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. Author manuscript; available in PMC: 2019 Nov 1.
Published in final edited form as: Appetite. 2018 Jul 19;130:20–28. doi: 10.1016/j.appet.2018.07.016

Additive Effects of Household Food Insecurity during Pregnancy and Infancy on Maternal Infant Feeding Styles and Practices

Rachel S Gross a, Alan L Mendelsohn b, Mary Jo Messito a
PMCID: PMC6815209  NIHMSID: NIHMS1054785  PMID: 30031787

Abstract

Food insecurity, or the limited access to food, has been associated with maternal child feeding styles and practices. While studies in other parenting domains suggest differential and additive impacts of poverty-associated stressors during pregnancy and infancy, few studies have assessed relations between food insecurity during these sensitive times and maternal infant feeding styles and practices. This study sought to analyze these relations in low-income Hispanic mother-infant pairs enrolled in a randomized controlled trial of an early obesity prevention program (Starting Early). Food insecurity was measured prenatally and during infancy at 10 months. Food insecurity timing was categorized as never, prenatal only, infancy only, or both. Regression analyses were used to determine relations between food insecurity timing and styles and practices at 10 months, using never experiencing food insecurity as the reference, adjusting for family characteristics and material hardships. 412 mother-infant pairs completed 10-month assessments. Prolonged food insecurity during both periods was associated with greater pressuring, indulgent and laissez-faire styles compared to never experiencing food insecurity. Prenatal food insecurity was associated with less vegetable and more juice intake. If food insecurity is identified during pregnancy, interventions to prevent food insecurity from persisting into infancy may mitigate the development of obesity-promoting feeding styles and practices.

Keywords: Food insecurity, Pregnancy, Infancy, Feeding styles, Hispanic

INTRODUCTION

Food insecurity, defined as a household’s inconsistent access to adequate and nutritious food, (Anderson, 1990) is common during pregnancy and infancy in families living in poverty. Reasons for this include significant financial burdens that result from higher nutritional needs, shifts in household responsibilities and employment changes (Braveman et al., 2010; Ivers et al., 2011; Laraia et al., 2006). Household food insecurity during these periods results in adverse impacts on child health outcomes (Shonkoff et al., 2012) in both low and high income countries, including child obesity (Alaimo et al., 2001; Casey et al., 2001; Casey et al., 2006; Cook et al., 2004; Dubois et al., 2006; Metallinos-Katsaras et al., 2009; Suglia et al., 2013; Farrell et al., 2017). Studies of food insecurity in households with older children found that food insecure households consumed more low-cost, high-energy-dense foods (Drewnowski et al., 2004), had fewer cooking supplies (Matheson et al., 2002), and focused on the amount of food rather than the quality (Matheson et al., 2006), compared to food secure households. However, the mechanisms linking food insecurity during pregnancy and infancy to child obesity remain unclear.

Maternal infant feeding styles and practices may represent a potential mechanism linking household food insecurity to childhood obesity. Maternal infant feeding styles are defined as a mother’s beliefs and practices related to regulating infant feeding. Feeding styles are a potential mechanism through which household food insecurity during pregnancy and infancy could affect child diet and growth (Bronte-Tinkew et al., 2007; Gross et al, 2012; Gross et al., 2016a; Laraia et al., 2006; Laraia et al., 2015). Studies suggest that obesity-promoting non-responsive maternal infant feeding styles (DiSantis et al., 2011; Hurley et al., 2011), in which mothers regulate feeding without responding appropriately to infant hunger and satiety cues, are associated with household food insecurity (Feinberg et al., 2008; Gross et al., 2012). Connecting food insecurity with non-responsive feeding styles is important because these styles have been linked to child obesity in two ways: 1) documented associations with obesogenic practices, such as decreased exclusive breastfeeding (Taveras et al., 2004), lower consumption of fruits and vegetables (Patrick et al., 2005; O’Connor et al., 2010; Blissett et al., 2011) and higher intake of sugary drinks (Hennessy et al., 2012); and 2) potential disruption of infant self-regulatory capacity, leading to eating in the absence of hunger and continued feeding beyond fullness, and ultimately increased caloric intake (Costanzo et al., 1985; Birch et al., 1995; 2001; Hurley et al., 2011; Disantis et al., 2011). However, the evidence linking food insecurity to feeding styles has been limited by the assessment of food insecurity at only a single time point (Bronte-Tinkew et al., 2007; Gross et al, 2012; Gross et al., 2016a; Laraia et al., 2006; Laraia et al., 2015). This is an important limitation because food insecurity is known to fluctuate over time and it is likely that vulnerability may differ depending on the timing and duration of exposure (Nord et al., 2007). Furthermore, pregnancy and infancy are known to be sensitive periods of vulnerability to stress more generally. Determining whether infants are more vulnerable to the impact of food insecurity if it occurs during both pregnancy and infancy would aid in targeting preventive efforts.

