Maternal child-feeding practices and dietary inadequacy of 4-year-old children

Associations between restrictive feeding practices and children's dietary intake: Systematic review and meta-analyses

BACKGROUND

Parents' attempt to limit or restrict children's intake of 'unhealthy' or discretionary foods has been widely considered as a counterproductive feeding practice associated with poorer dietary outcomes, but empirical evidence is varied.

AIM

The present systematic literature review aimed to investigate the association between parental restriction and children's dietary intake.

METHOD

Studies were identified through PsycInfo, MEDLINE, CINAHL, Web of Science, and Scopus databases on April 29th, 2022. Included were peer-reviewed, English-language articles published between 2001 and 2022, with an effect size between restriction and children's intake of foods that are 'healthy' (i.e., fruit, vegetables, other general healthy foods) or 'discretionary' (i.e., sweet or savoury energy-dense/nutrient poor foods, high-sugar foods, high-salt/fat foods, and high-energy/sugar-sweetened beverages), or overall diet quality. Risk of bias was assessed using a quality assessment checklist designed to evaluate survey studies.

RESULTS

Included studies (n = 44) were most often conducted in the USA, cross-sectional, and participants were mothers. Effect sizes (k = 59) from 21 studies were used in nine meta-analyses investigating various healthy and discretionary dietary intake variables. No meta-analytic effects were statistically significant. Qualitative synthesis of effect sizes ineligible for meta-analysis (k = 91) identified patterns of associations between restriction and increased intake of healthy foods, and decreased intake of discretionary foods.

CONCLUSIONS

Studies used a diverse selection of measures of restriction and dietary intake, limiting the ability of this review to make accurate cross-study comparisons. However, results suggest that instead of restriction being detrimental for children's dietary outcomes, it may be unrelated, or associated with more beneficial dietary outcomes. Research that utilises validated measures of restriction and dietary outcomes and a longitudinal design is needed to clarify this association.

Maternal depressive symptom trajectories and associations with child feeding

BACKGROUND

Responsive feeding, when caregivers attend to children's signals of hunger and satiation and respond in an emotionally supportive and developmentally appropriate way, is associated with the development of healthy eating behaviors, improved diet quality, and healthy weight status for children. However, gaps in the literature remain on how factors, such as maternal depressive symptoms and child temperament, influence feeding interactions.

METHODS

This longitudinal secondary data analysis explored the association between maternal depressive symptom trajectory and child temperament with maternal feeding practices in women with obesity who participated in a prenatal lifestyle intervention trial. Mothers self-reported depressive symptoms at baseline, 35 weeks gestation, and 6, 12, and 18 months postpartum. At 18- and 24-months postpartum, mothers completed self-reported assessments of feeding practices and child temperament and completed in-home video-recorded meals with their child, coded using the Responsiveness to Child Feeding Cues Scale. We used group-based trajectory modeling to identify distinct trajectories of depressive symptoms and generalized regressions to assess the association between symptom trajectory group and feeding. We also explored interactions between depressive symptoms and child temperament.

RESULTS

Three distinct trajectories of depressive symptoms were identified: No-Minimal and Decreasing, Mild-Moderate and Stable, and Moderate-Severe and Stable. At 18-months, when compared to the No-Minimal and Decreasing group, membership in the Moderate-Severe and Stable group was associated with higher observed responsiveness to child satiation cues ([Formula: see text] =2.3, 95%CI = 0.2, 4.4) and lower self-reported pressure to eat ([Formula: see text]=-0.4, 95%CI= -0.7, 0.0). When compared to the No-Minimal and Decreasing group, membership in the Mild-Moderate and Stable group was associated with higher self-reported restriction ([Formula: see text] =0.4, 95%CI = 0.0,0.7). The associations between trajectory group membership and feeding practices did not reach statistical significance at 24 months. Associations between depressive symptoms and restriction were moderated by child effortful control at 18 months [Formula: see text]) and surgency at 24 months [Formula: see text]).

CONCLUSION

A Moderate-Severe and Stable depressive symptom trajectory was associated with more responsive feeding practices and a Mild-Moderate and Stable trajectory was associated with higher restrictive feeding. Preliminary evidence suggests that depressive symptoms impact mothers' ability to match their use of restriction to the temperamental needs of their child.

The Association of Parental Feeding Practices, Parental Control Over children's Eating Behavior, and Sociodemographic Characteristics with Childhood Overweight and Obesity in Türkiye

Parents both respond to and influence their child's weight. This study aimed to investigate the association of parental feeding practices, parental control over children's eating behavior, and sociodemographic characteristics with childhood overweight and obesity. This descriptive cross-sectional study was conducted with 405 parents of children aged 7-11 years. Predictors that decreased the risk of childhood overweight/obesity were increase in child age (27.9%), high maternal education (61.7%), upper socioeconomic status (38.9%), increase in parental covert control (30.4%), and increase in parental pressure to eat (46.2%). Examining both parental attitudes and practices regarding child feeding and parental approaches to child food choices can benefit early intervention programs to prevent overweight and obesity in children.

Toddler dietary patterns from the INSIGHT randomized clinical trial comparing responsive parenting versus control: A latent class analysis

OBJECTIVE

The aim of this study was to examine the effect of a responsive parenting (RP) intervention on toddler diet and explore associations with mothers' infant feeding practices and child weight status.

METHODS

INSIGHT tested an RP intervention designed for the prevention of obesity against a safety control among primiparous mothers and their infants. Mothers reported on feeding practices, as well as toddler diet with a Food Frequency Questionnaire (n = 229). Trained research staff obtained child anthropometrics at age 2 years.

RESULTS

Latent class analysis identified three dietary patterns: high fruits and vegetables (HFV, 31%); meat, potatoes, and added sugars (MPAS, 24%); and high juice, low fruits and vegetables (JLFV, 45%). Toddler dietary pattern was not related to study group (RP, control) or child weight status at age 2 years. Mothers who reported more structure-based feeding had toddlers that were more likely to have the healthier, HFV dietary pattern than MPAS and JLFV. Findings for control-based feeding practices were mixed; maternal restriction was associated with the HFV dietary pattern, whereas the use of food as a reward was associated with MPAS and JLFV.

CONCLUSIONS

Mothers' structure-based feeding practices in infancy, as well as some control-based feeding practices, were associated with later healthier toddler dietary patterns.

