A qualitative study of parents' perceptions and use of portion size strategies for preschool children's snacks

'You just eyeball it': Parent and nursery staff perceptions and influences on child portion size: A reflexive thematic analysis

Background: Childhood obesity is one of the most serious public health epidemics of the 21st century. Observational studies report that increases in portion size (PS) have occurred in parallel with levels of obesity. Increased PSs of high-energy-dense foods can promote overeating, and without compensatory behaviours, can contribute to childhood obesity. Caregivers make decisions about PSs for children in the home and nursery environment, thus are gatekeepers to child food intake. Understanding caregiver PS decisions can aid in the best practice of PS provision to young children. The aim of this study was to explore parent and nursery staff influences on child PS selection and their suggestions for useful tools/strategies in PS decisions. Methods: A qualitative design was employed using focus group discussions (FGDs) with parents and nursery staff of children aged 3-5 years. FGDs were employed given their ability to generate rich data, as well as permit the exploration of collective perceptions, attitudes, behaviours and experiences. Data were analysed using an inductive, semantic approach to reflexive thematic analysis. Results: Four FGDs were conducted: two with parents (n = 13), two with nursery staff (n = 17). Four overarching themes were derived: (i) awareness of PS guidelines; (ii) control over PS; (iii) social influences on children's eating behaviours; (iv) child-specific, social and external factors influencing parent and nursery staff PS decisions. Additionally, participants discussed tools/strategies they believe would be useful in PS decisions. Conclusion: Data from the themes suggest that caregiver control, social, child-specific and external factors are more influential than PS guidelines in both parent and nursery staff PS decisions for young children aged 3-5 years. These findings can inform future childhood obesity prevention initiatives focussed on improving parent and nursery staff provision/use of age-appropriate PSs.

Child food portion sizes in the home environment: how do parents decide?

The consumption of larger portion sizes (PS) of food has been implicated in the increased prevalence of childhood obesity. The home is usually the first place children learn about food, however, little is known about how parents determine child PS in the home environment. This narrative review aimed to explore parental beliefs, decisions, strategies and barriers to the provision of appropriate food PS for children in the home environment. Results indicate that parental decisions on child food PS are based on the amounts they serve themselves, personal intuition and knowledge of child appetite. Owing to the habitual nature of food provision, parental decisions on child PS may be taken without conscious thought and/or could be part of a complex decision-making process influenced by several interlinked factors, including parental childhood mealtime experiences, other family members and child weight status. Strategies to determine child-appropriate PS include modelling the desired PS behaviour, use of unit-based food packaging and PS estimation aids, and providing the child with a degree of autonomy to rely on their own appetite cues. A lack of knowledge/awareness of PS guidance is a key barrier identified by parents to the provision of age-appropriate PS, warranting the inclusion of salient child-appropriate PS guidance within national dietary recommendations. Further home-based interventions to improve the provision of appropriate child PS are required, leveraged on parental strategies already in use, as outlined in this review.

Designing for downsizing: Home-based barriers and facilitators to reduce portion sizes for children

Evidence confirms that parents know that they should limit non-core foods for their children since these tend to be high in energy density (HED), fat, salt and sugar. However, it is unclear how knowledge of portion size limits, such as the 100 kcal guide from Public Health England are applied in practice. To observe in real-time children’s home food environment related to portion control and to explore with parents their reported portion size strategies, a mixed methods study was designed. Families with children aged 1–5 years were recruited (n = 21) to a three-part study: (1) to complete questionnaires and interviews on household food intake and portion control; (2) to report daily food intake for 4 days (n = 13) for one parent and their child(ren); (3) to observe home-based food provisioning via videorecording during dinner, breakfast and snack time (n = 6). Although the problem of large portion sizes of HED foods was recognised by mothers, strategies to downsize portions were not necessarily applied at home, as revealed in home observations and diaries. A mismatch between what was observed at home, what was reported in food diaries and what was said in interviews became apparent for some families. Mothers reported the need for greater support and guidance to downsize HED foods since they relied on pre-packaging as a guide to intake. Education and engagement were identified as important parameters for downsizing by mothers. One strategy which could be explored and applied by manufacturers is packaging design to faciliate the 100 kcal guidance using physical and engaging ways to assist parents in downsizing HED foods for their children. To facilitate effective government communication, innovative packaging design can be used to convey clear guidance and to tailor portion size messages for children. Packaging design, alongside government recommendations, can support parents’ goals to achieve healthy eating and can reinforce guidance for portion norms through innovation involving learning, playful engagement, and interaction.