Studies of other poverty-associated stressors, in particular maternal depression, demonstrate both differential and additive effects during the prenatal and infancy periods. Studies comparing mothers with only prenatal depression to mothers with only post-natal depression found differential effects, with post-natal depression resulting in increased child anti-social behaviors (Kim-Cohen et al., 2005), insecure attachments and behavioral problems (Murray, 1992). Depression occurring during both pregnancy and infancy has additive impacts on negative child developmental outcomes (Monk et al., 2012). No studies to our knowledge have longitudinally assessed the differential and additive impacts of household food insecurity during the prenatal and infancy periods on maternal infant feeding styles and practices during infancy. Therefore, we sought to address these gaps by determining the differential and additive impacts of household food insecurity during both the prenatal and infancy periods on obesity-promoting maternal infant feeding styles and practices at infant age 10 months. We hypothesized that food insecurity during pregnancy and infancy would be associated with decreased responsive maternal infant feeding styles and increased non-responsive maternal infant feeding styles, specifically controlling, indulgent and laissez-faire styles. We also hypothesized that food insecurity would be related to obesity-promoting infant feeding practices such as decreased breastfeeding and fruit and vegetables consumption and increased juice consumption.

METHODS

Study Design

We performed a secondary longitudinal analysis of data from the Starting Early Study, an ongoing randomized controlled trial whose primary outcomes are to improve growth trajectories and reduce child obesity in the first three years of life. (Gross et al., 2016b) The Starting Early Study, designed for low-income Hispanic families, began in the third trimester of pregnancy and continued until child age 3 years old. Upon enrollment, participants were informed that the purpose of the program was to help develop healthy infant feeding and activity habits and promote healthy infant growth. Study enrollment and prenatal baseline assessments occurred between August 2012 and December 2014 (Figure 1). A subsequent follow-up assessment occurred at infant age 10 months. Women (n=533) were randomly allocated to a standard care control group or an intervention group participating in prenatal and postpartum individual nutrition/breastfeeding counseling and subsequent nutrition and parenting support groups coordinated with well-child visits. This study was approved by the institutional review boards of New York University School of Medicine, Albert Einstein College of Medicine, Bellevue Hospital Center, and the New York City Health and Hospitals. This study was registered on clinicaltrials.gov ().

Figure 1:

Figure 1:

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Participant enrollment and assessment

Study Sample

This study took place in the prenatal and pediatric clinics of a large urban public hospital and an affiliated satellite neighborhood health center. We included women who: 1) were at least 18 years old, 2) Hispanic/Latina, 3) English or Spanish speaking, 4) had a singleton uncomplicated pregnancy, and 5) had the intention to receive well child care at the study sites. We excluded those with significant medical or psychiatric illness, homelessness, substance abuse or severe fetal anomalies. Women were assessed for eligibility at a prenatal visit between 28 and 32 weeks gestational age (Gross et al., 2016b). Interested participants signed written informed consent. All participants who completed prenatal baseline assessments and the follow-up assessment at infant age 10 months were included in these analyses (n=412). Mothers who did not complete the 10-month assessment were similar to those who did, except they were younger (26.3 years vs. 28.1 years, p<.003) and more likely first-time mothers (51.2% vs. 33.3%, p<0.001). There were no significant differences in the prevalence of food insecurity or other material hardships.

Assessments

Trained research assistants conducted surveys in English or Spanish in person at baseline during a prenatal visit and by telephone for the follow-up assessment at infant age 10 months. Assessments were obtained to determine the relations between food insecurity timing (Bickel et al., 2000) and maternal infant feeding style subscale scores (Thompson et al., 2009) and maternal infant feeding practices (Fein et al., 2008). Adjusted analyses controlled for family characteristics and other material hardships (U.S. Dept. of Commerce, Bureau of the Census., 1997; Shulman et al., 2006). Accounting for multiple other aspects of socioeconomic hardship would help distinguish the unique effects of food insecurity.

Independent Variables

Household food insecurity was assessed using the Core Food Security Module from the United States Department of Agriculture (alpha=.86 to .93) (Bickel et al., 2000; Carlson et al., 1999). The survey assessed food insecurity during the prior 12-month period. Food insecurity was first assessed at baseline during a third trimester prenatal visit, reflecting a period that overlapped with the pregnancy. Food insecurity was assessed again during the follow-up assessment at infant age 10 months. Continuous scores were generated from 10 questions at each time point and dichotomized using suggested cut points. Women were classified as food secure if they reported 2 or less food insecure conditions and food insecure if they reported 3 or more. Food insecurity timing was categorized as never (no food insecurity during pregnancy or infancy), prenatal only (food insecure during pregnancy but not during infancy), infancy only (food insecure during infancy but not during pregnancy), or both (food insecure during both pregnancy and infancy).