Parental child-feeding practices at 4 years of age are associated with dietary patterns of 7-year-olds

BACKGROUND

Parental child-feeding practices have been associated with child body mass index (BMI) and specific food group consumption; however, their role in the development of dietary patterns is less understood. We aim to study the association between parental child-feeding practices at 4 years old and dietary patterns at 7 years that explain BMI z-scores at age 10.

METHODS

Participants were children from the Generation XXI birth cohort (n = 3272). Three patterns of feeding practices at 4 years were previously identified: 'Perceived monitoring', 'Restriction' and 'Pressure to eat'. At 7 years, two dietary patterns were derived: 'Energy-dense foods', higher consumption of energy-dense foods and drinks and processed meats and lower consumption of vegetable soup (significantly associated with BMI z-scores at 10 years) and 'Fish-based', higher in fishery intake and lower in energy-dense food intake. Associations were estimated by linear regression models, adjusted for potential confounders (mother's age, education and pre-pregnancy BMI).

RESULTS

Girls whose parents used more Restriction, Perceived monitoring and Pressure to eat at 4 years were less likely to follow the 'Energy-dense foods' dietary pattern at 7 years (β̂ = -0.082; 95% confidence intervals [CI]: -0.134; -0.029; β̂ = -0.093; 95% CI: -0.146; -0.039; β̂ = -0.079; 95% CI: -0.135; -0.04, respectively). In both sexes, children whose parents used more Restriction and Perceived monitoring at 4 years were more likely to follow the 'Fish-based' dietary pattern at 7 years (girls: β̂ = 0.143; 95% CI: 0.077; 0.210; β̂ = 0.079; 95% CI: 0.011; 0.148; boys: β̂ = 0.157; 95% CI: 0.090; 0.224; β̂ = 0.104; 95% CI: 0.041; 0.168).

CONCLUSIONS

Children whose parents used more Restriction and Perceived monitoring at preschool age were more likely to follow healthier dietary patterns at age 7.

Childhood social adversity and clustering of health risk behaviours during early adolescence in a population-based birth cohort

OBJECTIVES

This study aimed to prospectively explore the association between early lifetime exposure to psychosocial adversity and engagement in health risk behaviours (HRBs) during early adolescence.

STUDY DESIGN

This was a prospective study.

METHODS

This study used data from the baseline (2005-2006), third (2016-2017) and fourth waves (2018-2020) of the Generation XXI birth cohort. Socio-economic circumstances (SECs) at baseline, adverse childhood experiences (ACEs; e.g. abuse, neglect, household dysfunction) at age 10 years and HRBs (i.e. alcohol consumption, smoking, physical exercise level, sedentary behaviours, sleep duration and eating behaviours) at age 13 years were measured. Patterns of HRBs were obtained using latent class analysis. Latent class regression analysis was used to estimate the likelihood of being engaged in HRBs according to the extent of exposure to ACEs (i.e. 0 ACEs, 1-3 ACEs, 4-5 ACEs and ≥6 ACEs) and negative family SECs.

RESULTS

Adolescents whose mothers had a low level of education (adjusted odds ratio [aOR] = 2.72 [95% confidence interval {CI}, 2.33-3.18]), low occupational status (aOR = 3.21 [95% CI, 2.68-3.85]) and low income (aOR = 2.70 [95% CI, 2.23-3.28]) were more likely to be engaged in HRBs than their peers with higher SECs. Adolescents who experienced more ACEs were at a significantly increased risk of involvement in HRBs (aOR = 1.86 [95% CI, 1.33-2.63] for 4-5 ACEs vs aOR 2.41 [95% CI, 1.72-3.43] for ≥6 ACEs). No significant gender differences were observed.

CONCLUSIONS

Adolescents from families with low SECs were more likely than their more affluent counterparts to be engaged in HRBs. Furthermore, more ACEs contributed to widening health inequalities.

Parental influences on children's dairy products consumption: a narrative review

OBJECTIVE

To review research on the influence of parent-related factors on children's dairy products consumption.

DESIGN

A search of electronic databases and a narrative synthesis of the literature were conducted. English-language articles were included if they reported data relating to parental influences on children's consumption of dairy products and if statistical significance was reported.

SETTING

Studies were carried out in the USA (n 8) and in a range of countries across Europe (n 12) and Asia (n 5).

PARTICIPANTS

The subjects of this research were children aged between 2 and 12 years of age, from a range of geographical locations.

RESULTS

Twenty-five studies met the inclusion criteria. The studies examined children's dairy products consumption in relation to parental socio-economic status (education level and income) (n 12), home availability (n 2), home food environment (n 3), parental dairy products consumption (n 4), parent feeding practices (n 3), parents' beliefs and attitudes (n 3) and parental nutrition knowledge (n 3). Results on the association between socio-economic status and children's dairy products consumption varied; however, studies reporting a significant association generally observed a positive relationship. Fifteen studies reported children's total dairy products intake as an outcome measure, with the remaining studies reporting intake of milk or other dairy products as individual foods.

CONCLUSIONS

This review identified literature exploring a range of parental factors in relation to children's dairy products intake. However, there were limited numbers of studies published within each category of modifiable factors. Further research on the parent-related determinants of dairy products consumption in children is required in order to identify potential intervention targets in this age group.

Biochemical markers and anthropometric profile of children enrolled in public daycare centers

OBJECTIVE

The nutritional status resultant from dietary habits along with socioeconomic conditions and the school environment are directly related to the individual's health condition not only in their childhood but also throughout adulthood. The aim of this study was to evaluate the effects of socioeconomic factors on the anthropometric profile and to analyze a probable association between this profile and biochemical markers in children attending public daycare centers.

METHODS

It is a transversal study developed in a probability sample of clusters of children from 6 months to 5 years old. Anthropometric and socioeconomic data were gathered at the CMEIs, questionnaires on the nutritional status were applied and blood was collected at the Family Health Units (USFs).

RESULTS

Female children are three times more likely to be underweight; in families with five members, it is 1/3 more likely that children of higher-educated parents are overweight. Among the results of the biochemical tests, hypervitaminosis A was a relevant aspect, positively correlating with copper (p=0.005) and zinc (p=0.008).

CONCLUSION

Therefore, since the influence of the family is an important predictor of overweight and its future outcomes related to nutritional deficiencies and inadequate dietary intake, educational interventions are vital as a way to pave the path to prevention.

Association between parental feeding practices and children's dietary intake: a cross-sectional study in the Gardermoen Region, Norway

Background

Parental feeding practices may be important determinants for children's diets. In Norway, few studies have assessed this association and to our knowledge, no studies have included fish as an outcome.

