Early Childhood Stress and Child Age Predict Longitudinal Increases in Obesogenic Eating Among Low-Income Children

Stress-induced eating in rural adolescents: Unique variability among boys and adolescents with obesity

Stress may contribute to the development of obesity through its effects on dysregulated eating, although this has not yet been examined among low-income, rural adolescents. We examined adolescents' stress-induced changes in eating an ad libitum meal, and after, in the absence of hunger (EAH), and the extent to which these varied by sex, race, and weight status. Participants included 260 adolescents, drawn from a sample of rural households experiencing poverty. Adolescents completed two home visits while salivary cortisol was measured; during the control (low stress) visit, they completed questionnaires and procedures thought to elicit low levels of stress and had BMI assessed. During the stress visit, adolescents completed a 20-min set of psychosocial stress challenges before eating. At each visit, adolescents consumed an ad-libitum meal after which they were additionally given large portions of snacks (EAH task). Results revealed that indeed cortisol was higher during the stress visit, across the sample. Boys showed stress-induced increases during ad-libitum meal intake (for calories, fat, and carbohydrates) whereas girls exhibited decreased intake. Further, adolescents with obesity showed stress-induced increases in fat intake, but only when hunger was satiated (EAH). There were no differences by race. These findings provide the first evidence of stress-induced alterations in food intake in a rural, low-income sample of adolescents and point to a strong vulnerability for stress-induced increases in eating in rural boys as well as stress-induced increases in fat intake when satiated as a possible contributor to obesity in youth.

Eating in the Absence of Hunger Is a Stable Predictor of Adiposity Gains in Middle Childhood

BACKGROUND

Eating in the absence of hunger (EAH) is a behavioral phenotype of pediatric obesity characterized by the consumption of palatable foods beyond hunger. Studies in children have identified EAH to be stable over time, but findings are unclear on whether it predicts the development of adiposity, particularly in middle childhood, a period of increased autonomy over food choices.

OBJECTIVES

We hypothesized that EAH would remain stable and be associated with increased adiposity over a ≥1-y prospective study in 7-8-y old children without obesity. Secondary hypotheses tested whether physical activity moderated the impact of EAH on adiposity.

METHODS

Children (n =72, age 7.8 ± 0.6 y; BMI% <90th), in a 7-visit longitudinal study, had EAH, adiposity, and physical activity assessed at baseline (time 1 - T1) and follow-up (time 2 - T2). EAH was determined by measuring children's intake from 9 energy-dense (>3.9 kcal/g) sweet and savory foods during a 10-min access period after intake of a standard meal eaten to satiation. Adiposity was measured by dual-energy X-ray absorptiometry (DXA), with an outcome of fat mass index (FMI; fat mass/height in m2). Seven days of wrist-worn Actigraphy quantified moderate-to-vigorous-physical activity (MVPA) and sedentary time.

RESULTS

EAH had moderate stability across time points (ICC = 0.54). ICCs were stronger for sweet (ICC = 0.53) than savory (ICC = 0.38) foods. Linear regression predicting 1-y change in FMI (adjusted for income, parent education, sex, time to follow-up, T2 Tanner stage, maternal weight status, and baseline adiposity) found that both total and sweet food EAH at baseline predicted increases in adiposity (P < 0.05 for both). EAH and adiposity were negatively correlated among children with high MVPA and low sedentary time.

CONCLUSIONS

These findings show that EAH is a stable predictive phenotype of increases in adiposity over 1 y among youth in middle childhood, although activity-related behaviors may moderate this effect. If replicated, targeting EAH as part of interventions may prevent excess adiposity gain.

TRIAL REGISTRATION NUMBER

The data was obtained from the Food and Brain study with registration number: NCT03341247.

Early life social conditions and adverse experiences are associated with childhood BMI and perceived overeating

BACKGROUND

Early life socioeconomic disadvantage and adverse experiences may lead to overeating, which is in turn associated with increased body mass index (BMI). However, recent evidence indicated that the association between childhood BMI and overeating might be bidirectional. This bidirectionality prompts the need for further investigation of early life predictors of BMI in childhood.

OBJECTIVES

To longitudinally assess the directionality of the association between childhood BMI and perceived overeating and to investigate their antecedent early life predictors.

METHODS

The sample included data from 5151 children from the ELSPAC study, collected between 18 months and 11 years of child age. The outcomes were child BMI and mother-reported overeating, assessed at the age of 3, 5, 7 and 11 years. Predictors included maternal BMI, maternal education, single parenthood, financial difficulties and adverse childhood experiences (ACEs) reported by parents and paediatricians. The random intercept cross-lagged panel model was applied.

RESULTS

The mean child's BMI at age 3 was 15.59 kg/m2 and increased to 17.86 kg/m2 at age 11. The percentage of parent-reported overeating increased in the following period, from about 12% at age 3 to 17% at age 11. The results showed temporal stability in perceived overeating and BMI, with a bidirectional relationship strengthening over time. The child's BMI was associated with maternal BMI. Maternal BMI was positively associated with child-perceived overeating, but a stronger effect was found for ACEs. ACEs mediated the impact of maternal education, financial difficulties and single parenthood on overeating.

CONCLUSIONS

We observed stable bidirectional associations between BMI and perceived overeating. The results indicated two main pathways: one linked to maternal BMI and early childhood BMI increase followed by perceived overeating and the second associated with ACEs mediating the effect of early childhood social factors on perceived overeating, leading to gradual BMI gain.

Maternal perceived stress, household disorder, eating behaviors and adiposity of women and their children

BACKGROUND

Stress is associated with physiological and behavioral adaptations that increase the risk for obesity and related diseases in adults and children. Mechanisms linking stress to chronic disease are diverse and not fully elucidated, but research suggests stress may impact eating behaviors and increase food intake and thereby, risk for obesity.

OBJECTIVE

The purpose of this study was to test the hypotheses that women's perceived stress and household disorder are associated with more uncontrolled and emotional eating among women, more food responsiveness and emotional overeating among their children, and greater adiposity in both women and their children.

METHODS

Women (n = 86) completed the Perceived Stress Scale, Confusion, Hubbub and Order Scale, Three Factor Eating Questionnaire, and Child Eating Behavior Questionnaire. Total body fat (%) was measured via dual-energy X-ray absorptiometry. Linear regression models evaluated associations of perceived stress and household disorder with eating behaviors and adiposity of women and their children (4-10 years old).