Systematic review of the portion size norm of discretionary foods

CONTEXT

Portion size norm is described as the perception of how much of a given food people choose to eat. Reducing the portion size norm of foods that are high in saturated fat, added sugar, and added salt toward smaller sizes might be a potential strategy to promote appropriate portion size selections. However, an overview of existing portion size norms for discretionary foods has yet to be established.

OBJECTIVE

The aim of this systematic review was to examine the portion size norm of discretionary foods and assess the methodologies used to investigate the norm.

DATA SOURCES

The literature search was conducted in 6 databases following the PRISMA guidelines (from inception to January 2022).

DATA EXTRACTION

Forty studies were eligible and grouped into 3 categories by portion size norm measures: normal (n = 26), appropriate (n = 8), and preferred portion sizes (n = 3). Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools.

DATA ANALYSIS

A wide range of portion sizes were considered normal for each food type, with means/medians varying from 2- to 4-fold among studies. Studies differed considerably in design, with variables including the setting, food type, food presentation, the manner in which portion-size-related questions were formulated, and the range and number of displayed serving size options. The quality of reviewed studies was mixed (25 studies had low or moderate risk of bias, 15 had high risk of bias), and the method of assessing portion size was not validated in 15 of 33 quantitative studies.

CONCLUSION

The assessment of portion size in future studies should be conducted using tools that are validated for the population of interest so that more definitive conclusions can be drawn regarding portion size norms for discretionary foods.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42021249911.

Evaluation of Parental Acceptability and Use of Intervention Components to Reduce Pre-School Children's Intake of Sugar-Rich Food and Drinks

Knowledge is needed about effective tools that reach public health objectives focused on reducing the intake of sugar-rich foods and drinks. The purpose of this study was to assess the parental acceptability, use and motivational potential of intervention components developed in the randomized family-based trial ‘Are you too sweet?’ aimed at reducing the intake of sugar-rich foods and drinks among children (5–7 y). Intervention components included guidance on sugar-rich foods and drinks at a school health nurse consultation, a box with home-use materials and a digital platform. The methods used were a questionnaire among intervention families (n = 83) and semi-structured interviews with parents in selected intervention families (n = 24). Results showed the good acceptability and usefulness of the components, with reported frequencies of use of materials ranging from 48% to 94% and a high satisfaction rate with the school health nurse consultation. Personalized feedback and guidance from the school health nurse seemed to be a motivational trigger, and components that were compatible with existing practices were most frequently used. However, the components were not considered engaging by all families. Overall, intervention components were well received and hold the potential for enhancing parental knowledge and parenting practices regarding limiting the intake of sugar-rich foods and drinks.

Factors That Influence Snacking Behaviors of Adolescents From Urban Communities: A Qualitative Study

OBJECTIVE

To qualitatively explore factors that influence snacking behaviors of adolescents from urban communities.

DESIGN

One-time, semistructured phone interviews based on Social Cognitive Theory.

SETTING

Boys and Girls Club in New York City.

PARTICIPANTS

A total of 30 adolescents (aged 12-18 years; mean age 15.2 years, mostly female [57%], and Black or African American [83%]) were purposively recruited. This sample is representative of adolescent members at this Boys and Girls Club in New York City.

PHENOMENON OF INTEREST

Adolescents were asked about personal, environmental, and behavioral factors influencing snacking.

ANALYSIS

Interviews were audio-recorded, transcribed, and transcripts were analyzed using the thematic analysis approach in NVivo (version 12).

RESULTS

In terms of personal factors, adolescents' snacking was influenced by preference (eg, taste and brand), health benefits, and health concerns. Regarding the social environment, adolescents remarked that snacking with peers promoted unhealthy snacking, while snacking, with family promoted healthier snacking. The family culture was also a salient factor. In addition, adolescents discussed how proximity to corner stores in their physical environment fostered unhealthy snacking. Finally, behavioral factors that influenced frequent snacking were high self-efficacy and food autonomy.

CONCLUSIONS AND IMPLICATIONS

Snacking among adolescents from urban communities is influenced by preference, health, family/peer influence, neighborhood availability/access, and high autonomy. These factors can be targeted in interventions to improve snacking among this demographic.

Parents' awareness and perceptions of the Change4Life 100 cal snack campaign, and perceived impact on snack consumption by children under 11 years

Background

Childhood obesity is a pertinent public health problem in the UK. Consumption of free sugars has been associated with the development of obesity. In 2018, the Change 4Life (C4L) 100 cal snack campaign was launched with the slogan ‘100 calorie snacks, two a day max’, aiming to encourage parents to choose lower sugar, fat and calorie snacks for their children. This study aimed to examine how the campaign has been perceived by parents.