Objective

The purpose of this study was to explore the association between multiple parental feeding practices and children's food intake.

Design

Parents (n = 111) of preschool children aged 1-5 years in the Gardermoen Region in Norway were recruited. The parents completed a web-based questionnaire regarding the use of 12 feeding practices measured by the Comprehensive Feeding Practices Questionnaire (CFPQ). Children's weekly food intake was measured using a food frequency questionnaire (FFQ). The association between parental feeding practices and food intake was assessed by logistic regression.

Results

The feeding practices involvement and environment increased the likelihood of children having a higher intake of fruit and berries (OR = 1.99, 95% CI = 1.15, 3.44 and OR = 2.10, 95% CI = 1.17, 3.78, respectively) when controlling for potential confounders. A positive association was found between the feeding practice environment and the children's intake of vegetables (OR = 2.94, CI = 1.55, 5.55), and between modeling and intake of vegetables (OR = 2.14, CI = 1.26, 3.63). Also, the feeding practice encourage balance and variety increased the likelihood of a higher consumption of vegetables (OR = 5.18, CI = 1.63, 16.5). Parents who more frequently encouraged the child to eat balanced and varied were more likely to have children with a higher consumption of fish (OR = 5.03, CI = 1.62, 15.7). If parents used more restriction for weight, the child was less likely to have a high SSB consumption (OR = 0.43, CI = 0.22, 0.83).

Conclusion

Findings suggest that children's intake of the favorite food item groups, fruit and berries, vegetables and fish, was associated with the use of positive feeding practices, such as involvement, environment, modeling and encouragement. For unfavorable food groups, only restriction for weight was negatively associated with SSB consumption. Findings should be interpreted carefully due to the relatively small sample size.

Sex-Heterogeneity on the Association between Dietary Patterns at 4 Years of Age with Adiposity and Cardiometabolic Risk Factors at 10 Years of Age

To evaluate the association of dietary patterns (DP) at 4 years with adiposity and cardiometabolic risk factors at 10 years, considering sex-heterogeneity. This prospective analysis included 3823 children enrolled in the population-based birth cohort, Generation XXI (Porto-Portugal, 2005-2006). Diet at 4 years was assessed by FFQ, with three DP being identified: high in energy-dense foods (EDF), intermediate in snacks (snacking), and healthier (reference). BMI at 10 years was considered as the Z-score according to the WHO. Other adiposity indicators-fat mass percentage (FM%), fat mass index (FMI), and waist-to-height ratio (WHtR)-were converted to z-scores using the sample's sex-specific means and standard deviations, as were the cardiometabolic risk factors (systolic and diastolic blood pressure, lipid profile, and insulin resistance). The associations of DP at 4 years with later adiposity or cardiometabolic factors were estimated by linear regression or by multinomial logistic regression models. In fully adjusted models, the EDF DP was significantly positively associated with the BMI (EDF vs. healthier: β = 0.139; 95% CI: 0.031, 0.246, P-interaction = 0.042) and obesity (OR = 2.68; 95% CI 1.55, 4.63, P-interaction = 0.005) only in girls, among whom, it increased insulin (β = 0.165; 95% CI: 0.020, 0.311) and HOMA-IR (β = 0.159; 95% CI: 0.013, 0.306) at 10 years. An EDF DP at 4 years is associated with later adiposity, insulin, and HOMA-IR in girls.

Associations of preschoolers' dietary patterns with eating behaviors and parental feeding practices at a 12-month follow-up of obesity treatment

Although dietary patterns are key to the management of childhood obesity, they are rarely assessed and thus poorly understood. This study examines preschoolers' dietary patterns and correlates 12 months after the start of obesity treatment (n = 99, mean age 5.2 years, 52% girls). A food frequency questionnaire (FFQ), the Child Eating Behavior Questionnaire (CEBQ), Child Feeding Questionnaire (CFQ) and Lifestyle Behavior Checklist (LBC) were answered by parents to assess children's food intake, eating behaviors, parental feeding practices, and obesity-related behaviors, respectively. Principal component analysis identified dietary patterns based on FFQ data. Through multiple linear regressions we examined correlations between a healthy (HD) and a less healthy (LHD) dietary pattern and mean scores of the CEBQ, CFQ, LBC scales as well as BMI z-scores. The reported intake of items in the LHD decreased after treatment while no differences were found for the HD. Children's eating behaviors, in particular food fussiness, showed consistent associations with diet (b = -0.39, 95% CI -0.63, -0.14 for HD and b = 0.41, 95% CI 0.15, 0.66 for LHD). Feeding practices and obesity-related behaviours were weakly associated with the dietary patterns (HD and Monitoring: b = 0.36, 95% CI 0.09, 0.62; LHD and Screen time b = 0.08, 95% CI 0.01, 0.15). Among the measured variables, eating behaviors had the largest impact on children's dietary patterns. The LHD was associated with a higher BMI z-score but no associations were found between changes in LHD intake and changes in BMI z-scores. Our findings suggest that decreasing food fussiness in children with obesity is key to positive dietary changes. Assessment of children's eating behaviors can help tailor dietary advice and provide support for families of children with obesity.

Parental feeding practices and ultra-processed food consumption in preschool children

ABSTRACT: Objective: To investigate the association between parental feeding practices and the consumption of ultra-processed foods in preschool children. Methods: Cross-sectional study with 140 parents (father and mother) and their children (2-6 year-old). Parental feeding practices were assessed using the Comprehensive Feeding Practices Questionnaire. Children’s body weight and height were measured, and body mass index z-score per age was calculated. Parental anthropometric measurements (body weight and height) were obtained by self-report, and body mass index was calculated. The consumption of ultra-processed foods was assessed through the Child Food Frequency Questionnaire and the daily intake score was calculated. Multivariable linear regression analyses were performed to investigate the association between parental feeding practices and the consumption of ultra-processed foods. Results: Children’s ultra-processed food consumption was negatively associated with the “Monitoring” parental feeding practices. On the other hand, “Emotion Regulation” and “Health restriction” parental feeding practices were positively associated with the ultra-processed food consumption score. Conclusion: Ultra-processed food consumption was associated to the “Monitoring”, “Emotion regulation” and “Health restriction” parental feeding practices in preschool children. These results support the importance of using successful parental feeding practices to promote healthy eating in preschoolers.