Dependent Variables

Maternal-infant feeding styles at infant age 10 months were assessed using the Infant Feeding Style Questionnaire (IFSQ), an instrument validated in a Hispanic sample (Thompson et al., 2009; Wood et al., 2016). It assessed five feeding style domains: (1) responsive, in which the mother is attentive to infant feeding cues while appropriately monitoring the quality and quantity of the infant’s diet; (2) pressuring/controlling, in which the mother encourages intake even if the infant is not hungry (3) restrictive/controlling, in which the mother excessively limits food even when the infant is still hungry; (4) indulgent, in which the mother is sensitive to cues but does not set limits on the food; and (5) laissez-faire, in which the mother does not limit infant diet and shows little interaction with the infant during feeding. These five broader feeding style domains have been further subdivided into 13 subscales (Table 1): 1) responsive included two subscales: attention (alpha=.84) and satiety (α=.92); 2) pressuring/controlling included three subscales: pressuring to finish (α=.79), pressuring with cereal (α=.78) and pressuring to soothe (α=.84); 3) restrictive/controlling included two subscales: amount consumed (α=.75) and diet quality (α=.85); 4) indulgent included four subscales: permissive (α=.82), coaxing (α=.89), soothing (α=.87) and pampering (α=.94); and 5) laissez-faire included two subscales: attention (α=.80) and diet quality (α=.91). These scales range from mean scores of 1 to 5, with higher scores being more representative of the given construct.

Table 1:

Infant Feeding Style Questionnaire sub-scales and sample questionsa

Feeding Style Sub-Scales Number of Items Sample Question Mean (SD)b
Responsive – attention 5 I talk to my child to encourage him or her to eat. 3.95 (.86)
Responsive – satiety 5 I pay attention when my child seems to be telling me that s/he is full or hungry. 4.46 (.49)
Pressuring to finish 8 If my child seems full, I encourage him/her to finish his/her food anyway. 2.65 (.86)
Pressuring with cereal 5 I gave my child cereal in the bottle. 2.13 (.96)
Pressuring – soothing 4 When my child cries, I immediately feed him/her. 2.57 (1.18)
Restrictive – amount consumed 4 I am very careful not to feed my child too much. 3.90 (1.05)
Restrictive – diet quality 7 I let my baby eat junk food like potato chips, Doritos and cheese puffs.c 4.19 (.66)
Indulgent – permissive 8 I allow child to eat fast food if he or she wants to. 1.39 (.47)
Indulgent – coaxing 8 I allow child to eat fast food to make sure he or she gets enough. 1.15 (.32)
Indulgent – soothing 8 I allow child to eat fast food to keep him/her from crying. 1.15 (.32)
Indulgent – pampering 8 I allow child to eat fast food to keep him/her happy. 1.16 (.33)
Laissez-faire – attention 5 I watch TV while feeding my child. 1.57 (.64)
Laissez-faire – diet quality 6 I make sure my child does not eat sugary food like candy,
ice cream, cakes or cookies.c 		1.73 (.63)
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a

Thompson, A. L., Mendez, M. A., Borja, J. B., Adair, L. S., Zimmer, C. R., & Bentley, M. E. (2009). Development and validation of the infant feeding style questionnaire. Appetite, 53(2), 210–221.

b

Mean scores for each subscale are based on scores ranging from 1 to 5.

c

Sample question is inversely related to feeding style.

Maternal-infant feeding practices were assessed using questions adapted from the Infant Feeding Practices Study II, a national longitudinal study of infant feeding (Fein et al., 2008). Breastfeeding was assessed by asking: “What kind of milk is your baby drinking now?” Breast milk as the only milk source was defined as breast milk only vs. any other milk or combination of milk. The number of times the infant ate fruit and vegetables and a family meal together in the last 7 days was assessed. These practices were dichotomized as 7 or more vs. less than 7 to estimate daily behaviors. Juice intake and self-feeding defined as whether the infant uses his/her fingers to feed him/herself was also assessed.

Covariates

Family characteristics and other material hardships were assessed at baseline during the third trimester of pregnancy. Family characteristics assessed included education, marital status, employment, country of birth, and having other children. Prenatal depressive symptoms was measured using the Patient Health Questionnaire-9 (Kroenke et al., 2001), a validated tool used to measure symptoms in the prior 2 weeks (α=.89). Depressive symptoms (scale of 0–27) were dichotomized at recommended cut points with no symptoms (0–4) versus mild or greater symptoms (5–27). Pre-pregnancy body mass index (calculated as weight [kg]/height [m2]) was calculated using weight and height from medical record review and categorized as underweight (<18.5), normal weight (18.5–24.9), overweight (25–29.9), and obese (>30) (Kuczmarski et al., 1997).