Methods

An online survey was developed to explore parent awareness, perceptions and understanding of the C4L 100 cal snack campaign. Respondents were recruited via Leeds City Council, posters displayed at primary schools and children’s centres across Leeds and via social media. Paper surveys were also shared with voluntarily led playgroups. Survey data was analysed using descriptive statistics. Thematic analysis was performed on open text responses.

Results

Three hundred forty-two 342 respondents completed the survey. Just over half of the respondents had come across the campaign, most seeing the leaflet or a television advert. Over two-thirds of respondents ‘agreed’ or ‘strongly agreed’ that the campaign caught their attention. A similar proportion ‘agreed’ or ‘strongly agreed’ that the campaign informed them about 100 cal snacks and just over a half thought it was memorable. Most respondents used positive language to describe the campaign, but there was no clear consensus of a perceived positive impact on healthier snack purchasing, nor preparing more 100 cal snacks at home. Respondents provided examples of how the campaign could be improved to positively impact eating behaviours: better publicity and information delivery; healthier snack examples made more visible; improved nutritional labelling and access to healthier products in supermarkets (availability, promotion, display, choice).

Conclusions

The C4L 100 cal snack campaign was perceived positively by parents and carers, with many agreeing that the campaign was informative and memorable. However, there was no agreement in terms of the parents reporting an impact of the campaign on behaviour change and healthier snack habits. Future social marketing campaigns could be improved through more formal pilot testing to assess the understanding and acceptance of the campaign amongst the target audience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12789-7.

Food and beverage offerings by parents of preschoolers: A daily survey study of dinner offerings during COVID-19

The COVID-19 pandemic is likely to have altered parents' daily feeding practices, including what and how much they feed their children, which may have negative implications for children's weight. The primary aim of this study was to examine patterns of and variation in parents' daily food and beverage offerings at dinner across 10 days during the COVID-19 pandemic using descriptive analysis and non-parametric tests. Ninety-nine parents (M_age = 32.90, SD_age = 5.60) of children ages 2–4 years (M = 2.82, SD = 0.78) completed an online baseline survey and 10 daily surveys (929 completed surveys) assessing their daily food and beverage offerings at dinner. On average, parents did not offer recommended foods and beverages on a daily basis; parents offered vegetables and protein most often across the 10 days, however, less than 50% of parents offered the recommended serving size for each group. The intraclass correlations and random sampling plots revealed considerable within-parent variation in food and beverage offerings. Eating dinner as a family, planning dinner in advance, and preparing a homemade dinner were associated with more vegetable and protein offerings, while processed, fast, or fried foods were offered less often when dinner was planned or homemade. Dairy, water, and refined grains were offered more often when dinner was homemade, while whole grains, processed, fast, or fried foods, and sugar-sweetened beverages were offered less often when dinner was homemade. The results provide documentation of parents' daily food and beverage offerings at dinner within the context of COVID-19 and point towards the importance of examining predictors and consequences of parents' daily feeding practices.

What is a "Snack"? Perspectives from Adolescents in Urban Communities

Snacking contributes significantly to U.S. adolescents' dietary intake and is a particularly significant eating occasion for urban adolescents, who have high amounts of food autonomy and access to corner stores. Consequently, research has focused on understanding and improving snacking among urban adolescents. However, the word "snack" possesses several definitions in the literature, leading to inconsistences in research efforts. As such, the aim of this study was to explore the definition of a snack among urban adolescents by conducting phone interviews with 30 adolescents from a Boys & Girls Club in New York City. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis. Overall, adolescents defined a snack as a small, unhealthy food item that can be quickly eaten to reduce hunger between meals. Future directions include using the definition of a snack that emerged from this study to improve subsequent adolescent snacking interventions.

How Do French Parents Determine Portion Sizes for Their Pre-Schooler? A Qualitative Exploration of the Parent-Child Division of Responsibility and Influencing Factors

Large portion sizes can make children overeat, alter their self-regulation abilities and induce weight gain. However, little is known about how parents determine portion sizes for their children. Using semi-structured interviews with 5 fathers and 32 mothers of pre-schoolers, this study examined French parents' food portioning practices. The division of responsibility between parent and child in deciding portion sizes was explored, as well as the influencing factors and possible sources of information. Parents described a wide range of practices. For most, determining portion sizes is an intuitive action that depends on habits and mainly arises from experiences with feeding their child and his/her appetitive traits. Few parents grant autonomy to their child for portioning and serving food, especially for the first serving. Many influencing factors were identified, including child-related (e.g., appetite, food preferences), parent-related (e.g., avoiding food waste), and external factors (e.g., influence of siblings, French food culture). Most parents do not search for information/recommendations to guide their practices. Stimulating optimal self-regulation of eating in children is important and parents can play a crucial role in this. This study identified barriers and facilitators to guide parents in providing appropriate portion sizes and help include children in this decision process.