Dietary Patterns and Oral Health Behaviours Associated with Caries Development from 4 to 7 Years of Age

The association between modifiable risk factors and caries in children has been documented; however, most studies have been cross-sectional and have not considered the complexity of dietary factors and oral health habits. This study aimed to investigate the prospective association between dietary patterns and oral health behaviours at 4 years of age and the development of new decayed, missing, and filled teeth (d3-6mft/D3-6MFT) over a period of three years. Participants were children from the Generation XXI population-based birth cohort. At 4 years of age, diet patterns were assessed using a food frequency questionnaire, with three dietary patterns being identified. For the purpose of capturing the new development of caries between 4 and 7 years of age, two dental outcomes were defined in the mixed dentition: "dental caries development" and "severe dental caries development" in the mixed dentition. Bivariate analysis and multivariate logistic regression were used. From 4 to 7 years of age, 51.2% of the children had at least one new d3-6mft/D3-6MFT and 27.4% had more than two new d3-6mft/D3-6MFT. Children belonging to the "energy-dense foods" (OR = 2.19; 95% CI: 1.20-4.00) and "snacking" (OR = 2.19; 95% CI: 1.41-3.41) dietary patterns at 4 years old were associated with severe dental caries development three years later. Preventive strategies should be implemented in an attempt to reduce snacking and the consumption of energy-dense, micronutrient-poor foods to promote children's oral health.

Serum Levels of Vitamin D and Dental Caries in 7-Year-Old Children in Porto Metropolitan Area

Vitamin D deficiency has been associated with significant changes in dental structures. In children, it can induce enamel and dentin defects, which have been identified as risk factors for caries. This study aimed to assess the association between low serum 25-hydroxyvitamin D (25(OH) D) levels (<30 ng/mL) and the prevalence of caries in the permanent teeth and mixed dentition of 7-year-old children. A sample of 335 children from the population-based birth cohort Generation XXI (Porto, Portugal) was included. Data on children’s demographic and social conditions, health status, dental health behaviours, dental examination including erupted permanent first molars, and blood samples available for vitamin D analysis were collected. Dental outcomes included the presence of caries, including non-cavitated lesions (d_1–6mft/D_1–6MFT > 0), and advanced caries (d_3–6mft/D_3–6MF > 0). Serum 25(OH) D was measured using a competitive electrochemiluminescence immunoassay protein-binding assay. Bivariate analysis and multivariate logistic regression were used. Advanced caries in permanent teeth was significantly associated with children’s vitamin D levels <30 ng/mL, gastrointestinal disorders, higher daily intake of cariogenic food, and having had a dental appointment at ≤7 years old. Optimal childhood levels of vitamin D may be considered an additional preventive measure for dental caries in the permanent dentition.

Associations of family feeding and mealtime practices with children's overall diet quality: Results from a prospective population-based cohort

Food parenting practices are considered to have a key influence on children's dietary habits, with potential long term effects. In this study, we explored the associations of parental feeding practices and family mealtime practices in early childhood with children's overall diet quality at school age among 3626 parents and their children in a population-based cohort study in Rotterdam, the Netherlands. Parental feeding practices (monitoring, pressure to eat, and restriction) and family mealtime practices (meal skipping behaviors and family meal frequency) at age 4 years were assessed by parental questionnaires. Children's dietary intake was assessed at age 8 years using a food-frequency questionnaire, from which diet quality scores (range 0-10) were calculated, reflecting adherence to age-specific dietary guidelines. Using multivariable linear regression models, we found that monitoring was associated with higher diet quality of children (β = 0.12; 95%CI: 0.08, 0.16), whereas pressure to eat was associated with lower diet quality (β = -0.08; 95%CI: -0.12, -0.04)), both independent of child BMI. Restriction was associated with a higher child diet quality, but this association was explained by child BMI. As compared to children who did not skip meals, children who skipped meals had a lower diet quality (e.g. breakfast skipping: β = -0.32; 95%CI: -0.48, -0.17). Similarly, children who had less frequent family meals had a lower diet quality compared with those who had family meals every day (e.g. family dinner ≤2 days/week: β = -0.37; 95%CI: -0.60, -0.14). These associations were not driven by single food groups. In conclusion, parental monitoring and family mealtime routines in early childhood may provide a supportive food environment that promotes children's overall diet quality. Longitudinal studies with repeated measurements are needed to replicate our findings.

Controlling and less controlling feeding practices are differentially associated with child food intake and appetitive behaviors assessed in a school environment

BACKGROUND

Child food intake and appetitive behaviors show an inconsistent pattern of associations with parental feeding practices. Relationships likely vary depending on parent feeding style, and on the method by which child eating behaviors are measured.

OBJECTIVES

We tested relationships of controlling and less controlling forms of parental promotion and limitation of eating with food intake and appetitive behaviors assessed in preschoolers' normal school environments.

METHODS

As part of a 5-day protocol, preschoolers consumed standardized lunches, and caloric compensation, eating rate and eating in the absence of hunger were assessed. Feeding practices were measured using the Child Feeding Questionnaire (CFQ) and Parent Feeding Styles Questionnaire (PFSQ). CFQ-Pressure to eat and CFQ-Restriction were controlling forms of promotion/limitation of child intake, and CFQ-Monitoring and PFSQ-Prompting to eat were less controlling forms.

RESULTS

Children (3-5y, n = 70) of parents with higher CFQ-Pressure to eat scores showed lower total intake, consuming significantly fewer calories from bread, snacks and fruits and vegetables. Higher PFSQ-Prompting to eat was associated with lower fruit and vegetable intake only. CFQ-Restriction and CFQ-Monitoring scores were unassociated with food intake. Higher CFQ-Pressure to eat was associated with slower eating rate, while higher CFQ-Monitoring was associated with lower intake in absence of hunger.

CONCLUSIONS

Parental promotion and limitation of intake were associated with preschoolers' eating behaviors assessed in an ecologically valid setting, without parents present. Controlling and less controlling forms showed differential patterns of associations. Results were consistent with child-to-parent and parent-to-child effects, but research using longitudinal designs is needed to test bidirectional relationships.

Association between parental feeding practices and shared family meals. The Food4toddlers study

Background

Parental feeding practices and family meals are important determinants for infants' diet and health. Still, there is no previous research of the association between feeding practices and family meals in infants.

Objective

Explore potential associations between feeding practices and family meals among infants.