Other material hardships that were assessed included difficulty paying bills, housing disrepair and neighborhood stress. Difficulties paying bills was assessed using two questions from the Survey of Income and Program Participation about the ability to pay monthly bills including rent or mortgage, and times when the household had service turned off by the gas, electric or telephone company in the past 12 months (U.S. Dept. of Commerce, Bureau of the Census., 1997). Continuous scores were generated based on the sum of the responses from the two questions. A categorical variable was created and defined as responding positively to either questions. Housing disrepair was also measured using questions from the Survey of Income and Program Participation (U.S. Dept. of Commerce, Bureau of the Census., 1997). We assessed whether households experienced: 1) a leaking roof or ceiling, 2) broken toilet, hot water heater or other plumbing, 3) broken windows, 4) exposed wires, 5) rats, mice, roaches or other insects, 6) holes in floor, and 7) open cracks or holes in the walls or ceiling. Continuous scores were generated based on the number of housing conditions experienced. A categorical variable for housing disrepair was created and defined as responding positively to any of the listed housing conditions. Neighborhood stress was measured using questions from the Pregnancy Risk Assessment Monitoring System Centers for Disease Control and Prevention model surveillance protocol (Shulman et al., 2006). Mothers were asked whether because they felt unsafe to leave or return to their neighborhood: 1) they missed doctor or other appointments; 2) they limited grocery or other shopping; and 3) they stayed with other family members or friends. Responses were based on a 5-point Likert scale ranging from never, almost never, sometimes, fairly often and always. Continuous scores were generated from the sum of the three questions. A categorical variable was defined as never versus ever experiencing neighborhood stress.

Statistical Analysis

Data analyses were performed using SPSS statistical software version 18.0 (SPSS Inc, Chicago, Il). First, we described family characteristics and other material hardships based on food security timing using chi-square analyses. We performed bivariate analyses of the associations between food insecurity timing and maternal infant feeding style subscale scores at infant age 10 months using one-way analysis of variance and Cohen’s d was calculated. To investigate differential and additive effects of household food insecurity timing on maternal infant feeding styles, we performed separate multiple linear regression models to predict each individual feeding style subscale, using “never” as the reference group. The distribution of five feeding style subscales were skewed: laissez-faire attention (skewness [standard error] = 1.37 [.12]); indulgent permissive (1.54 [.12]); indulgent coaxing (3.67 [.12]); indulgent soothing (3.38 [.12]) and indulgent pampering (3.15 [.12]). Multiple linear regression analyses for these five subscales were performed using log-transformation to account for skewing. Given that all significant and non-significant variables remained the same, associations for non-transformed feeding scales were reported to facilitate the interpretability of the effect sizes. Due to concern of heteroscedascity, a sensitivity analysis was undertaken using logistic regression with dichotomous feeding style subscales dichotomized at the top tertile, and found no differences in statistical inferences. Multicollinearity was not significant when examined using variance inflation factors and correlation matrices. Model 1 determined unadjusted relations between food insecurity timing and each individual feeding style subscale. Model 2 adjusted for family characteristics, including education, marital status, employment, country of birth, having other children, prenatal depressive symptoms, and pre-pregnancy weight status. Model 2 also adjusted for intervention group status. Model 3 further adjusted for other material hardships to determine the independent association of food insecurity above other poverty-associated risks. We added an interaction term, which multiplies together the dichotomous variables for prenatal depressive symptoms and food insecurity timing to determine if depressive symptoms moderated the relations between food insecurity timing and feeding styles. To investigate differential and additive effects of household food insecurity timing on maternal infant feeding practices, we performed separate logistic regression models to predict each feeding practice, using “never” as the reference group. We tested the same three models for each outcome separately as described above for the maternal infant feeding styles. Given that only 5 or 6 cases had missing data, if models included cases with missing data for any of the variables, then that case was excluded from the analysis (Graham et al., 1993).

RESULTS

Study Sample

Thirty-nine percent of the mothers experienced food insecurity during at least one period, including 32% during pregnancy and 19% during infancy. 12% of those households experience food insecurity during both pregnancy and infancy (Table 2). Women with household food insecurity, in particular prolonged food insecurity during both pregnancy and infancy were more likely to be non-US born, have less educational attainment, and have prenatal depressive symptoms. Women with household food insecurity were also more likely to experience other material hardships including difficulty paying bills, housing disrepair and neighborhood stress. We did not find intervention status group differences in the rates of household food insecurity during either the prenatal or infancy periods.

Table 2:

Family characteristics based on household food insecurity timing

Food Insecurity Timing
Total Sample
(n=410)
n (%)		 Never
(n=248)
n (%)		 Prenatal Only
(n=82)
n (%)		 Infancy Only
(n=30)
n (%)		 Both
(n=50)
n (%)		 p-valuea
Family characteristics
Non-US born 333 (81.2) 192 (77.4) 66 (80.5) 28 (93.3) 47 (94.0) .01*
Education, less than high school 140 (34.1) 69 (27.8) 35 (42.7) 14 (46.7) 22 (44.0) .01*
Marital status, single 110 (26.8) 60 (24.2) 27 (32.9) 11 (36.7) 12 (24.0) .25
Working 100 (24.4) 70 (28.2) 16 (19.5) 7 (23.3) 7 (14.0) .11
First child 136 (33.2) 88 (35.5) 26 (31.7) 9 (30.0) 13 (26.0) .58
Prenatal depressive symptoms 131 (32.1) 58 (23.5) 37 (45.7) 9 (30.0) 27 (54.0) <.001*
Pre-pregnancy overweight status 248 (60.6) 143 (57.7) 51 (62.2) 22 (73.3) 32 (65.3) .32
Material hardships
Difficulty paying bills 106 (25.9) 36 (14.5) 35 (42.7) 6 (20.0) 29 (58.0) <.001*
Housing disrepair 143 (34.9) 78 (31.5) 24 (29.3) 9 (30.0) 32 (64.0) <.001*
Neighborhood stress 38 (9.3) 13 (5.2) 13 (15.9) 2 (6.7) 10 (20.0) .001*
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a

We examined bivariate relationships between food insecurity timing and family characteristics and material hardships using chi square analyses.