RESULTS

In a sample of predominantly non-Hispanic Black women (84.9%, n = 73), more perceived stress and household disorder were associated with more uncontrolled and emotional eating (p < 0.05). Women's perceived stress was not associated with their children's eating behaviors; however, household disorder was positively associated with children's food responsiveness and emotional overeating (p < 0.05). Perceived stress and household disorder were not associated with adiposity of women or their children.

CONCLUSIONS

These findings suggest household disorder may be a factor for home-based interventions to consider when addressing eating behaviors among families with children.

Associations Between Weight-Loss Attempts, Weight-Related Stress, and Body Image During Childhood and Adolescence in Children With Parental Obesity

Background: Few longitudinal studies have investigated the role of weight-loss attempts or weight-related stress on body image during childhood. We examined whether weight-loss attempts and weight-related stress are associated with weight misperception and body dissatisfaction across childhood and adolescence. Methods: Data were drawn from the Quebec Adipose and Lifestyle InvesTigation in Youth (QUALITY) cohort of Canadian children with parental obesity (8-10 years: n = 630; 10-12 years: n = 564; 15-17 years: n = 377). We assessed weight-loss attempts and weight-related stress at baseline and first follow-up, and perceived and desired silhouettes at first and second follow-up with questionnaires. Weight misperception consisted of the difference in BMI z-score (zBMI) from the perceived silhouette and the measured zBMI. Body dissatisfaction consisted of the discordance between perceived and desired silhouettes. We estimated multivariable mixed-effects regression models adjusting for age, sex, pubertal stage, parental BMI and education, and sport-based teasing. Results: Weight loss attempts were associated with a higher weight misperception score (ever tried, beta [95% confidence intervals; CI]: 0.13 [0.01-0.24]) and with 2.13 times higher desire to be thinner (95% CI: 1.39-3.26) at the subsequent follow-up. Similarly, children stressed by their weight had a higher misperception score (beta [95% CI]: 0.15 [0.02-0.27]) and greater desire to be thinner at the next follow-up (odds ratio [95% CI]: 1.73 [0.999-3.00]). Conclusions: Weight-loss attempts and weight-related stress in children and adolescents are associated with weight misperception and body dissatisfaction, supporting empowerment and counseling focusing on healthy eating behaviors and a positive body image. Clinical Trial Registration Number: NCT03356262.

Association of adverse childhood experiences with dietary patterns of school-age children: evidence from the birth cohort Generation XXI

BACKGROUND

Adverse Childhood Experiences (ACEs) have been associated with health-risk behaviors and several chronic diseases in adulthood. However, the relationship between exposure to ACEs and dietary patterns at school age is unknown.

OBJECTIVES

To investigate the association between ACEs and dietary patterns of 10-year-olds.

METHODS

The study included 5034 children from the Generation XXI cohort, recruited in 2005/2006 in Porto, Portugal. ACEs were assessed through a self-administered questionnaire covering the first 10 years (y) of life, quantified and grouped into 5 dimensions: "abuse," "school problems," "death/severe disease," "life changes," and "household dysfunction." Dietary patterns were identified by latent class analysis using data collected with a validated food frequency questionnaire. Five dietary patterns were studied: "low consumption," "energy-dense foods," "snacking," "intermediate consumption," and "healthier" (used as reference). Multinomial regression analyses were conducted, adjusted for the child's sex, household income, family structure, and mother's age [odds ratio (OR) and 99% confidence intervals (CIs)].

RESULTS

Most children were exposed to ≥1 ACE (96%), and ∼27% had reported 6 or more ACEs throughout life. Those reporting 4-5 and ≥6 ACEs were more likely to follow the "Energy-dense foods" dietary pattern compared with those with no ACEs (OR: 2.41; 99% CI: 1.00, 5.77 and OR: 2.65; 99% CI: 1.10, 6.39, respectively). Children exposed to "abuse" in the first 10 y showed 28% higher odds of following the "low consumption" dietary pattern when compared to children with no reported ACEs and using the "healthier" dietary pattern as a reference (OR: 1.28; 99% CI: 1.00, 1.63).

CONCLUSIONS

Exposure to ACEs was associated with less healthy dietary patterns in school-aged children. Results suggest a cumulative effect of the adverse experiences resulting in a dietary pattern higher in energy-dense foods. Children with ACEs reported under the dimension of "abuse" seemed to have reduced food consumption.

PACE: a Novel Eating Behavior Phenotype to Assess Risk for Obesity in Middle Childhood

BACKGROUND

Behavioral phenotypes that predict future weight gain are needed to identify children susceptible to obesity.

OBJECTIVES

This prospective study developed an eating behavior risk score to predict change in adiposity over 1 y in children.

METHODS

Data from 6 baseline visits (Time 1, T1) and a 1-y follow-up visit (Time 2, T2) were collected from 76, 7- to 8-y-old healthy children recruited from Central Pennsylvania. At T1, children had body mass index (BMI) percentiles <90 and were classified with either high (n = 33; maternal BMI ≥30 kg/m2) or low (n = 43; maternal BMI ≤25 kg/m2) familial risk for obesity. Appetitive traits and eating behaviors were assessed at T1. Adiposity was measured at T1 and T2 using dual-energy x-ray absorptiometry, with a main outcome of fat mass index (FMI; total body fat mass divided by height in meters squared). Hierarchical linear regressions determined which eating measures improved prediction of T2 FMI after adjustment for covariates in the baseline model (T1 FMI, sex, income, familial risk, and Tanner stage).

RESULTS

Four eating measures-Portion susceptibility, Appetitive traits, loss of control eating, and eating rate-were combined into a standardized summary score called PACE. PACE improved the baseline model to predict 80% variance in T2 FMI. PACE was positively associated with the increase in FMI in children from T1 to T2, independent of familial risk (r = 0.58, P < 0.001). Although PACE was higher in girls than boys (P < 0.05), it did not differ by familial risk, income, or education.

CONCLUSIONS

PACE represents a cumulative eating behavior risk score that predicts adiposity gain over 1 y in middle childhood. If PACE similarly predicts adiposity gain in a cohort with greater racial and socioeconomic diversity, it will inform the development of interventions to prevent obesity. This trial was registered at clinicaltrials.gov as NCT03341247.

Eating behaviors as pathways from early childhood adversity to adolescent cardiometabolic risk

OBJECTIVE

To identify specific eating behavior pathways that mediate associations between financial difficulties, negative life events, and maternal depressive symptoms from 0 to 5 years and cardiometabolic risk in adolescence.