Design

We present cross-sectional results (baseline) from the Food4toddlers study. In total 298 parents of 1-year-olds, recruited from all over Norway, filled in a questionnaire regarding frequency of shared family meals (breakfast, lunch, dinner) and feeding practices using the validated instrument Comprehensive Feeding Practices Questionnaire. Logistic regression was used to explore the associations between having family meals every day and feeding practices (10 dimensions).

Results

The children included were about 11 months old, and 55% were boys. Parents were highly educated. Most children had family breakfast and dinner (60-65%), while fewer had family lunch every day (35%). We found that eating family breakfast and lunch every day was associated with use of the positive feeding practices: encourage balance and variety, environment and modelling (ORs ranging from 1.15 to 1.37), while eating family breakfast and family lunch less often was associated with the negative feeding practice pressure to eat (OR, 95% CI: 0.90 (0.83, 0.96) and 0.91 (0.84, 0.97), respectively). Eating family dinner every day was associated with more use of the positive feeding practice balance and variety (OR, 95% CI: 1.21 (1.06, 1.38), while having family dinner less often was associated with use of the negative feeding practices pressure to eat and restriction to health (OR, 95% CI: 0.89 (0.83, 0.96) and 0.94 (0.87, 1.01), respectively).

Discussion and conclusion

In this group of infants, having family meals every day was associated with positive feeding practices, while having family meals less often was associated with negative feeding practices. Shared family meals provide an important setting for healthy eating, development of feeding skills and dietary habits formation.

Examining Determinants and Co-associations Between Fruit and Vegetable and Sugar-Sweetened Beverage Monitoring Practices Among a Sample of Low-Income Hispanic Mothers

The etiology of obesity is complex, and a growing body of research suggests that changing two or more behaviors at the same time will likely have a stronger impact than changing one behavior in isolation. A lack of fruit and vegetable (FV) intake and high sugar-sweetened beverage (SSB) consumption are two behaviors related to childhood obesity in the Hispanic community. The purpose of this study was to evaluate theory-based determinants of monitoring practices of FV and SSB among Hispanic mothers with young children using the reasoned action approach. The study also examined the co-associations among the theoretical antecedents for both behaviors. Surveys were distributed in several community settings to urban Hispanic mothers (n = 238) of 2-5-year-old children. Surveys assessed FV and SSB monitoring practices, attitudes, perceived norms, perceived behavioral control (PBC), and intentions. Two models were evaluated using structural equation modeling: attitudes, perceived norms, and PBC of both behaviors were associated with intentions for both behaviors, and PBC and intentions were associated with monitoring practices of FV and SSB. Both models had adequate fit (FV (CFI = 0.973; GFI = 0.980; RMSEA = 0.121); SSB (CFI = 0.994; GFI = 0.993; RMSEA = 0.066)). PBC for both FV and SSB monitoring was significantly associated with SSB monitoring, whereas FV intentions was only significantly associated with FV monitoring. Results from this study gives evidence that among Hispanic mothers, FV and SSB monitoring behaviors are interrelated. To promote SSB monitoring, more implementation strategies (i.e., skills-based interventions) are warranted, whereas to promote FV monitoring, motivational strategies are warranted.

Behavior Modification of Diet and Parent Feeding Practices in a Community- Vs Primary Care-Centered Intervention for Childhood Obesity

OBJECTIVE

To evaluate behavior modification of diet and parent feeding practices in childhood obesity interventions.

DESIGN

Secondary analysis of randomized, controlled trial comparing Mind, Exercise, Nutrition … Do It! (MEND2-5 and MEND/Coordinated Approach to Child Health [CATCH6-12]) vs Next Steps at baseline and 3 and 12 months.

SETTING

Austin and Houston, TX.

PARTICIPANTS

A total of 549 Hispanic and black children randomized to programs by age groups (2-5, 6-8, and 9-12 years) INTERVENTIONS: Twelve-month MEND2-5 and MEND/CATCH6-12 vs Next Steps.

MAIN OUTCOME MEASURE(S)

Diet (MEND-friendly/unfriendly food groups and Healthy Eating Index-2010) and parent feeding practices (parental overt control, discipline, limit setting, monitoring, reinforcement, modeling, and covert control; and food neophobia).

ANALYSIS

Mixed-effects linear regression.

RESULTS

Changes in diet quality, consumption of MEND-unfriendly foods, and parent feeding practices did not differ between programs. In both interventions, MEND-unfriendly vegetables, grains, dairy and protein, added fat and desserts/sugar-sweetened beverages declined in 2-5- and 6-8-year-olds (P < .001). Healthy Eating Index-2010 improved in 2-5- (treatment; P = .002) and 6-8-year-olds (P = .001). Parental overt control decreased and limit setting, discipline, monitoring, reinforcement, and covert control increased with both interventions in 2-5- and 6-8-year-olds (P < 0.01-0.001).

CONCLUSIONS

Diet quality, consumption of MEND-unfriendly foods, and parent feeding practices were altered constructively in 2 pediatric obesity interventions, especially in 2-5- and 6-8-year-olds.

Home Food Environment Factors Associated With Hispanic Preschoolers' Intake of Fruits and Vegetables

The purpose of this study was to evaluate the relationship of home fruit and vegetable (F&V) availability and maternal feeding practices with Hispanic preschoolers' F&V intake (N = 238). "Availability' of total fruit" (P < .0001) and "modeling" (P < .020) increased the odds of consuming 1 or more cups of fruit. "Pressure" (P < .009) and the child being female (P < .028) increased the odds of consuming 1 or more cups of vegetables, while having a greater number of children in the home (P < .037) reduced the odds of consuming 1 or more cups of vegetables. To increase preschoolers' intake of F&V, interventions should target specific environmental factors in the home and maternal monitoring practices.

Evaluation of a short food frequency questionnaire for dietary intake assessment among children

BACKGROUND/OBJECTIVES

The objective of this study was to evaluate the performance of a short food frequency questionnaire (FFQ) to assess dietary intake at 4 and 7 years of age, against 3d food diaries (FD) and serum biomarkers, using two methods to convert the FFQ to daily intake in grams and nutrients (standard and z-score method).

SUBJECTS/METHODS

The present analysis comprises data from 2482 4-year-old children and 3511 7-year-old children, from the birth cohort Generation XXI (Porto, Portugal). To estimate daily consumption from the FFQ, the frequency response was multiplied by a standard mean portion (standard method) or adjusted with data from the FD (z-score method). The dietary intake obtained from the FFQ was compared with the FD and serum biomarkers, using Intra-Class Correlation Coefficients (ICC), de-attenuated Pearson's correlation coefficients and Bland Altman analysis.