*

Significant p<.05

Food Insecurity Timing and Maternal Infant Feeding Styles

Overall, mothers scored highest on responsive and restrictive feeding constructs and lowest on indulgent and laissez-faire feeding constructs (Table 1). In unadjusted analyses (Table 3; Model 1), food insecurity during both pregnancy and infancy was associated with increased pressuring (1 subscale: soothing (Cohen’s d=.59)), indulgent (3 subscales: permissive (d=.49), coaxing (d=.47) and pampering (d=.58)) and laissez-faire (1 subscale: attention (d=.61)) feeding styles. Those with food insecurity during the prenatal period only were more likely to exhibit pressuring with cereal and pressuring to soothe compared to those who never experienced food insecurity, although these relations were no longer significant in adjusted models. In models adjusting for family characteristics (Model 2), mothers experiencing food insecurity during both pregnancy and infancy were more likely to exhibit higher pressuring (1 subscale: soothing), indulgent (3 subscales: permissive, coaxing and pampering) and laissez-faire (1 subscale: attention) feeding styles than those who never experienced food insecurity. Experiencing food insecurity during both pregnancy and infancy remained independently associated with the same feeding style subscales after further adjusting for other material hardships (Model 3). Being US born (B (SE) −.74 (.15), p=<.001), completing high school (−.74 (.15), p=<.001), reporting housing disrepair (−.27 (.12), p=.03) and neighborhood stress (.43 (.20), p=.03) were independently associated with pressuring to soothe. Maternal pre-pregnancy overweight/obese status was associated with indulgent – coaxing style (−.07 (.13), p=.04) and first born was associated with indulgent – pampering style (.09 (.04), p=.01). Neighborhood stress was independently associated with laissez-faire – attention style (.32 (.11), p=.003). Depressive symptoms did not moderate the relations between food insecurity timing and feeding styles.

Table 3:

Household food insecurity timing and maternal infant feeding styles at 10 months old