METHOD

Hypotheses were tested with data from birth to age 15 years using the Avon Longitudinal Study of Parents and Children, a birth cohort in the United Kingdom (n = 3,887 for current analyses). Mothers reported on financial difficulties, negative life events, and maternal depressive symptoms at multiple points from 0 to 5 years and reported on worry about child overeating at 8 years. Youth self-reported restrained, emotional, and external eating at age 14. Youth completed a cardiometabolic health assessment at age 15 where waist circumference, triglycerides, high-density lipoprotein, and insulin resistance were measured. Longitudinal structural equation modeling with bootstrapping was used to test mediation models.

RESULTS

Greater negative life events and maternal depressive symptoms predicted greater parental worry about child overeating at age 8, which directly predicted greater restrained and emotional eating at 14 and cardiometabolic risk at 15. Restrained and emotional eating at 14 directly predicted greater cardiometabolic risk at age 15.

CONCLUSIONS

Negative life events and maternal depressive symptoms in infancy/early childhood are associated with cardiometabolic risk in adolescence through pathways of parental worry about child overeating in middle childhood and youth-reported restrained and emotional eating in adolescence. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Adverse Childhood Experiences and BMI: Lifecourse Associations in a Black-White U.S. Women Cohort

INTRODUCTION

Although adverse childhood experiences (ACEs) have been positively associated with adiposity, few studies have examined long-term race-specific ACE-BMI relationships.

METHODS

A Black and White all-women cohort (N=611; 48.6% Black) was followed between 1987 and 1997 from childhood (ages 9-10 years) through adolescence (ages 19-20 years) to midlife (ages 36-43 years, between 2015 and 2019). In these 2020-2022 analyses, the interaction between race and individual ACE exposures (physical abuse, sexual abuse, household substance abuse, multiple ACEs) on continuous BMI at ages 19-20 years and midlife was evaluated individually through multivariable linear regression models. Stratification by race followed as warranted at α=0.15.

RESULTS

Race only modified ACE-BMI associations for sexual abuse. Among Black women, sexual abuse was significantly associated with BMI (Badjusted=3.24, 95% CI=0.92, 5.57) at ages 19-20 years and marginally associated at midlife (Badjusted=2.37, 95% CI= -0.62, 5.35); among White women, corresponding associations were null. Overall, having ≥2 ACEs was significantly associated with adolescent BMI (Badjusted=1.47, 95% CI=0.13, 2.80) and was marginally associated at midlife (Badjusted=1.45, 95% CI= -0.31, 3.22). This was similarly observed for physical abuse (adolescent BMI: Badjusted=1.23, 95% CI= -0.08, 2.54; midlife BMI: Badjusted=1.03, 95% CI= -0.71, 2.78), but not for substance abuse.

CONCLUSIONS

Direct exposure to certain severe ACEs is associated with increased BMI among Black and White women. It is important to consider race, ACE type, and life stage to gain a more sophisticated understanding of ACE-BMI relationships. This knowledge can help strengthen intervention, prevention, and policy efforts aiming to mitigate the impacts of social adversities and trauma on persistent cardiometabolic health disparities over the lifecourse.

Aberrant functional connectivity between reward and inhibitory control networks in pre-adolescent binge eating disorder

BACKGROUND

Behavioral features of binge eating disorder (BED) suggest abnormalities in reward and inhibitory control. Studies of adult populations suggest functional abnormalities in reward and inhibitory control networks. Despite behavioral markers often developing in children, the neurobiology of pediatric BED remains unstudied.

METHODS

58 pre-adolescent children (aged 9-10-years) with BED (mBMI = 25.05; s.d. = 5.40) and 66 age, BMI and developmentally matched control children (mBMI = 25.78; s.d. = 0.33) were extracted from the 3.0 baseline (Year 0) release of the Adolescent Brain Cognitive Development (ABCD) Study. We investigated group differences in resting-state functional MRI functional connectivity (FC) within and between reward and inhibitory control networks. A seed-based approach was employed to assess nodes in the reward [orbitofrontal cortex (OFC), nucleus accumbens, amygdala] and inhibitory control [dorsolateral prefrontal cortex, anterior cingulate cortex (ACC)] networks via hypothesis-driven seed-to-seed analyses, and secondary seed-to-voxel analyses.

RESULTS

Findings revealed reduced FC between the dlPFC and amygdala, and between the ACC and OFC in pre-adolescent children with BED, relative to controls. These findings indicating aberrant connectivity between nodes of inhibitory control and reward networks were corroborated by the whole-brain FC analyses.

CONCLUSIONS

Early-onset BED may be characterized by diffuse abnormalities in the functional synergy between reward and cognitive control networks, without perturbations within reward and inhibitory control networks, respectively. The decreased capacity to regulate a reward-driven pursuit of hedonic foods, which is characteristic of BED, may in part, rest on this dysconnectivity between reward and inhibitory control networks.

Children's eating behaviours and related constructs: conceptual and theoretical foundations and their implications

BACKGROUND

There is a substantial body of research on children's eating behaviours (e.g., food responsiveness and fussiness) and related constructs (e.g., eating in the absence of hunger, appetite self-regulation). This research provides a foundation for understanding children's dietary intakes and healthy eating behaviours, as well as efforts at intervention, whether in relation to food avoidance, overeating and/or trajectories to excess weight gain. The success of these efforts and their associated outcomes is dependent on the theoretical foundation and conceptual clarity of the behaviours and constructs. This, in turn contributes to the coherence and precision of the definitions and measurement of these behaviours and constructs. Limited clarity in these areas ultimately creates uncertainty around the interpretation of findings from research studies and intervention programs. At present there does not appear to be an overarching theoretical framework of children's eating behaviours and associated constructs, or for separate domains of children's eating behaviours/constructs. The main purpose of the present review was to examine the possible theoretical foundations of some of the main current questionnaire and behavioural measures of children's eating behaviours and related constructs.

METHODS

We reviewed the literature on the most prominent measures of children's eating behaviours for use with children aged ~ 0-12 years. We focused on the explanations and justifications for the original design of the measures and whether these included theoretical perspectives, as well as current theoretical interpretations (and difficulties) of the behaviours and constructs.

RESULTS

We found that the most commonly used measures had their foundations in relatively applied or practical concerns rather than theoretical perspectives.