Occasions, purposes, and contexts for offering snacks to preschool-aged children: Schemas of caregivers with low-income backgrounds

OBJECTIVE

Snacking among preschool aged children is nearly universal and has been associated with overconsumed nutrients, particularly solid fats and added sugars (SoFAS). This research examined caregivers' schemas, or cognitive frameworks, for offering snacks to preschool-aged children.

METHODS

A qualitative design utilizing card sort methods was employed. Participants were 59 Black, Hispanic, and White caregivers of children aged 3-5 years with low-income backgrounds. Caregivers sorted 63 cards with images of commonly consumed foods/beverages by preschool-aged children in three separate card sorts to characterize snacking occasions, purposes, and contexts. The mean SoFAS content (kcal/100 g) of foods/beverages was evaluated by occasions (snacks vs. not-snacks), purposes, and contexts.

RESULTS

Just under two-thirds (38/63 food cards) of foods/beverages were classified as snacks with moderate to high agreement. Snacks were offered for non-nutritive (e.g., requests, rewards) and nutritive (e.g., hunger/thirst) purposes in routine (e.g., home, school) and social contexts (e.g., with grandparents). Snacks offered for non-nutritive purposes and in social contexts were higher in SoFAS than those offered for nutritive reasons and in routine contexts.

CONCLUSIONS

Caregivers of young children offered various types of foods/beverages as snacks, with higher SoFAS snacks given for non-nutritive purposes and in social contexts. Understanding of caregivers' schemas for offering snacks to young children may inform targets for obesity prevention and anticipatory guidance to promote the development of healthful eating behaviors.

A Remote Nutritional Intervention to Change the Dietary Habits of Patients Undergoing Ablation of Atrial Fibrillation: Randomized Controlled Trial

BACKGROUND

The Prevention With Mediterranean Diet (PREDIMED) trial supported the effectiveness of a nutritional intervention conducted by a dietitian to prevent cardiovascular disease. However, the effect of a remote intervention to follow the Mediterranean diet has been less explored.

OBJECTIVE

This study aims to assess the effectiveness of a remotely provided Mediterranean diet-based nutritional intervention in obtaining favorable dietary changes in the context of a secondary prevention trial of atrial fibrillation (AF).

METHODS

The PREvention of recurrent arrhythmias with Mediterranean diet (PREDIMAR) study is a 2-year multicenter, randomized, controlled, single-blinded trial to assess the effect of the Mediterranean diet enriched with extra virgin olive oil (EVOO) on the prevention of atrial tachyarrhythmia recurrence after catheter ablation. Participants in sinus rhythm after ablation were randomly assigned to an intervention group (Mediterranean diet enriched with EVOO) or a control group (usual clinical care). The remote nutritional intervention included phone contacts (1 per 3 months) and web-based interventions with provision of dietary recommendations, and participants had access to a web page, a mobile app, and printed resources. The information is divided into 6 areas: Recommended foods, Menus, News and Online resources, Practical tips, Mediterranean diet classroom, and Your personal experience. At baseline and at 1-year and 2-year follow-up, the 14-item Mediterranean Diet Adherence Screener (MEDAS) questionnaire and a semiquantitative food frequency questionnaire were collected by a dietitian by phone.

RESULTS

A total of 720 subjects were randomized (365 to the intervention group, 355 to the control group). Up to September 2020, 560 subjects completed the first year (560/574, retention rate 95.6%) and 304 completed the second year (304/322, retention rate 94.4%) of the intervention. After 24 months of follow-up, increased adherence to the Mediterranean diet was observed in both groups, but the improvement was significantly higher in the intervention group than in the control group (net between-group difference: 1.8 points in the MEDAS questionnaire (95% CI 1.4-2.2; P<.001). Compared with the control group, the Mediterranean diet intervention group showed a significant increase in the consumption of fruits (P<.001), olive oil (P<.001), whole grain cereals (P=.002), pulses (P<.001), nuts (P<.001), white fish (P<.001), fatty fish (P<.001), and white meat (P=.007), and a significant reduction in refined cereals (P<.001), red and processed meat (P<.001), and sweets (P<.001) at 2 years of intervention. In terms of nutrients, the intervention group significantly increased their intake of omega-3 (P<.001) and fiber (P<.001), and they decreased their intake of carbohydrates (P=.02) and saturated fatty acids (P<.001) compared with the control group.

CONCLUSIONS

The remote nutritional intervention using a website and phone calls seems to be effective in increasing adherence to the Mediterranean diet pattern among AF patients treated with catheter ablation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03053843; https://www.clinicaltrials.gov/ct2/show/NCT03053843.