RESULTS

In general, the mean daily food intake estimated by the z-score method had a higher agreement with the FD, than the standard method. The highest ICC was obtained for "vegetable soup" (ICC = 0.536), using the z-score method, compared to an ICC of 0.373 using the standard method. Significant correlation coefficients were observed for all nutrients; the average of correlation coefficients was 0.39 at 4 years and 0.42 at 7 years of age. For the majority of nutrients, the correlation between mean and mean difference was lower using the z-score method, in comparison with the standard method.

CONCLUSIONS

The results suggest that the FFQ is a reasonably good instrument to estimate dietary intake in children. Moreover, adjusting the FFQ portion size, by using a z-score method, seems to increase the accuracy of dietary data in children.

Appetite-Related Eating Behaviours: An Overview of Assessment Methods, Determinants and Effects on Children’s Weight

Identifying the underlying child-eating behaviours that contribute to weight differences across growth has been a constant challenge. This report reviews the various literature approaches for assessing appetite regulation. In doing so, it attempts to understand how appetite control develops and determines the eating habits in early childhood, and its effects on children’s weight status. The interaction between homeostatic and hedonic mechanisms largely explains the appetite regulation process. Homeostatic mechanisms are mediated by the biological need to maintain the body’s energy reserves, increasing the motivation to eat. On the contrary, the hedonic mechanisms are mediated by food reward, increasing the craving for high-palatable foods and triggering the release of dopamine and serotonin. There are many biological methods (plasma measurements of hormones, like leptin, ghrelin and insulin) and behavioural evaluation methods of appetite. The Children’s Eating Behaviour Questionnaire is most commonly used, due to its adequate psychometric properties tested in several population settings. The development of eating behaviours begins in utero, and several determinants may contribute to a decrease in the ability to self-regulate dietary intake. Examples include genetic predisposition, the first taste experiences and the family environment, a key determinant in this process. Several eating behaviours contribute most to childhood obesity. Among them, are the external eating (eating by external stimuli, such as the mere presence of the food or its smell), food restriction (which may potentiate the uninhibited increased intake of the restricted foods) and emotional eating (intake due to emotional variations, especially negative feelings). These eating behaviours have been linked to childhood obesity.

The association of problematic eating behaviours with food quality and body mass index at 7 years of age

BACKGROUND/OBJECTIVES

There is scarce evidence of how certain eating behaviours compromise the compliance with dietary guidelines and weight status in school-aged children. This study aims to evaluate the association of children's problematic eating behaviours with food quality and body mass index at 7 years of age.

SUBJECTS/METHODS

Participants were children aged 7 years old from a population-based cohort study from Porto, Portugal-Generation XXI. Children's quantity and speed of ingestion, food refusal at the table and food rewards requesting were evaluated by caregiver's perception. Food consumption was evaluated by a food frequency questionnaire and compared with age-appropriate guidelines. Children's weight status was assessed by objective measurements and parent's perceptions. Associations were estimated by logistic regressions (odds ratio (OR), 95% confidence intervals (95% CI)) adjusted for maternal age, education, smoking during pregnancy, birth type, child's sex, weight-for-gestational age and sports (n = 3801).

RESULTS

Children eating small amounts of food, refusing to eat at the table with the rest of the family during meals and asking for food rewards showed a higher consumption of energy-dense foods (OR = 1.51; 95% CI:1.23-1.86; OR = 1.58; 95% CI:1.16-2.16; OR = 1.56; 95% CI:1.14-2.12) and presented higher odds of consuming fruit and vegetables below recommendations (OR = 1.41; 95% CI:1.22-1.64; OR = 1.20; 95% CI:1.00-1.45; OR = 1.28; 95% CI:1.05-1.55). Children displaying these eating behaviours were less likely to be overweight/obese, hence their parents were less likely to show concern with their weight. Including food quality as covariate in the final models with obesity status did not change the associations.

CONCLUSIONS

Problematic eating behaviours were associated with poorer food quality (more energy-dense foods and low fruit and vegetables), but food quality does not seem to explain the association with obesity status. Parents were less likely to be concerned about their child's weight if the child ate slowly or poorly, and accordingly the odds of them being overweight or obese were lower.

Tracking diet variety in childhood and its association with eating behaviours related to appetite: The generation XXI birth cohort

Research on the influence of early eating habits on eating behaviours related to appetite using a prospective approach is scarce, especially in children. The aim of this study was to explore the relationship between changes in diet variety from 4 to 7 years of age and appetitive traits measured at 7 years of age. Participants are from the population-based birth cohort Generation XXI (2005-2006). The present analysis included 4537 children with complete data on a food frequency questionnaire (FFQ) at both ages, and on the Children's Eating Behaviour Questionnaire at 7y. A healthy diet variety index (HDVI) was calculated at both ages using data from the FFQ. To assess tracking of diet variety, tertiles of HDVI scores were calculated and then re-categorized as 'maintain: low', 'maintain: high', 'increase' and 'decrease'. Although the HDVI score decreased from 4 to 7y (p < .001), it showed a high stability, a positive predictive value, and a fair agreement. Increasing diet variety, compared to maintaining a low variety, was inversely associated with the 'Desire to Drink' (β = -0.090, 95%CI: 0.174; -0.006) and 'Satiety Responsiveness' (β = -0.119, 95%CI: 0.184; -0.054) subdimensions and positively with 'Enjoyment of Food' (β = 0.098, 95%CI: 0.023; 0.172) and 'Emotional Overeating' (β = 0.073, 95%CI: 0.006; 0.139). Those classified as either increase or maintain a high diet variety, in comparison with maintaining a low variety, had lower scores of 'Food Fussiness'. In conclusion, diet variety decreased from 4 to 7y with a fair tracking. Children with a higher diet variety were less fussy, had a lower desire to drink and a higher general interest in food.