CONCLUSIONS

We concluded, consistent with Lumeng & Fisher (1), that although existing measures have served the field well, to advance the field as a science, and better contribute to knowledge development, increased attention should be directed to the conceptual and theoretical foundations of children's eating behaviours and related constructs. Suggestions for future directions are outlined.

Factors Associated with Eating in the Absence of Hunger among Children and Adolescents: A Systematic Review

Eating in the absence of hunger (EAH) has been extensively studied over the past two decades and has been associated with excess body weight and the development of obesity. However, determinants of EAH remain uncertain. This systematic review aims to identify individual, familial, and environmental factors associated with EAH among children and adolescents. We included studies with a measure of EAH in participants aged 3-17 years old and including ≥1 factor associated with EAH. Our search identified 1494 articles. Of these, we included 81 studies: 53 cross-sectional, 19 longitudinal and nine intervention studies. In childhood (≤12 years old), EAH increases with age, it is greater in boys compared to girls, and it is positively associated with adiposity. Moreover, EAH development seems to be influenced by genetics. In adolescence, the number of studies is limited; yet, studies show that EAH slightly increases or remains stable with age, is not clearly different between sexes, and findings for overweight or obesity are less consistent across studies in adolescence. For familial factors, parental restrictive feeding practices are positively associated with EAH during childhood, mostly for girls. Studies assessing environmental factors are lacking and robust longitudinal studies spanning from early childhood to adolescence are needed.

Stress and eating responses in adolescent females predisposed to obesity: A pilot and feasibility study

OBJECTIVE

To explore how chronic stress, reactivity to acute stress, and obesogenic eating are linked in adolescent females predisposed to obesity.

METHODS

Participants included 21 adolescent females (m_age = 14.57 years) and their biological mothers with obesity (body mass index [BMI] ≥ 30 kg/m²). The pilot and feasibility study involved adolescent self-report of chronic stress, an acute stress-induction paradigm (Trier Social Stress Task, TSST), salivary cortisol collection to assess stress reactivity, and both subjective (self-report) and objective (snack buffet) measures of obesogenic eating.

RESULTS

Adolescent females reporting high chronic stress were significantly more likely to engage in self-reported emotional and external eating and to have higher food cravings (p's < .05) compared to adolescents with low chronic stress. Effect size estimates suggested a blunting effect of cortisol in the high chronic stress group. Blunted cortisol reactivity significantly predicted higher self-reported food cravings for the high chronic stress group (p = .04). Associations among chronic stress, cortisol, and self-reported and objective obesogenic eating reflected medium to large effect sizes.

CONCLUSIONS

This study built on limited extant research on stress and eating to demonstrate that chronic stress was associated with self-reported obesogenic eating patterns in adolescent females predisposed to obesity. Different patterns of cortisol reactivity and eating emerged depending on chronic stress group (low versus high). Understanding these eating patterns in the context of chronic stress can inform interventions to reduce obesity risks in adolescence.

Emotion Regulation Moderates the Associations of Food Parenting and Adolescent Emotional Eating

OBJECTIVE

To explore parental feeding practices and eating behavior as predictors of the child's emotional eating (EE) and child's emotion regulation (ER) as a potential moderator.

DESIGN

Parental eating behavior (emotional, external, and restrained eating), 9 parental feeding practices (restriction, food as reward, food as ER, monitoring, healthy modeling, healthy environment, child control, and child involvement), ER, and EE were analyzed cross-sectionally and 5 parental practices longitudinally (subsample, n = 115).

SETTING

Belgium.

PARTICIPANTS

Two hundred eighteen adolescents (aged 13.7 ± 1.77 years) and parent dyads.

MAIN OUTCOME MEASURES

Child's EE.

ANALYSIS

Linear regression and moderation (cross-sectional) and linear mixed models (longitudinal). Models adjusted for multiple testing with a false discovery rate of 10% (Benjamini-Hochberg), age, sex, body mass index, socioeconomic status, and cohort.

RESULTS

Cross-sectionally but not longitudinally, there was a positive association between predictors restriction and monitoring with the outcome child's EE (β = 0.19, P = 0.006; β = 0.17, P = 0.01, respectively). Restrained eating of the parent was negatively associated with the child's EE (β = -0.22, P = 0.003). The child's maladaptive ER significantly moderated the associations of 5 feeding practices and parental EE with the child's EE.

CONCLUSIONS AND IMPLICATIONS

Parents continue to play a role in the eating behavior of their adolescent offspring, not only through their feeding practices (restrictive parenting was most detrimental) but also by displaying restrained eating (beneficial). A child's ER appears as an important moderator of the established associations; however, more research is needed to better understand these observations.

Adolescent-Reported Household Food Insecurity and Adolescents' Poor Mental and Physical Health and Food Insufficiency in Kenya

Background

Assessing adolescents' experiences of food insecurity in households is important for promoting healthy development. Although parental reports have been traditionally used, emerging research highlights the importance of child and adolescent reports of the household food environment.

Objectives

Extending research from high- and upper-middle-income countries, this study of adolescent compared with adult reports of household food insecurity in Kenya, a lower-middle-income country, examined 1) prevalence of and correspondence between adolescent and adult reports of household food insecurity, and 2) associations of adolescent and adult reports of household food insecurity with adolescent nonnutritional and nutritional outcomes.

Methods

Using data from the Kenya Violence Against Children Surveys (n = 1182), we assessed prevalence of household food insecurity reported by adolescents (ages 13-17 y) and adults, with McNemar χ2 and κ analysis of correspondence between reports. Ordinal and binary logistic regression assessed associations between adolescent and adult reports and adolescent mental health and self-rated physical health and food sufficiency outcomes.

Results

Household food insecurity was reported by 36% of adolescents and 63% of adults; 36% of adult reports were discordant with adolescent reports (κ = 0.333). Odds of adolescent mental health difficulties were highest with adolescent-only report (OR = 2.11, P = 0.02), followed by adult and adolescent (OR = 1.83, P = 0.001) and adult-only (OR = 1.06, P = 0.77) report. Odds of poor adolescent self-rated physical health were highest with adult and adolescent report (OR = 2.47, P < 0.001) followed by adolescent-only (OR = 2.04, P = 0.08) and adult-only (OR = 1.37, P = 0.20) report. Odds of adolescents eating ≤1 meals the previous day were highest with adult and adolescent (OR = 21.38, P < 0.001) followed by adult-only (OR = 7.44, P = 0.01) and adolescent-only (OR = 2.31, P = 0.34) report.