A laboratory-based assessment of mother-child snack food selections and child snack food consumption: Associations with observed and maternal self-report of child feeding practices

This study explored how mothers' observed and self-reported child feeding practices (child control over food choices, encouragement of balance and variety, and teaching about nutrition) were associated with mother-child snack food selections and child snack food consumption in a laboratory setting. Mothers (N = 107) and their 4.5-year-old children (52% female) selected up to 5 snack foods (out of 9 snack foods: 6 higher-energy-density [ED] and 3 lower-ED) for optional child consumption throughout a one-hour laboratory visit. Mothers' in-the-moment child feeding practices during the snack food selection task were coded using observational coding schemes, and mothers' global child feeding practices (i.e., across meals and snacking occasions) were self-reported using the Comprehensive Feeding Practices Questionnaire (Musher-Eizenman & Holub, 2007). Results of multiple linear regression analyses with covariates showed that higher-ED snack food selections were positively associated with observed child control over food choices (B = 0.35, SE = 0.12, p = .006) and self-reported teaching about nutrition (B = 0.49, SE = 0.19, p = .010), and negatively associated with self-reported encouragement of balance and variety (B = -0.66, SE = 0.24, p = .007). Lower-ED snack food selections were positively associated with self-reported encouragement of balance and variety (B = 0.53, SE = 0.20, p = .008). Child consumption of higher-ED or lower-ED snack foods were not significantly associated with mothers' child feeding practices (observed or self-reported). We discuss the implications of these findings for future research on children's snack food selection and consumption.

Snack Portion Sizes for Preschool Children Are Predicted by Caregiver Portion Size, Caregiver Feeding Practices and Children's Eating Traits

Caregivers are mostly responsible for the foods young children consume; however, it is unknown how caregivers determine what portion sizes to serve. This study examined factors which predict smaller or larger than recommended snack portion sizes in an online survey. Caregivers of children aged 2 to 4 years were presented with 10 snack images, each photographed in six portion sizes. Caregivers (n = 659) selected the portion they would usually serve themselves and their child for an afternoon snack. Information on child eating traits, parental feeding practices and demographics were provided by caregivers. Most caregivers selected portions in line with recommended amounts for preschool children, demonstrating their ability to match portion sizes to their child's energy requirements. However, 16% of caregivers selected smaller than recommended low energy-dense (LED, e.g., fruits and vegetables) snacks for their child which was associated with smaller caregiver's own portion size, reduced child food liking and increased satiety responsiveness. In contrast, 28% of caregivers selected larger than recommended amounts of high energy-dense (HED, e.g., cookies, crisps) snacks for their child which were associated with larger caregiver's own portion size, greater frequency of consumption, higher child body mass index (BMI), greater pressure to eat and lower child food liking. These findings suggest that most caregivers in this study select portions adjusted to suit their child's age and stage of development. Future interventions could provide support to caregivers regarding the energy and nutrient density of foods given the relatively small portion sizes of LED and large portions of HED snacks offered to some children.

Maternal Decisions on Portion Size and Portion Control Strategies for Snacks in Preschool Children

Caregivers are responsible for the type and amount of food young children are served. However, it remains unclear what considerations caregivers make when serving snacks to children. The aim of the study was to explore mothers' decisions and portion control strategies during snack preparation in the home environment. Forty mothers of children aged 24-48 months participated in the study. Mothers prepared five snack foods for themselves and their child whilst verbalizing their actions and thoughts. Mothers were then asked about their portion size decisions in a semi-structured interview. Transcripts were imported into NVivo and analyzed thematically. Three key themes were identified: (1) portion size considerations, (2) portion control methods, and (3) awareness and use of portion size recommendations. Transient, food-related situational influences influenced mothers and disrupted planning and portion control. Food packaging and dishware size were used as visual cues for portion control; however, these vary widely in their size, thus emphasizing mothers' uncertainty regarding appropriate portion sizes. Mothers called for portion size information to be accessible, child-centered, and simple. These findings reveal multiple considerations when deciding on the correct snack portion sizes for children. These decisions are complex and vary across situations and time, and according to the types of snacks offered.

Determinants of Portion Size in Children and Adolescents: Insights from the UK National Diet and Nutrition Survey Rolling Programme (2008-2016)

Large portion sizes have been identified as contributing to overweight and obesity, particularly in children and adolescents. This study examined predictors of portion sizes of high energy snack foods eaten by children aged 1.5–18 years. Specifically, we examined whether portion sizes were adjusted for age, and what external features of the environment might be linked to large portion sizes. Portion sizes were derived from four-day food diaries that form the UK National Diet and Nutrition Survey. Diaries from 5942 children were examined and multilevel models were used to discover whether age, gender, location, time of day, household income, and watching TV while eating predicted portion sizes of savoury snacks, chocolate, confectionery and biscuits. Portion sizes of all the target foods were predicted by age. Boys had larger portions, and portion sizes were larger when target foods were consumed later in the day. Portion sizes were larger outside the home, for example in leisure venues, but the target foods were eaten more frequently in the home. As dietary patterns change to include more snack intake outside the home, these locations could be an important space to target for interventions for portion control.