Food parenting practices and their association with child nutrition risk status: comparing mothers and fathers

In Canada, little is known about how food parenting practices are associated with young children’s dietary intakes and no studies have examined food parenting practices of Canadian fathers. This study aimed to examine associations between food parenting practices and preschool-age children’s nutrition risk. We conducted a cross-sectional analysis of thirty-one 2-parent families; 31 mothers, 31 fathers, and 40 preschool-age children. Parents completed an adapted version of the Comprehensive Feeding Practices Questionnaire. We calculated children’s nutrition risk using their NutriSTEP score. To account for sibling association, we used generalized estimating equations, adjusting for child age, sex, household income, and parental body mass index. Both mothers’ and fathers’ involvement of children in meal preparation were associated with lower child nutrition risk (mother [Formula: see text] = –3.45, p = 0.02; father [Formula: see text] = –1.74, p = 0.01), as were their healthy home environment scores (mother [Formula: see text] = –8.36, p < 0.001; father [Formula: see text] = –2.69, p = 0.04). Mothers’ encouragement of balance and variety was associated with lower nutrition risk ([Formula: see text] = –8.88, p = 0.01), whereas mothers’ use of food as a reward was associated with higher nutrition risk ([Formula: see text] = 4.67, p < 0.001). Fathers’ modelling of healthy behaviours was associated with lower nutrition risk ([Formula: see text] = –2.21, p = 0.01), whereas fathers’ restriction for health ([Formula: see text] = 2.21, p = 0.03) and pressure-to-eat scores ([Formula: see text] = 3.26, p = <0.001) were associated with higher nutrition risk. No associations were found between child nutrition status and parental emotion regulation, control, monitoring, or restriction for weight. In conclusion, both mothers’ and fathers’ food parenting practices are associated with their children’s nutrition status. Fathers should be included in food parenting practices interventions.

Association between dietary patterns and adiposity from 4 to 7 years of age

OBJECTIVE

The present study aimed to evaluate the association of 4-year-old children's dietary patterns with adiposity at 7 years, according to child's sex, using a conceptual model.

DESIGN

Prospective cohort study. Diet was assessed using an FFQ. Age- and sex-specific BMI standard deviation scores (Z-scores) were defined according to the WHO. Fat mass percentage (FM%), fat mass index (FMI) and waist-to-height ratio (WHtR) were also considered, converted into Z-scores using sex-specific means and standard deviations of the current sample. Dietary patterns were identified by latent class analysis and their association with adiposity was estimated by linear regression models.

SETTING

Population-based birth cohort Generation XXI (Porto, Portugal, 2005-2006).

SUBJECTS

Children (n 3473) evaluated at both 4 and 7 years of age.

RESULTS

Three dietary patterns were identified: high in energy-dense foods (EDF); low in foods typically consumed at main meals and intermediate in snacks (Snacking); and higher in vegetables and fish and lower in EDF (Healthier, reference). The EDF dietary pattern at 4 years of age was positively associated with later BMI only in girls (β=0·075, 95 % CI 0·009, 0·140, P-interaction=0·046). The EDF dietary pattern was also associated with other adiposity indicators only in girls (FMI: β=0·071, 95 % CI 0·000, 0·142; WHtR: β=0·094, 95 % CI 0·023, 0·164). Snacking was not significantly associated with any marker of adiposity in either girls or boys.

CONCLUSIONS

Although dietary patterns and adiposity persisted across the two ages in both sexes, EDF at 4 years of age increased adiposity at 7 years of age only in girls.

A Parental Health Education Model of Children's Food Consumption: Influence on Children's Attitudes, Intention, and Consumption of Healthy and Unhealthy Foods

This study proposes that parental mediation of television advertising and parental guidance of food consumption differentially influence children's attitude, intention, and behavior toward the consumption of healthy and unhealthy foods. Structural equation modeling based on a survey of 1,119 children aged 9-12 supported our model, revealing that parental education strategies influence children's food consumption in a complex manner that is highly context-dependent. Parental guidance of food consumption enhanced children's healthy food attitude and intention to consume, while reducing the intention to consume unhealthy food. However, parental mediation of television advertising influenced unhealthy food attitude to a greater extent than healthy food attitude. Implications for health promotion and education, as well as parents and policy makers are discussed.

The influence of parental practices on child promotive and preventive food consumption behaviors: a systematic review and meta-analysis

Background

The family is an important social context where children learn and adopt eating behaviors. Specifically, parents play the role of health promoters, role models, and educators in the lives of children, influencing their food cognitions and choices. This study attempts to systematically review empirical studies examining the influence of parents on child food consumption behavior in two contexts: one promotive in nature (e.g., healthy food), and the other preventive in nature (e.g., unhealthy food).

Methods

From a total of 6,448 titles extracted from Web of Science, ERIC, PsycINFO and PubMED, seventy eight studies met the inclusion criteria for a systematic review, while thirty seven articles contained requisite statistical information for meta-analysis. The parental variables extracted include active guidance/education, restrictive guidance/rule-making, availability, accessibility, modeling, pressure to eat, rewarding food consumption, rewarding with verbal praise, and using food as reward. The food consumption behaviors examined include fruits and vegetables consumption, sugar-sweetened beverages, and snack consumption.

Results

Results indicate that availability (Healthy: r = .24, p < .001; Unhealthy: r = .34, p < .001) and parental modeling effects (Healthy: r = .32, p < .001; Unhealthy: r = .35, p < .001) show the strongest associations with both healthy and unhealthy food consumption. In addition, the efficacy of some parenting practices might be dependent on the food consumption context and the age of the child. For healthy foods, active guidance/education might be more effective (r = .15, p < .001). For unhealthy foods, restrictive guidance/rule-making might be more effective (r = −.11, p < .01). For children 7 and older, restrictive guidance/rule-making could be more effective in preventing unhealthy eating (r = − .20, p < .05). For children 6 and younger, rewarding with verbal praise can be more effective in promoting healthy eating (r = .26, p < .001) and in preventing unhealthy eating (r = − .08, p < .01).

Conclusions

This study illustrates that a number of parental behaviors are strong correlates of child food consumption behavior. More importantly, this study highlights 3 main areas in parental influence of child food consumption that are understudied: (1) active guidance/education, (2) psychosocial mediators, and (3) moderating influence of general parenting styles.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0501-3) contains supplementary material, which is available to authorized users.