Conclusions

Measuring household food insecurity with both adolescent report and adult report is important for having a comprehensive understanding of household resources and needs and of the nonnutritional (mental and physical health) and nutritional (diet and food) outcomes of household food insecurity for adolescents.

Parenting Stress, Child Weight-Related Behaviors, and Child Weight Status

Background: There has been limited examination of the association between parenting stress and child weight-related behaviors. We aimed to determine whether parenting stress is associated with child weight-related behaviors, including physical activity, screen time, diet, sedentary time, and eating in the absence of hunger (EAH). Secondarily, we assessed association between parenting stress and child weight status. Methods: Mother-child dyads (N = 291) enrolled in the Newborn Epigenetic STudy (NEST), a longitudinal cohort study, completed surveys to describe parenting stress, and child diet. Children participated in the EAH task and wore accelerometers to assess sedentary time and physical activity. Child weight status was assessed using measured height and weight. Outcomes and exposures were examined using generalized linear models and restricted cubic splines as appropriate based on linear lack-of-fit test. Results: Child sedentary time and vegetable consumption were inversely associated with parenting stress (Total Stress B = -0.78; 95% confidence interval [CI]: -1.35 to -0.20; p = 0.017; and Total Stress adjusted odds ratio [aOR] = 0.98; 95% CI: 0.99 to 1.00; p = 0.022, respectively). Child screen time was directly associated with parenting stress (Total Stress = aOR 1.01; 95% CI: 1.00-1.02; p = 0.032). Fast-food intake was nonlinearly associated with parenting stress. There was no evidence of association between parenting stress and child EAH, physical activity, or weight status. Associations between parenting stress and child weight-related behaviors were not moderated by race or family structure. Conclusions: Parenting stress was associated with important child weight-related behaviors but not weight status. Management of parenting stress may represent a reasonable adjunct to family-based behavioral interventions.

Regional gray matter abnormalities in pre-adolescent binge eating disorder: A voxel-based morphometry study

BACKGROUND

Binge eating disorder (BED) is a pernicious psychiatric disorder which is linked with an array of multisystemic organ morbidity, broad psychiatric morbidity, and obesity. Despite behavioral markers often developing in early childhood, the neurobiological markers of early-onset BED remain understudied, and developmental pathophysiology remains poorly understood.

METHODS

71 preadolescent children (aged 9-10-years) with BED and 74 age, BMI and developmentally matched control children were extracted from the 3.0 baseline (Year 0) release of the Adolescent Brain Cognitive Development (ABCD) Study. We investigated group differences in gray matter density (GMD) via voxel-based morphometry (VBM). We additionally performed region of interest analyses, assessing the association between GMD in nodes of the reward (orbitofrontal cortex; OFC) and inhibitory control (dorsolateral prefrontal cortex; dlPFC) networks, and parent-reported behavioral inhibition and approach tendencies.

RESULTS

Diffuse elevations in cortical GMD were noted in those with BED, which spanned prefrontal, parietal, and temporal regions. No areas of reduced GMD were noted in those with BED. No alterations in subcortical GMD were noted. Brain-behavioral associations suggest a distinct and negative relationship between GMD in the OFC and dlPFC, respectively, and self-reported markers of hedonic behavioral approach tendencies.

CONCLUSIONS

Early-onset BED may be characterized by diffuse morphological abnormalities in gray matter density, suggesting alterations in cortical architecture which may reflect decreased synaptic pruning and arborization, or decreased myelinated fibers and therefore inter-regional afferents.

Conceptualizing and Measuring Appetite Self-Regulation Phenotypes and Trajectories in Childhood: A Review of Person-Centered Strategies

This review uses person-centered research and data analysis strategies to discuss the conceptualization and measurement of appetite self-regulation (ASR) phenotypes and trajectories in childhood (from infancy to about ages 6 or 7 years). Research that is person-centered provides strategies that increase the possibilities for investigating ASR phenotypes. We first examine the utility of examining underlying phenotypes using latent profile/class analysis drawing on cross-sectional data. The use of trajectory analysis to investigate developmental change is then discussed, with attention to phenotypes using trajectories of individual behaviors as well as phenotypes based on multi-trajectory modeling. Data analysis strategies and measurement approaches from recent examples of these person-centered approaches to the conceptualization and investigation of appetite self-regulation and its development in childhood are examined. Where relevant, examples from older children as well as developmental, clinical and educational psychology are drawn on to discuss when and how person-centered approaches can be used. We argue that there is scope to incorporate recent advances in biological and psychoneurological knowledge about appetite self-regulation as well as fundamental processes in the development of general self-regulation to enhance the examination of phenotypes and their trajectories across childhood (and beyond). The discussion and conclusion suggest directions for future research and highlight the potential of person-centered approaches to progress knowledge about the development of appetite self-regulation in childhood.

Self-reported weight loss attempts and weight-related stress in childhood: Heightening the risk of obesity in early adolescence

OBJECTIVE

Weight loss attempts occur as early as childhood. The impacts of weight loss attempts and weight-related stress on the occurrence of obesity during childhood remain unknown. We aimed to: (a) assess the prevalence of self-reported weight loss attempts and weight-related stress in 8-10 year-old children and (b) determine associations with adiposity 2 years later.

METHOD

Data were collected from a cohort study of 564 Canadian children aged 8-10 years, having one or both biological parents with obesity (Quebec Adipose and Lifestyle Investigation in Youth cohort). Self-reported weight loss attempts and weight-related stress were assessed at baseline in the child's questionnaire. Adiposity was measured at baseline and 2 years later using body mass index z-scores (zBMI), waist-to-height ratio (WHtR), and percentage of body fat (%BF) obtained from dual-energy x-ray absorptiometry. Linear and logistic regression analyses were used while adjusting for potential confounders.

RESULTS

Forty-eight percent of children reported previous weight loss attempts and 20% reported weight-related stress. Self-reported weight loss attempts and weight-related stress were associated with higher zBMI, WHtR, and %BF 2 years later in adjusted models, although estimates were attenuated when including baseline adiposity measures. Self-reported weight loss attempts, but not weight-related stress, increased the risk of becoming overweight among children who were normal weight at baseline.

DISCUSSION

Weight loss attempts are prevalent in children with parental obesity. Children reporting weight loss attempts and weight-related stress tend to have higher adiposity 2 years later and are more likely to become overweight.