Feeding Styles Subscales Food Insecurity Timing Scores Model 1a Model 2b Model 3c
Mean Scores (SD) B (SE) p-value B (SE) p-value B (SE) p-value
Responsive – attentiond Never 3.95 (.86) Ref Ref Ref
Prenatal only 4.00 (.93) .07 (.11) .55 .07 (.11) .53 .10 (.12) .41
Infancy only 3.71 (.75) −.24 (.17) .15 −.24 (.17) .16 −.23 (.17) .18
Both 4.03 (.87) .07 (.14) .60 .04 (.14) .79 .09 (.15) .54
Responsive – satietye Never 4.45 (.51) Ref Ref Ref
Prenatal only 4.53 (.45) .09 (.06) .16 .10 (.07) .11 .07 (.07) .27
Infancy only 4.47 (.44) .02 (.10) .81 .03 (.10) .80 .02 (.10) .83
Both 4.40 (.52) −.06 (.08) .42 −.04 (.08) .60 −.08 (.09) .38
Pressuring to finishe Never 2.63 (.88) Ref Ref Ref
Prenatal only 2.60 (.80) −.03 (.11) .80 −.03 (.11) .76 −.01 (.12) .95
Infancy only 2.71 (.93) .07 (.17) .66 .07 (.17) .66 .08 (.17) .65
Both 2.83 (.80) .18 (.14) .19 .12 (.14) .39 .18 (.15) .22
Pressuring with cereald Never 2.03 (.93) Ref Ref Ref
Prenatal only 2.29 (1.00) .26 (.12) .04* .20 (.12) .10 .19 (.13) .13
Infancy only 2.21 (1.06) .18 (.19) .33 .16 (.18) .38 .16 (.18) .37
Both 2.32 (.91) .28 (.15) .06 .24 (.15) .11 .24 (.16) .13
Pressuring – soothinge Never 2.40 (1.12) Ref Ref Ref
Prenatal only 2.76 (1.20) .34 (.15) .02* .23 (.15) .12 .23 (.15) .13
Infancy only 2.77 (1.40) .36 (.23) .11 .17 (.22) .45 .17 (.22) .44
Both 3.07 (1.13) .68 (.18) <.001* .49 (.18) .01* .60 (.19) .002*
Restrictive – amount consumede Never 3.88 (1.06) Ref Ref Ref
Prenatal only 3.90 (1.04) .02 (.14) .87 .002 (.14) .99 .02 (.14) .89
Infancy only 4.05 (.97) .16 (.20) .42 .11 (.21) .58 .12 (.21) .58
Both 3.88 (1.12) −.01 (.17) .96 −.03 (.17) .87 −.02 (.18) .93
Restrictive – diet qualityd None 4.20 (.68) Ref Ref Ref
Prenatal only 4.21 (.58) −.003 (.08) .97 .003 (.09) .97 −.03 (.09) .71
Infancy only 4.18 (.63) −.02 (.13) .88 −.002 (.13) .99 −.01 (.13) .91
Both 4.06 (.69) −.11 (.10) .27 −.10 (.11) .34 −.13 (.12) .27
Indulgent – permissivee Never 1.34 (.45) Ref Ref Ref
Prenatal only 1.39 (.47) .06 (.06) .30 .07 (.06) .27 .06 (.06) .36
Infancy only 1.49 (.57) .15 (.09) .10 .17 (.09) .06 .18 (.09) .05
Both 1.57 (.49) .23 (.07) .002* .23 (.08) .003* .20 (.08) .02*
Indulgent – coaxinge Never 1.12 (.30) Ref Ref Ref
Prenatal only 1.15 (.32) .03 (.04) .42 .03 (.04) .53 .04 (.04) .38
Infancy only 1.21 (.35) .09 (.06) .14 .09 (.06) .14 .10 (.06) .12
Both 1.27 (.35) .14 (.05) .01* .13 (.05) .01* .14 (.05) .01*
Indulgent – soothinge Never 1.13 (.31) Ref Ref Ref
Prenatal only 1.16 (.34) .04 (.04) .36 .03 (.04) .48 .04 (.04) .40
Infancy only 1.15 (.27) .02 (.06) .80 .01 (.06) .86 .02 (.06) .81
Both 1.24 (.33) .09 (.05) .06 .08 (.05) .12 .08 (.05) .12
Indulgent – pamperinge Never 1.13 (.32) Ref Ref Ref
Prenatal only 1.16 (.31) .03 (.04) .41 .03 (.04) .54 .03 (.04) .47
Infancy only 1.18 (.32) .05 (.06) .47 .04 (.06) .49 .05 (.06) .47
Both 1.32 (.34) .18 (.05) <.001* .16 (.05) .002* .16 (.06) .004*
Laissez-faire – attentione Never 1.48 (.55) Ref Ref Ref
Prenatal only 1.61 (.71) .14 (.08) .09 .10 (.08) .23 .09 (.08) .28
Infancy only 1.66 (.78) .18 (.12) .15 .16 (.12) .18 .17 (.12) .16
Both 1.89 (.77) .38 (.10) <.001* .32 (.10) .002* .29 (.11) .01*
Laissez-faire – diet qualityd Never 1.69 (.59) Ref Ref Ref
Prenatal only 1.73 (.71) .05 (.08) .55 .02 (.08) .83 .04 (.09) .65
Infancy only 1.86 (.64) .17 (.12) .16 .17 (.12) .17 .18 (.12) .15
Both 1.81 (.68) .10 (.10) .29 .08 (.10) .44 .13 (.11) .25
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a

Model 1: Unadjusted.

b

Model 2: Adjusting for covariates including country of birth (US born, non-US born), educational attainment (less than high school, high school graduate), marital status (married/living as married, single/divorced/widowed), having other children (no, yes), working (no, yes), prenatal depressive symptoms (no, yes), and pre-pregnancy overweight/obese (no, yes) and intervention group status.

c

Model 3: Adjusting for covariates from Model 2 and other material hardships (difficulty paying bills, housing disrepair and neighborhood stress).

d

Model included sample size of n=406.

e

Model included sample size of n=407.

*

Significant p<.05

Food insecurity Timing and Maternal Infant Feeding Practices

Mothers with food insecurity prenatal only reported less infant vegetable intake (AOR .45, p=.01) and greater juice intake (AOR 1.95, p=.04) compared to mothers who never experienced food insecurity even after adjusting for family characteristics and other material hardships (Table 4). Mothers with food insecurity during both pregnancy and infancy reported decreased infant self-feeding (AOR .30, p=.01) compared to those who never experienced food insecurity. Breastfeeding as the only milk source, fruit intake, and eating family meals together were not related to food insecurity.

Table 4:

Household food insecurity timing and maternal infant feeding practices at 10 months olda

Infant Feeding Practices Food Insecurity Timing Sample Model 1b Model 2c Model 3d
n (%) OR p-value AOR p-value AOR p-value
Breastfeeding Never 71 (29.8) Ref Ref Ref
Prenatal only 16 (19.5) .58 .08 .59 .11 .60 .13
Infancy only 11 (36.7) 1.35 .45 1.39 .44 1.41 .43
Both 14 (28.0) .84 .63 .79 .54 .83 .65
Daily fruit intake Never 205 (82.7) Ref Ref Ref
Prenatal only 68 (82.9) .98 .95 1.05 .90 1.03 .95
Infancy only 24 (80.0) .82 .68 .88 .80 .92 .86
Both 38 (76.0) .63 .22 .70 .38 .57 .20
Daily vegetable intake Never 181 (73.0) Ref Ref Ref
Prenatal only 45 (54.9) .47 .004* .46 .01* .45 .01*
Infancy only 17 (56.7) .49 .07 .51 .09 .49 .08
Both 31 (62.0) .59 .10 .59 .12 .63 .22
Juice intake ever Never 158 (63.7) Ref Ref Ref
Prenatal only 65 (79.3) 2.16 .01* 2.06 .02* 1.95 .04*
Infancy only 23 (76.7) 1.88 .16 2.02 .14 2.08 .13
Both 34 (68.0) 1.18 .61 1.07 .84 .92 .83
Self-feeding with fingers Never 227 (91.5) Ref Ref Ref
Prenatal only 77 (93.9) 1.41 .50 1.58 .39 1.75 .32
Infancy only 29 (96.7) 2.70 .34 3.12 .29 3.43 .25
Both 38 (76.0) .29 .002* .28 .004* .30 .01*
Daily family meals together Never 188 (75.8) Ref Ref Ref
Prenatal only 60 (73.2) .84 .55 .96 .91 .88 .70
Infancy only 25 (83.3) 1.57 .38 1.68 .33 1.63 .35
Both 37 (74.0) .87 .69 1.03 .93 1.00 .99
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a