Association of maternal characteristics and behaviours with 4-year-old children's dietary patterns

This study examined the association of family and maternal characteristics with preschool children's dietary patterns. Trained interviewers evaluated subsample 3422 mothers and children enrolled in the population-based birth cohort Generation XXI (Porto, Portugal, 2005-2006). Maternal characteristics and behaviours (exercise, smoking habits, diet and child-feeding practices) and family characteristics were evaluated. Maternal diet was classified by a dietary score, and children's dietary patterns were identified by latent class analysis. Odds ratios (OR) and confidence intervals (95% CI) were estimated by multinomial regression models. The analysis was based on a framework with four conceptual levels: maternal socio-economic position (SEP) at 12 years, maternal socio-economic and demographic characteristics at child's delivery, family characteristics and maternal behaviours at child's 4 years. Three dietary patterns were identified in children: high in energy-dense foods (EDF); low in foods typically consumed at main meals and intermediate in snacks (Snacking); higher in healthy foods; and lower in unhealthy ones (Healthier, reference). Lower maternal SEP had an overall effect on children's diet (low vs. high SEP; EDF, OR = 1.76, 95% CI: 1.42-2.18; Snacking, OR = 1.73, 95% CI: 1.27-2.35), while maternal education was directly associated with it (≤9 vs. >12 schooling years, EDF, OR = 2.19, 95% CI: 1.70-2.81; Snacking, OR = 2.22, 95% CI: 1.82-3.55). Children whose mothers had worse dietary score were significantly more likely to follow unhealthier patterns (first vs. fourth quartile; EDF, OR = 9.94, 95% CI: 7.35-13.44, P-trend < 0.001; Snacking, OR = 4.21, 95% CI: 2.94-6.05, P-trend < 0.001). Maternal diet was the key factor associated with children's diet, above and beyond socio-economic and demographic characteristics, accounting for one-third of the determination coefficient of the fully adjusted model. At preschool age, interventions should give a particular focus on maternal diet and low SEP groups.

The Diet of Preschool Children in the Mediterranean Countries of the European Union: A Systematic Review

This systematic review discusses data on the dietary intake of preschool children living in the Mediterranean countries of the European Union, including the comparison with a Mediterranean-like diet and the association with nutritional status. Specifically, data from the multinational European Identification and Prevention on Dietary and life style induced health effects in children and infants (IDEFICS) study and national studies, such as the Estudo do Padrão Alimentar e de Crescimento Infantil (EPACI) study and Geração XXI cohort in Portugal, ALimentando la SAlud del MAñana (ALSALMA) study in Spain, Étude des Déterminants pré-et postnatals précoces du développement et de la santé de l’ENfant (EDEN) cohort in France, Nutrintake 636 study in Italy, and Growth, Exercise and Nutrition Epidemiological Study in preSchoolers (GENESIS) cohort in Greece, were analyzed. In the majority of countries, young children consumed fruit and vegetables quite frequently, but also consumed sugared beverages and snacks. High energy and high protein intakes mainly from dairy products were found in the majority of countries. The majority of children also consumed excessive sodium intake. Early high prevalence of overweight and obesity was found, and both early consumption of energy-dense foods and overweight seemed to track across toddler and preschool ages. Most children living in the analyzed countries showed low adherence to a Mediterranean-like diet, which in turn was associated with being overweight/obese. Unhealthier diets were associated with lower maternal educational level and parental unemployment. Programs promoting adherence of young children to the traditional Mediterranean diet should be part of a multi-intervention strategy for the prevention and treatment of pediatric overweight and obesity.

Nutritional composition of school meals serving children from 7 to 36 months of age in municipal day-care centres in the metropolitan area of Curitiba, Paraná, Brazil

The Brazilian National School Feeding Program (PNAE) seeks to meet student's nutritional needs during the period they remain in school. This study aimed to determine the nutritional composition of meals provided in municipal day-care centres serving children of 7-11 months (group A) and 12-36 months (group B) of age and to compare observed values with the PNAE's and dietary reference intakes' (DRI) recommendations. This cross-sectional study was conducted in 4 day-care centres in the metropolitan area of Curitiba, Paraná, Brazil, between June and November 2013. Food samples of six daily meals were collected during 20 non-consecutive days, totalling 120 samples. For each meal, average served and consumed portions were submitted for laboratory analysis of moisture, ash, proteins, lipids, carbohydrates, dietary fibre, Na, Ca and Fe and compared with the PNAE's and DRI's values. No statistically significant difference was found between age groups (P=0·793) regarding portion sizes and nutritional composition. The same menu was offered to both groups in 95 % of the meals (n 114), although the groups' nutritional needs were different. For group A, served meals met PNAE's recommendations for energy, carbohydrates, proteins, Na and Ca content, and consumed portions provided 70 % of the nutritional needs for carbohydrates, proteins and Ca. For group B, served portions complied with the PNAE's values for proteins, Na and Ca. Proteins and Na reached 70 % of the nutritional needs when consumed food was evaluated. School feeding in day-care centres partially meet PNAE's guidelines and children's nutritional requirements, contradicting the primary objective established by the national programme.

Bidirectional association between parental child-feeding practices and body mass index at 4 and 7 y of age

BACKGROUND

Evidence of the association between parental child-feeding practices and the child's body mass index (BMI) is controversial, and bidirectional effects have been poorly studied.

OBJECTIVE

We aimed to examine bidirectional associations between parental child-feeding practices and BMI at 4 and 7 y of age.

DESIGN

This study included 3708 singleton children from the Generation XXI birth cohort with data on parental child-feeding practices and BMI at 4 and 7 y old. Feeding practices were assessed through a self-administered questionnaire by combining the Child Feeding Questionnaire and the Overt/Covert Control scale and then adapting it to Portuguese preschool children. Weight and height were measured according to standardized procedures, and age- and sex-specific BMI z scores were computed based on the WHO Growth References. Linear regression models were used to estimate the bidirectional associations between each practice and BMI z score. Crosslagged analyses were performed to compare the directions of those associations (the mean score of each practice and BMI z score at both ages were standardized to enable effect size comparisons).

RESULTS

After adjustments, pressure to eat and overt control at 4 y of age were associated with a lower BMI z score 3 y later (β: -0.05; 95% CI: -0.08, -0.03 and β: -0.05; 95% CI: -0.09, -0.01, respectively). Regarding the opposite direction of association, a higher BMI z score at 4 y of age was significantly associated with higher levels of restriction and covert control at 7 y of age (β: 0.06; 95% CI: 0.03, 0.08 and β: 0.06; 95% CI: 0.04, 0.08, respectively) and with lower levels of pressure to eat (β: -0.17; 95% CI: -0.20, -0.15). The only bidirectional practice, pressure to eat, was more strongly influenced by the BMI z score than the reverse (βstandardized: -0.17 compared with βstandardized: -0.04; likelihood ratio test: P < 0.001).

CONCLUSIONS

We found that parents both respond to and influence the child's weight; thus, this child-parent interaction should be considered in future research.