Life-course effects of early life adversity exposure on eating behavior and metabolism

Environmental variations in early life influence brain development, making individuals more vulnerable to psychiatric and metabolic disorders. Early life stress (ELS) has a strong impact on the development of eating behavior. However, eating is a complex behavior, determined by an interaction between signals of energy homeostasis, neuronal circuits involved in its regulation, and circuits related to rewarding properties of the food. Although mechanisms underlying ELS-induced altered feeding behavior are not completely understood, evidence suggest that the effects of ELS on metabolic, mood, and emotional disorders, as well as reward system dysfunctions can contribute directly or indirectly to altered feeding behavior. The focus of this chapter is to discuss the effects of ELS on eating behavior and metabolism, considering different factors that control appetite such as energy homeostasis, hedonic properties of the food, emotional and cognitive status. After highlighting classic studies on the association between ELS and eating behavior alterations, we discuss how exposure to adversity can interact with genetics characteristics to predict variable outcomes.

Appetite self-regulation declines across childhood while general self-regulation improves: A narrative review of the origins and development of appetite self-regulation

This narrative review discusses the origins and development of appetite self-regulation (ASR) in childhood (from infancy to age 6 or 7 years). The origins, or foundations, are the biological infrastructure associated with appetite regulation and appetite self-regulation. Homeostatic regulation in infancy is examined and then evidence about developmental change in components of ASR. The main ASR-related components covered are: delay-of-gratification, caloric compensation, eating in the absence of hunger, food responsiveness/hedonics and fussy eating. The research included behavioral measures, parent-reports of appetitive traits and fMRI studies. There were two main trends in the evidence: a decline across childhood in the components of ASR associated with food approach (and therefore an increase in disinhibited eating), and wide individual differences. The decline in ASR contrasts with general self-regulation (GSR) where the evidence is of an improvement across childhood. For many children, bottom-up automatic reactive processes via food reward/hedonics or food avoidance as in fussy eating, appear not to be matched by improvements in top-down regulatory capacities. The prominence of bottom-up processes in ASR could be the main factor in possible differences in developmental paths for GSR and ASR. GSR research is situated in developmental science with its focus on developmental processes, theory and methodology. In contrast, the development of ASR at present does not have a strong developmental tradition to access and there is no unifying model of ASR and its development. We concluded (1) outside of mean-level or normative changes in the components of ASR, individual differences are prominent, and (2) there is a need to formulate models of developmental change in ASR together with appropriate measurement, research designs and data analysis strategies.

Getting to the heart of food craving with resting heart rate variability in adolescents

BACKGROUND

There is an epidemic of obesity in children and adolescents. Research into the self-regulatory factors that drive eating behavior is of critical importance. Food craving contributes to overeating and difficulty with weight loss and is strongly correlated with self-regulation. High-frequency heart rate variability (HF HRV) reflects parasympathetic activity and is positively associated with self-regulation. Few studies of HF HRV and food craving have been conducted in adolescents. The current study examined the association between HF HRV and food craving in a large-scale sample of healthy adolescents.

METHOD

Electrocardiogram (ECG) was recorded in 134 healthy adolescents aged 10-17 during a 7-min resting state. Participants also completed the Food Craving Questionnaire-Trait (FCQ-T). The relative power of HF HRV was calculated. Association between HF HRV and food craving was examined in the context of sex and age. Next, the relative significance of all food craving subscales was considered in relation to HF HRV.

RESULTS

HF HRV was inversely correlated with food craving, taking into account sex and age. Considering all the subscales of FCQ-T in relation to HF HRV, the "lack of control over eating" subscale accounted for the most significant variance.

CONCLUSION

This was the first study to evaluate resting HRV and eating behaviors in a large-scale adolescent sample. HF HRV was negatively associated with food craving, with lower HF HRV correlating with higher food craving, especially in the context of diminished control over eating. HF HRV could be a potential biomarker for food craving and food-related self-regulation capacity, and therefore may aid weight management interventions.

Adversity exposure and obesogenic food consumption in young children: The transgenerational role of emotion dysregulation

BACKGROUND

Childhood adversity is linked with unhealthy eating behaviours and obesity, but the mechanisms underlying this association are unclear, specifically the transgenerational behavioural precursors that develop in early childhood.

OBJECTIVE

To determine whether adversity predicts change in obesogenic food consumption through child emotion dysregulation, and whether caregiver emotion dysregulation modifies this association.

METHODS

Participants included 190 low-income caregiver-child dyads (mean child age = 4.31 years [SD = 0.85]). Cumulative lifetime adversity exposure was assessed via study-created measure. The Difficulties with Emotion Regulation Scale and Emotion Regulation Checklist assessed caregiver and child emotion dysregulation, respectively. Children's obesogenic food consumption was assessed at two time points 6 months apart using a caregiver-report measure: the Children's Eating Habits Questionnaire. Moderated mediation models were tested using autoregressive structural equation modelling.

RESULTS

Cumulative lifetime adversity was associated with child emotion dysregulation only when caregiver emotion dysregulation was high. Child emotion dysregulation in turn was associated with greater obesogenic food consumption 6 months later.

CONCLUSIONS

Among young children with caregivers high in emotion dysregulation, cumulative lifetime adversity was linked to an increase in obesogenic food consumption through child emotion dysregulation.

Rural-urban differences in body mass index and obesity-related behaviors among low-income preschoolers

BACKGROUND

With one in eight preschoolers classified as obese in the USA, childhood obesity remains a significant public health issue. This study examined rural-urban differences in low-income preschoolers' body mass index z-scores (BMIz), eating behaviors, dietary quality, physical activity (PA) and screen time.

METHODS

Pre-intervention data from 572 preschooler-parent dyads participating in a randomized, controlled obesity prevention trial in the Midwest USA were analyzed. We examined the associations among living in rural versus urban areas, child BMIz and child obesity-related behaviors, including eating behaviors, dietary quality, PA and screen time.

RESULTS

Rural children had higher BMIz, more emotional overeating behaviors and more time spent playing outdoors compared with urban children. We found no associations between children living in rural versus urban areas and dietary quality and screen time.

CONCLUSIONS

The study found that rural-urban differences in BMIz may start as early as 3-4 years of age, if not earlier. To reverse the weight-related health disparities between rural and urban low-income preschoolers, structural changes in rural locations and family supports around coping skills may be needed.