All models included sample size of n=407.

b

Model 1: Unadjusted.

c

Model 2: Adjusting for covariates including country of birth (US born, non-US born), educational attainment (less than high school, high school graduate), marital status (married/living as married, single/divorced/widowed), having other children (no, yes), working (no, yes), prenatal depressive symptoms (no, yes), and pre-pregnancy overweight/obese (no, yes) and intervention group status.

d

Model 3: Adjusting for covariates from Model 2 and other material hardships (difficulty paying bills, housing disrepair and neighborhood stress).

*

Significant p<.05

DISCUSSION

Our study of low-income Hispanic mother-infant pairs found that experiencing prolonged household food insecurity during both pregnancy and infancy significantly increased non-responsive maternal infant feeding styles at infant age 10 months. In particular, experiencing food insecurity during both pregnancy and infancy was associated with pressuring, indulgent and laissez-faire feeding styles. Prolonged food insecurity was also associated with decreased infant self-feeding. Prenatal food insecurity was associated with less infant vegetable intake and more juice intake. These relations remained significant after adjusting for family characteristics and other material hardships, highlighting that the relations with prolonged food insecurity are not simply confounded by other poverty-associated hardships.

Maternal child feeding styles, adapted from research on general parenting styles, are based on the balance between responsiveness to child cues and behavioral control. Non-responsive feeding styles, including pressuring, restrictive, indulgent and laissez-faire, that fail to respond appropriately to child feeding cues or to set healthy limits, have all been associated with child weight (Frankel et al., 2014; Hennessy et al., 2010; Hughes et al., 2008; Tovar et al., 2012; Vollmer & Mobley, 2013). Pressuring is often related to lower infant weight-for-age and restriction to higher weight-for-age (Thompson et al., 2013), and these styles are commonly associated with concern for the child being underweight and overweight respectively (Gross et al., 2011). Studies of low-income Hispanic families found that indulgent maternal infant feeding styles have been most associated with higher child weight status in both cross-sectional and longitudinal studies of pre-school aged children (Frankel et al., 2014; Hennessy et al., 2010; Hughes et al., 2016; Tovar et al., 2012). Overall, non-responsive feeding styles may represent a potentially critical mediator of poverty-related disparities in early child obesity since they are more prevalent in low-income ethnic minority mothers beginning in early infancy (Hughes et al, 2005; Tovar et al., 2012; Vollmer & Mobley, 2013). However, the mechanism through which poverty during sensitive periods of pregnancy and infancy relates to these feeding styles remains unclear.

Poverty during the prenatal and infancy periods has been associated with multiple stressors known to adversely impact child growth. Food insecurity represents a commonly experienced stressor for families living in poverty that increases the risk factors associated with childhood obesity. Food insecurity during pregnancy has been associated with higher rates of gestational weight gain, gestational diabetes mellitus, disordered eating, and dietary fat intake postpartum (Laraia et al., 2010; Laraia et al., 2015). In addition to impacts on the pregnant women’s diet and weight, prenatal food insecurity has been associated with higher prenatal stress and obesity-promoting infant feeding attitudes (Gross et al., 2016a; Laraia et al., 2015). Prenatal food insecurity has been associated with a lower internal locus of control over the prevention of child obesity (Gross et al., 2016a). Lower self-efficacy associated with food insecurity has been related to increased controlling feeding styles (Salarkia et al., 2016) and decreased provision of fruits and vegetables to their children (Hilmers et al., 2012). Focusing on strengthening parenting self-efficacy during pregnancy for women with food insecurity may help to prevent the development of non-responsive feeding styles.

Household food insecurity during infancy has been associated with key aspects of parenting related to childhood obesity (Bronte-Tinkew et al., 2007). We previously found that food insecurity reported by WIC participants with infants in the first six months of life was associated with increased pressuring and restrictive maternal infant feeding styles (Gross et al., 2012). These relations were mediated by maternal concern for her child becoming overweight in the future. However, indulgent and laissez-faire styles were not assessed at that time and household food insecurity during pregnancy was unknown. No prior studies to our knowledge have directly assessed how food insecurity during both pregnancy and infancy relates to non-responsive maternal infant feeding styles in the older infant, a period when infant feeding involves the transition to more solid foods and self-feeding.

