S, Jansen A. Do not eat the red food!: prohibition of snacks leads to their relatively higher consumption in children. Appetite. 2007;49(3):572–577. doi: 10.1016/j.appet.2007.03.229. [DOI] [PubMed] [Google Scholar]
- 66.Ogden J, Cordey P, Cutler L, Thomas H. Parental restriction children’s diets. The chocolate coin and Easter egg experiments. Appetite. 2013;61:36–44. doi: 10.1016/j.appet.2012.10.021. [DOI] [PubMed] [Google Scholar]
- 67.Farrow CV, Haycraft E, Blissett JM. Teaching our children when to eat: how parental feeding practices inform the development of emotional eating—a longitudinal experimental design. Am J Clin Nutr. 2015;101(5):908–913. doi: 10.3945/ajcn.114.103713. [DOI] [PubMed] [Google Scholar]
- 68.Liem DG, Mars M, De Graaf C. Sweet preferences and sugar consumption of 4- and 5-year-old children: role of parents. Appetite. 2004;43(3):235–245. doi: 10.1016/j.appet.2004.05.005. [DOI] [PubMed] [Google Scholar]
- 69.Jansen E, Mulkens S, Emond Y, Jansen A. From the Garden of Eden to the land of plenty: Restriction of fruit and sweets intake leads to increased fruit and sweets consumption in children. Appetite. 2008;51(3):570–575. doi: 10.1016/j.appet.2008.04.012. [DOI] [PubMed] [Google Scholar]
- 70.Draxten M, Fulkerson JA, Friend S, Flattum CF, Schow R. Parental role modeling of fruits and vegetables at meals and snacks is associated with children’s adequate consumption. Appetite. 2014;78:1–7. doi: 10.1016/j.appet.2014.02.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 71.Cullen KW, Baranowski T, Rittenberry L, Cosart C, Hebert D, de Moor C. Child-reported family and peer influences on fruit, juice and vegetable consumption: reliability and validity of measures. Health Educ Res. 2001;16(2):187–200. doi: 10.1093/her/16.2.187. [DOI] [PubMed] [Google Scholar]
- 72.Farrow CV, Galloway AT, Fraser K. Sibling eating behaviours and differential child feeding practices reported by parents. Appetite. 2009;52(2):307–312. doi: 10.1016/j.appet.2008.10.009. [DOI] [PubMed] [Google Scholar]
- 73.Powers SW, Chamberlin LA, van Schaick KB, Sherman SN, Whitaker RC. Maternal feeding strategies, child eating behaviors, and child BMI in low-income African-American preschoolers. Obesity. 2006;14(11):2026–2033. doi: 10.1038/oby.2006.237. [DOI] [PubMed] [Google Scholar]
- 74.Loth KA, MacLehose RF, Fulkerson JA, Crow S, Neumark-Sztainer D. Eat this, not that! Parental demographic correlates of food-related parenting practices. Appetite. 2013;60:140–147. doi: 10.1016/j.appet.2012.09.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 75.Loth K, MacLehose R, Fulkerson JA, Crow S, Neumark-Stzainer DR. Are food-related parenting practices associated wiht adolescent disordered eating behaviors? A population-based study. Int J Eat Disord. doi: 10.1002/eat.22189. In Press. [DOI] [PMC free article] [PubMed] [Google Scholar]