Abnormal weight gain with fatigue and stress in early survivorship after childhood brain tumor diagnosis

BACKGROUND

Diagnosis and treatment for individuals with brain tumors during childhood involves sequelae, including abnormal weight gain. This symptom is commonly clustered with fatigue and increased risk for cardiovascular disease. Children's Oncology Group recommendations include annual surveillance of body mass index (BMI) and cardiometabolic comorbidities; however, there has been little emphasis on individualized screening early in survivorship.

PURPOSE

The primary purpose of this paper is to describe the findings of abnormal weight gain and its correlates in a sample of young childhood brain tumor survivors during early survivorship.

DESIGN AND METHODS

This cross-sectional multi-site study included brain tumor survivors of ages 8-12 years who were less than 6 years posttreatment. Convenience sampling from two pediatric cancer centers in the southern United States was utilized. Data collected included BMI, parent report of sleep, and child report of fatigue and stress.

RESULTS

The sample (N = 21) consisted of children who had received chemotherapy, radiation treatment, and surgery for childhood brain tumor. BMI in overweight and obese categories exceeded normative samples with 38% at or above the 85th percentile. There were clinically significant relationships with fatigue, stress about weight, tumor location, cranial radiation, chemotherapy, and recurrence PRACTICE IMPLICATIONS: Screening for abnormal weight gain and related factors, such as fatigue should begin early in survivorship after childhood brain tumor treatment completion with the aim of health promotion and disease prevention. Adiposity measurement techniques should be utilized in future clinical and research settings to improve assessment of cardiometabolic risk.

Parental substance use and child reward-driven eating behaviors

Family history of substance use is a well-established risk factor for greater substance use in adolescence and adulthood. The biological vulnerability hypothesis proposes that family history of substance use might also confer risk for obesogenic eating behavior because of similar rewarding characteristics between substances and certain foods (e.g., processed foods high in refined carbohydrates and fat). Indeed, preliminary research shows that family history of substance use is linked with sweet liking and obesity in adults; however, it is unknown whether this factor is linked to eating behavior earlier in development. The present study (n = 52) tested the association of severity of parental nicotine dependence and alcohol use (drinking frequency, drinking quantity, binge drinking, and number of annual drinks consumed) with two types of child [Mage = 10.18 (0.83) years] eating behavior: homeostatic eatingbehavior, or eating regulated by internal satiety cues, and reward-driven eatingbehavior, or eating motivated by pleasure. Results indicated that-over and above the influence of child age, child biological sex, and family income-more severe parental nicotine dependence and frequent and/or heavy, frequent parental alcohol use were associated with significantly greater child reward-driven eating behaviors as indexed by the Food Responsiveness and Enjoyment of Food subscales on the Child Eating Behavior Questionnaire. Parental substance use was not associated with child homeostatic eating behavior as indexed by the Satiety Responsiveness subscale. Family history of substance use may be an important transdiagnostic risk factor that identifies children at risk for obesogenic, reward-driven eating behaviors.

Maternal nicotine dependence is associated with longitudinal increases in child obesogenic eating behaviors

BACKGROUND

Meta-analysis shows that parental cigarette smoking is associated with child obesity.

OBJECTIVES

This study tested for associations between severity of maternal nicotine dependence and longitudinal changes in child eating behavior in archival data analysis.

METHODS

Maternal nicotine dependence was assessed with the Fagerstrom Test for Nicotine Dependence. Child eating behavior was assessed with the Child Eating Behavior Questionnaire when children were ages 4, 6, 8, and 10.

RESULTS

Over and above the influence of child age, child biological sex, and family income-to-needs ratio, more severe maternal nicotine dependence was associated with greater increases in child Food Responsiveness (γ = 0.07, SE_γ  = 0.03, P = .014, 95% CI [0.01, 0.13]) and Emotional Overeating (γ = 0.06, SE_γ  = 0.03, P = .024, 95% CI [0.01, 0.11]) across 6 years.

CONCLUSIONS

Maternal nicotine dependence may be a transdiagnostic risk factor that identifies children at risk for reward-driven, obesogenic eating behavior.

Evaluating the Reliability and Validity of the Children's Vitality-Relaxation Scale

This study developed the Children's Vitality-Relaxation Scale (CVRS) by revising the adult version of the Restoration Outcome Scale (ROS). The CVRS was translated and culturally adapted into Korean, and its reliability and validity were evaluated in a cross-sectional, descriptive design study. Data collected from 181 elementary school students in grades 4‒6 were used to test the validity and reliability of the CVRS. Exploratory factor analysis, Pearson's correlation, known-groups comparison, and Cronbach's alpha were used for analysis. The factor analysis indicated a two-factor structure, and all factor loadings were above 0.40. The CVRS was a seven-point Likert scale consisting of eight items, which were classified as "vitality" (four items) and "relaxation" (four items). The external construct validity with the PANAS, PSS, and SRI was acceptable. In the known-groups comparison, the CVRS score was significantly higher for boys than for girls, and the CVRS score for high-income students was higher than low-income students. The Cronbach's α for the scale was 0.84 and ranged from 0.72-0.87 for the subscales. Results showed that the CVRS is a valid and reliable scale with acceptable psychometric characteristics in Korean children. The scale can be used to measure children's affect in various settings.

Longitudinal associations between overweight/obesity and stress biology in low-income children

Background/Objectives

Associations between overweight and altered stress biology have been reported cross-sectionally during childhood, but it is unclear whether overweight precedes altered stress biology or if altered stress biology predicts greater likelihood of overweight over time. The current longitudinal study investigates associations between overweight/obesity, salivary alpha amylase and cortisol morning intercept, diurnal slope, and reactivity to social stress in a cohort of low-income children during preschool and middle childhood.

Subjects/Methods

Children were recruited through Head Start and were observed and followed into middle childhood (N = 257; M = 8.0 years). Height and weight were measured at both time points. Saliva samples were collected across the day and in response to a social challenge at both ages for alpha amylase and cortisol determination.

Results

Cross-lagged panel analyses indicated that overweight/obesity at preschool predicted lower morning alpha amylase (β = −0.18, 95% CI: −0.34, −0.03; p = .023), lower morning cortisol (β = −0.22, 95% CI: −0.38, −0.06; p = .006), lower sAA diurnal slope (β = −0.18, 95% CI: −0.34, −0.03; p = .021), and lower cortisol stress reactivity (β = −0.19, 95% CI: −0.35, −0.02; p = .031) in middle childhood. Lower alpha amylase reactivity at preschool was the only biological factor that predicted higher likelihood of overweight/obesity at middle childhood (β = −0.20, 95% CI: −0.38, −0.01; p = .035).