Cultural influence on mindful eating: traditions and values as experienced by Mexican-American and non-Hispanic white parents of elementary-school children

OBJECTIVE

To examine perceptions of mindful eating and mindful food parenting among parents of elementary school children.

METHODS

Four focus groups were conducted with 19 Mexican-American parents and 13 non-Hispanic white parents of children from a northern California elementary school.

RESULTS

Themes emerging from this research included food traditions during mealtime, perceptions of mindful eating, mindful food parenting and portion control, mindful food parenting practices through gardening, and mindful food parenting with traditional foods. Mexican-American participants identified cooking traditional foods as an important part of their mindful eating and food parenting practices. Mexican-American participants also highlighted the importance of using their senses to appreciate food. Both Mexican-American and non-Hispanic white participants emphasized the importance of involving children in gardening and meal preparation. Mexican-American parents had different perceptions of food portion control than the non-Hispanic white participants.

CONCLUSIONS

The current study indicates the importance of mindfulness in broad food-related practices such as gardening, cooking and preserving food traditions in mindful eating practices. More research is needed to further understand how culture shapes and impacts these food practices among different cultural groups.

The effect of food type on the portion size effect in children aged 2-12 years: A systematic review and meta-analysis

Visual cues such as plate size, amount of food served and packaging are known to influence the effects of portion size on food intake. Unit bias is a well characterised heuristic and helps to determine consumption norms. In an obesogenic environment where large portions are common place, the unit or segmentation bias may be overridden promoting overconsumption of both amorphous or unit foods. The aim of this review was to investigate the impact of offering unit or amorphous food on the portion size effect (PSE) in children aged 2-12 years. A systematic search for literature was conducted in Medline, PsycInfo and Web of Science in February 2018. A total of 1197 papers were retrieved following the searches. Twenty-one papers were included in the systematic review, of which 15 provided requisite statistical information for inclusion in a random effects meta-analysis. Increasing children's food portion size by 51-100% led to a significant increase in intake (SMD = 0.47, 95% CI: 0.39-0.55). There was no evidence to suggest that increases in consumption were related to food type (p = 0.33), child age (p = 0.47) or initial portion size served (p=0.14). Residual heterogeneity was not significant (p=0.24). The PSE was demonstrated in children aged 2-12 years when offered both unit and amorphous food items. The effect was not restricted by food type, child age or influenced by initial portion size served. Of the studies included in the meta-analysis between study heterogeneity was low suggesting minimal variation in treatment effects between studies, however, more research is required to understand the mechanisms of the PSE in preschool children. Future research should determine feasible methods to downsize portion sizes served to children.

Plating up appropriate portion sizes for children: a systematic review of parental food and beverage portioning practices

Consumption of larger portion sizes is associated with higher energy intake and weight status in children. As parents play a pivotal role in child feeding, we synthesized literature on 'parental portioning practices' using a mixed methods systematic design to inform future strategies addressing portion sizes served to children. Electronic databases PubMed, EMBASE, SCOPUS, PsycINFO and CINAHL Plus were searched. Two reviewers independently screened 385 abstracts and assessed 71 full-text articles against eligibility criteria: studies assessing portioning of foods or beverages by parent(s) with ≥1 child aged 2-12 years. Narrative synthesis of 14 quantitative studies found that portion sizes parents serve vary substantially and are influenced by amounts parents serve themselves, perceived child hunger and parent and child body size. Thematic synthesis of 14 qualitative studies found that parents serve the portion sizes they learn to be appropriate for their child to be fed. Portioning is influenced by parents' desires for a healthy child with a balanced diet. Future guidance on appropriate portion sizes for children would ideally present recommended portion sizes for first serving, incremental with age. Future research is however needed to assess the adoption and efficacy of providing such guidance to families.