This current study found that prolonged food insecurity, or the additive effects of experiencing food insecurity during both pregnancy and infancy, was most associated with non-responsive feeding styles at infant age 10 months. Perhaps pressuring and indulgent styles were most related because mothers were trying to compensate for concerns about not having enough food, either by encouraging infants to eat more when food is available or encouraging feeding to soothe infants to keep them from crying by giving them what they want. The feeding style of using food to soothe which has been documented in food insecure households, has been related to excess infant weight gain. Prior studies of mothers observed to use food to soothe during laboratory visits at infant age 6, 12 and 18 months old were more likely to have infants with excess weight gain compared to infants of mothers who did not feed to soothe (Stifter & Moding, 2015). Pressuring to soothe specifically focuses on immediately feeding when infants cry. This style therefore may fail to consider that not all crying means hunger and that alternative methods of soothing can sometimes be tried prior to feeding (Gross et al., 2010). Greater uninvolved or laissez-faire feeding styles have also been related to maternal stress, which may potentially mediate the relations between food insecurity and laissez-faire feeding styles (Barrett et al., 2016; Hughes et al., 2015). Qualitative research is needed to better understand how the experience of household food insecurity during pregnancy and infancy shapes maternal attitudes and beliefs, and the development of specific feeding styles.

The extent to which prolonged food insecurity has adverse effects on child growth may be related to the duration, intensity, timing, and context of the stressful experience. Studies are needed to determine how even under stressful conditions, supportive, responsive parenting may be enhanced and whether decreasing non-responsive feeding styles would prevent or even reverse the harmful effects of toxic stressors, like household food insecurity. Further study is needed to determine if food insecurity is screened for and identified during pregnancy, whether interventions to prevent food insecurity from persisting into infancy could mitigate the development of obesity-promoting maternal infant feeding styles. A strength of this study is that given that associations between food insecurity and feeding styles were only found when food insecurity occurred in both pregnancy and infancy, screening during only one time point is probably is not sufficient to understanding these relations. Although moderate effect size differences were detected, the clinical impact of these associations on later weight trajectories remains unclear. Longitudinal studies are needed to determine the role that household food insecurity during these sensitive periods plays in the development of later child feeding practices and child growth trajectories.

While our findings support the relations between household food insecurity and maternal infant feeding styles at 10 months, fewer associations with feeding practices were found. While studies of food insecurity and feeding practices in older children found that food insecure households consume more low-cost, high-energy-dense foods (Drewnowski et al., 2004), previous study of infant feeding practices revealed no associations with breastfeeding, introducing juice, and adding cereal to the bottle based on household food security status in the first six months of life (Gross et al., 2012). Given that maternal feeding practices may vary depending on the infant’s developmental stage, longitudinal research is needed to better understand how household food insecurity relates to feeding practices across the life course. In addition, our findings that food insecurity during pregnancy was associated with less infant vegetable intake and more juice intake, highlights the need to include prenatal assessments in future studies.

This study has several limitations. First, our sample was a cohort of low-income Hispanic women, which might limit generalizability to all pregnant women and mothers. The food insecurity variables provide information about the timing and duration of household food insecurity during separate 12-month periods encompassing pregnancy and the first year of life. However, we were not able to determine whether the severity of food insecurity fluctuated during the 12-month periods assessed. Another potential limitation is that food insecurity, other material hardships and feeding styles and practices were measured using maternal report instead of direct observation, possibility introducing social desirability bias. Although analyses adjusted for a range of potential confounders, other unmeasured family and community level confounders might exist. Following the cohort longitudinally throughout the child’s first 3 years of life will help to determine how food insecurity during these early sensitive periods will affect later feeding styles and practices and ultimately child growth trajectories.

CONCLUSIONS

Our study of low-income Hispanic mother-infant pairs found that experiencing prolonged household food insecurity during both pregnancy and infancy significantly increased obesity-promoting non-responsive maternal infant feeding styles at infant age 10 months. These findings highlight the importance of developing effective prevention strategies which span sensitive time points in the life course. Prenatal and pediatric primary care may represent a universal platform for food insecurity screening and referral to nutrition assistance programs. Our results indicate that if food insecurity is identified during pregnancy, interventions to prevent it from persisting into infancy may mitigate the development of obesity-promoting maternal infant feeding styles and practices. Future research studies should explore how early obesity prevention programs that begin during pregnancy could incorporate food insecurity screening and the provision of community resources as part of their intervention.

ACKNOWLEDGEMENTS

We thank the Starting Early Program staff who contributed to this project. This work was supported by the National Institute of Food and Agriculture, US Department of Agriculture, award number 2011-68001-30207, and the National Institutes of Health/National Institute of Child Health and Human Development through a K23 Mentored Patient-Oriented Research Career Development Award (K23HD081077; PI Gross). These funding sources had no involvement in conducting the research or in preparing this article.

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