Conclusions

These findings suggest that overweight/obesity may be driving changes in stress biology across early to middle childhood, particularly in down-regulation of morning levels of stress hormones, diurnal sAA slope, and cortisol reactivity to stress, rather than stress biology driving overweight/obesity.

Eating in the absence of hunger in young children is related to brain reward network hyperactivity and reduced functional connectivity in executive control networks

BACKGROUND

Recent work has implicated disinhibited eating behaviours (DEB) as a potential pathway toward obesity development in children. However, the underlying neurobiology of disinhibited eating behaviours in young, healthy weight children, prior to obesity development, remains unknown.

OBJECTIVES

This study tested the relationship between DEB and intrinsic neuronal activity and connectivity in young children without obesity.

METHODS

Brain networks implicated in overeating including reward, salience and executive control networks, and the default mode network were investigated. DEB was measured by the eating in the absence of hunger (EAH) paradigm with postlunch kilocalories consumed from highly palatable foods (EAH kcal) used as the predictor. Intrinsic neuronal activity within and connectivity between specified networks were measured via resting-state functional magnetic resonance imaging. Eighteen typically developing children (mean age = 5.8 years) were included.

RESULTS

EAH kcal was positively associated with activity of the nucleus accumbens, a major reward network hub (P < 0.05, corrected). EAH kcal was negatively associated with intrinsic prefrontal cortex connectivity to the striatum (P < 0.01, corrected).

CONCLUSIONS

These results suggest that neural aspects of DEB are detectable in young children without obesity, providing a potential tool to better understand the development of obesity in this population.

Weight status moderates stress-eating in the absence of hunger associations in children

OBJECTIVE

The association between stress and eating remains unclear in children potentially due to factors that may moderate the association. We examined whether weight status or sex moderated associations between response to a stress induction and eating in the absence of hunger (EAH), among low-income children.

METHOD

Children (n = 223; M age = 7.8 years, SD = 0.7 years) participated in a stress induction protocol (modified Trier Social Stress Test for Children [TSST-C]) during which behavioral coding of observed anxiety and change in self-reported distress were measured. Afterwards, participants completed a standardized EAH protocol where they were offered palatable foods. Total kilocalories consumed during the EAH protocol was calculated. Weight and height were measured and weight status calculated as overweight (BMI ≥ 85th percentile for age and sex) vs. not overweight. Multivariate linear regression models adjusting for covariates were conducted to test whether child weight status or sex moderated the stress response-EAH association, for both stress response variables.

RESULTS

Weight status moderated the association between observed stress response and EAH such that children with overweight engaged in more EAH as observed anxiety increased, whereas children without overweight engaged in less EAH as observed anxiety increased (β_interaction = 0.48; p = .010). Weight status did not moderate associations between self-reported distress and EAH. Child sex was not a significant moderator.

CONCLUSIONS

After exposure to stress, children with overweight in middle childhood may eat more palatable food compared to children without overweight, possibly due to hypersensitization to food cues or weight stigma experienced by youth with overweight. It may be helpful to encourage youth with overweight to engage in stress-management techniques that do not involve eating as a response to stress.

Sleep duration and quality are associated with eating behavior in low-income toddlers

OBJECTIVE

The present study examined whether different sleep health parameters (duration, timing, and quality) are associated with obesity-related eating behaviors including emotional overeating, food responsiveness, enjoyment of food, satiety responsiveness, and eating in the absence of hunger (EAH), during toddlerhood.

DESIGN

Among 134 low-income 33-month-old children, parents reported on child sleep parameters, including sleep quality (Children's Sleep Wake Scale; CSWS) and usual bedtimes and wake times on weekdays and weekends (weeknight sleep duration, weekday-to-weekend bedtime delay). Child eating behaviors were assessed using both observed and parent-report measures. Child Emotional Overeating, Food Responsiveness, Enjoyment of Food, and Satiety Responsiveness were measured by parent report using the Child Eating Behavior Questionnaire-Toddler. Observed child EAH was evaluated by measuring kilocalories of palatable foods consumed following a meal. Multivariable linear regression was used to examine the associations between sleep parameters and eating behaviors.

RESULTS

Poorer child sleep quality was associated with greater Emotional Overeating (standardized β = -0.20 (SE 0.09), p < .05) and greater Food Responsiveness (β = -0.18 (SE 0.09), p < .05). Shorter child nighttime sleep duration was associated with greater EAH kcal consumed (standardized β = -0.22 (SE 0.09), p < .05). Child bedtime delay was not associated with any of the eating behaviors, and no child sleep variables were associated with either Enjoyment of Food or Satiety Responsiveness.

CONCLUSIONS

Shorter nocturnal sleep duration and poorer sleep quality during toddlerhood were associated with some, but not all, of the obesity-related eating behaviors. Poor sleep health may promote childhood obesity risk through different eating behavior pathways. As children growing up in poverty may experience greater sleep decrements, sleep duration and sleep quality may be important targets for intervention among low-income families with young children.

An investigation of maternal food intake and maternal food talk as predictors of child food intake

Though parental modeling is thought to play a critical role in promoting children's healthy eating, little research has examined maternal food intake and maternal food talk as independent predictors of children's food intake. The present study examines maternal food talk during a structured eating protocol, in which mothers and their children had the opportunity to eat a series of familiar and unfamiliar vegetables and desserts. Several aspects of maternal talk during the protocol were coded, including overall food talk, directives, pronoun use, and questions. This study analyzed the predictors of maternal food talk and whether maternal food talk and maternal food intake predicted children's food intake during the protocol. Higher maternal body mass index (BMI) predicted lower amounts of food talk, pronoun use, and questions. Higher child BMI z-scores predicted more first person pronouns and more wh-questions within maternal food talk. Mothers of older children used fewer directives, fewer second person pronouns, and fewer yes/no questions. However, maternal food talk (overall and specific types of food talk) did not predict children's food intake. Instead, the most robust predictor of children's food intake during this protocol was the amount of food that mothers ate while sitting with their children. These findings emphasize the importance of modeling healthy eating through action and have implications for designing interventions to provide parents with more effective tools to promote their children's healthy eating.