The Feasibility and Acceptability of Two Methods of Snack Portion Control in United Kingdom (UK) Preschool Children: Reduction and Replacement

Large portions of high energy dense (HED) snacks are offered to children from a young age and are pervasive in our food environment. This study aimed to explore the feasibility, acceptability, and preliminary efficacy of two strategies of snack portion control: reduction and replacement. Forty-six mother-child dyads aged 22⁻56 months (36.6 ± 9.5 m, 48% female) completed a three-week intervention. In week 1 (baseline) no changes were made to the child's diet; week 2 (acclimation) children received a standardised selection of HED snacks, and in week 3 (intervention) participants were randomly assigned to snack replacement (n = 24) or snack reduction (n = 22). Snack replacement involved swapping HED snacks for fruits and vegetables, whilst snack reduction involved reducing the size of HED snacks by 50%. Food and energy intake were measured using a weighed food diary for four consecutive days. Snack replacement resulted in more positive changes to children's diets; vegetable intake increased (p < 0.01), and total daily energy intake decreased when compared to snack reduction (p < 0.05). Mothers expressed a more favourable attitude to snack replacement, although snack reduction was also well received by mothers. Despite increased preliminary efficacy of snack replacement on dietary intake, both strategies were feasible and acceptable. The current pilot study provides the necessary information to inform the design of future interventions.

Understanding the science of portion control and the art of downsizing

Offering large portions of high-energy-dense (HED) foods increases overall intake in children and adults. This is known as the portion size effect (PSE). It is robust, reliable and enduring. Over time, the PSE may facilitate overeating and ultimately positive energy balance. Therefore, it is important to understand what drives the PSE and what might be done to counter the effects of an environment promoting large portions, especially in children. Explanations for the PSE are many and diverse, ranging from consumer error in estimating portion size to simple heuristics such as cleaning the plate or eating in accordance with consumption norms. However, individual characteristics and hedonic processes influence the PSE, suggesting a more complex explanation than error or heuristics. Here PSE studies are reviewed to identify interventions that can be used to downsize portions of HED foods, with a focus on children who are still learning about social norms for portion size. Although the scientific evidence for the PSE is robust, there is still a need for creative downsizing solutions to facilitate portion control as children and adolescents establish their eating habits.

Research into food portion size: methodological aspects and applications

Portion sizes for certain foods have been increasing dramatically in recent years alongside obesity rates, concurring with the phenomenon of the portion size effect (more is consumed when more is offered). Portion size may be defined based on different purposes such as for dietary assessment, or therapeutic advice or food labelling, resulting in a variety of measurement methods and specifications. This situation has resulted in disagreements on establishing portion size recommendations by manufacturers, food distributors, restaurants, health professionals and policy makers, contributing to confusion amongst consumers on the amounts of food to be consumed, and potentially increasing the likelihood of overeating and other obesity-related behaviours. Such variability is also reflected in the research field making comparison across studies on portion size difficult. The aim of this review is to provide an overview of definitions and methods used in research to evaluate portion-size related outcomes, including methods to estimate amounts consumed by individuals as part of dietary assessment; methods to analyse cognitive mechanisms related to portion size behaviour; and methods to evaluate the impact of portion size manipulations as well as individual plus environmental factors on portion size behaviour. Special attention has been paid to behavioural studies exploring portion size cognitive processes given the lack of previous methodological reviews in this area. This information may help researchers, clinicians and other stakeholders to establish clearer definitions of portion size in their respective areas of work and to standardise methods to analyse portion size effects.

Maternal responses to difficult food request scenarios: Relationships with feeding style and child unhealthy snack intake

This study sought to identify parent-feeding behaviours in real-life difficult feeding situations through the use of a set of scenarios. These were then used to examine links between parent feeding and child snack intake. Mothers of children aged 2–7 years ( n = 611) completed an online survey containing five snack food request scenarios, two commonly used parent-feeding scales (Restriction and Covert Control), and reported on their child’s snack intake. Results showed that parent-feeding styles (restrictive or covert) translated into specific behaviours in response to the scenarios. These parent behaviours predicted children’s intake of unhealthy snack food over and above the feeding style.

Association of Overweight with Food Portion Size among Adults of São Paulo - Brazil

BACKGROUND

Although studies show that portion size affects energy intake, few have demonstrated a link between portion size and weight status, especially in free-living populations. The objective of the present study was to assess the relationship between food portion sizes and overweight in a representative population of adults of São Paulo, Brazil.

METHODS

Cross-sectional population-based study with 1005 adults from São Paulo, Brazil. Dietary data were obtained from two 24-hour recalls. Reported foods were classified into groups and energy contribution, prevalence of consumers and portion sizes were calculated. Individuals were classified according to BMI in with and without overweight. Logistic regression models were used to evaluate the association between food portion sizes and being overweight.

RESULTS

The most consumed food groups were: beans, breads/rolls, coffee/tea, milk, rice, and sugar. Rice, red meat, breads/rolls, and white meat were the groups with the highest percentage of contribution to total energy intake. Butter/margarine, toasts/biscuits, sugar, and cakes were the groups with the highest energy density. After adjustment for confounding variables, overweight was associated with larger portions of pizza (OR = 1.052; p = 0.048), red meat (OR = 1.025; p = 0.043), rice (OR = 1.033; p<0.001), salted snacks (OR = 1.078; p = 0.022), and soft drinks (OR = 1.016; p = 0.007).

CONCLUSIONS

Larger portions of few food groups with different energy densities were associated with being overweight, suggesting that overweight may be related to the consumption of larger portion sizes of a series of food groups, not a food group alone. Additionally, we highlight the importance of considering underreporting as a confounding factor in these associations.

Eat, play, view, sleep: Exploring Mexican American mothers' perceptions of decision making for four behaviors associated with childhood obesity risk

OBJECTIVE

This mixed methods study sought to understand who makes decisions about whether preschool-aged Mexican American children engage in eating, outdoor play, sleep, and screen time behaviors.

METHODS

Forty Mexican American mothers of children ages 3-4 participated in two interviews, during which both closed- and open-ended questions elicited perceptions of who made decisions for the four behaviors, as well as who was present, mealtime rules, and food choice values. Interviews were transcribed, coded for emergent themes, and compared across participants.

RESULTS

Participants generally perceived themselves to be primary decision makers for all four behaviors; however, food decisions often seemed to be made collaboratively with the child. Fathers were most likely to participate in evening television decisions. Other family members were rarely mentioned. Selecting foods that children liked was a strong food choice value, while cost was rarely mentioned. Participants appeared to have low perceived control over their child's behaviors relative to their perceived roles in decision making.

CONCLUSIONS

Mothers may be the primary audience for obesity prevention messages for preschool-aged, Mexican American children; however, health promotion programs may need to increase mothers' awareness of their control over children's behaviors. Understanding how children's behaviors are regulated is an important aspect of obesity prevention for low-income, Mexican American children.

"What do you think of when I say the word 'snack'?" Towards a cohesive definition among low-income caregivers of preschool-age children

Despite agreement that snacks contribute significant energy to children's diets, evidence of the effects of snacks on health, especially in children, is weak. Some of the lack of consistent evidence may be due to a non-standardized definition of snacks. Understanding how caregivers of preschool-aged children conceptualize and define child snacks could provide valuable insights on epidemiological findings, targets for anticipatory guidance, and prevention efforts. Participants were 59 ethnically-diverse (White, Hispanic, and African American), low-income urban caregivers of children age 3-5 years. Each caregiver completed a 60-90 min semi-structured in-depth interview to elicit their definitions of child snacks. Data were coded by two trained coders using theoretically-guided emergent coding techniques to derive key dimensions of caregivers' child snack definitions. Five interrelated dimensions of a child snack definition were identified: (1) types of food, (2) portion size, (3) time, (4) location, and (5) purpose. Based on these dimensions, an empirically-derived definition of caregivers' perceptions of child snacks is offered: A small portion of food that is given in-between meals, frequently with an intention of reducing or preventing hunger until the next mealtime. These findings suggest interrelated dimensions that capture the types of foods and eating episodes that are defined as snacks. Child nutrition studies and interventions that include a focus on child snacks should consider using an a priori multi-dimensional definition of child snacks.

Reasons Low-Income Parents Offer Snacks to Children: How Feeding Rationale Influences Snack Frequency and Adherence to Dietary Recommendations

Although American children snack more than ever before, the parental role in promoting snacking is not well understood. In 2012–2013 at baseline in an intervention study to prevent childhood obesity in low-income Massachusetts communities, n = 271 parents of children aged 2–12 years completed surveys regarding nutritive and non-nutritive reasons they offered children snacks, demographics, and dietary factors. An analysis of variance demonstrated that parents reported offering snacks (mean/week; standard deviation (SD)) for nutritive reasons like promoting growth (x̄ = 2.5; SD 2.2) or satisfying hunger (x̄ = 2.4; SD 2.1) almost twice as often as non-nutritive reasons like keeping a child quiet (x̄ = 0.7; SD 1.5) or celebrating events/holidays (x̄ = 0.8; SD 1.1). Parents reported giving young children (2–5 years) more snacks to reward behavior (1.9 vs. 1.1, p < 0.001), keep quiet (1.0 vs. 0.5, p < 0.001), and celebrate achievements (1.7 vs. 1.0, p < 0.001) than parents of older children (6–12 years). Multivariable logistic regression models were used to obtain adjusted odds ratios, which indicated reduced child adherence to dietary recommendations when parents offered snacks to reward behavior (Odds Ratio (OR) = 0.83; 95% Confidence Interval (CI) 0.70–0.99), celebrate events/holidays (OR = 0.72; 95% CI 0.52–0.99), or achievements (OR = 0.82; 95% CI 0.68–0.98). Parental intentions around child snacking are likely important targets for obesity prevention efforts.