AJCN. First published ahead of print September 29, 2010 as doi: 10.3945/ajcn.2010.30112.
Child adiposity and maternal feeding practices: a longitudinal analysis1–3 Laura Webber, Lucy Cooke, Claire Hill, and Jane Wardle ABSTRACT Background: Parental control has been hypothesized to cause weight gain in children by weakening self-regulatory processes. However, most studies that link control with weight have been cross-sectional, and therefore causation is uncertain. It remains possible that parental control is a response to child overweight rather than a cause. Objective: We investigated the direction of the association between parental feeding practices and children’s adiposity in a longitudinal study. Design: Three subscales of the Child Feeding Questionnaire (CFQ) that measure “pressure,” “restriction,” and “monitoring” were completed by 213 mothers of 7–9-y-old children as part of the Physical Exercise and Appetite in CHildren Study (PEACHES) and repeated by 113 mothers 3 y later. Baseline and follow-up anthropometric measurements [body mass index (BMI); fat mass index (FMI), and waist circumference (WC)] were made by researchers when the children were aged 7–9 y and 10–11 y. Results: Regression analyses showed no association between any of the CFQ scales at baseline and change in child adiposity. In contrast, higher child BMI at baseline predicted a smaller decrease in followup CFQ “monitoring” (P = 0.003) and a larger decrease in “pressure to eat” (P = 0.04) after baseline scores were controlled for. Similar results were observed for FMI and WC, although they did not reach significance for WC. There were no significant longitudinal associations between child adiposity and the CFQ “restriction” subscale. Conclusion: The results were more consistent with a “child-responsive” model whereby a mother’s choice of feeding practice is influenced by her child’s weight status rather than her feeding practices influencing the child’s weight gain. Am J Clin Nutr doi: 10.3945/ajcn. 2010.30112. INTRODUCTION
As a potentially modifiable risk factor for childhood obesity, parental feeding practices have attracted considerable interest. Parental control has been hypothesized to increase the risk of childhood weight gain by weakening the child’s ability to selfregulate energy intake (1). However, research findings are mixed, and the causal direction of the relation is poorly understood. Cross-sectional studies in North American children have reported a positive association between restriction of food intake and adiposity (2–4), but more heterogeneous and ethnically diverse samples have generated null or negative findings (5, 6). Pressuring a child to eat has, somewhat paradoxically, been associated with lower adiposity (5, 7–9). This could indicate that pressure is protective against weight gain or, more likely, that pressure is the mother’s response to her child’s low weight.
Longitudinal designs exploring associations between child adiposity and maternal feeding practices potentially offer some insight into causality. Birch et al (10) measured maternal restriction and child eating in the absence of hunger (EAH) in a sample of girls at ages 5, 7, and 9 y. Among girls who were overweight at age 5 y, those who had been more restricted showed higher EAH at age 9, but there was no association between restriction and EAH in normal-weight girls. A similar association has been observed in daughters of overweight compared with normal-weight mothers (11, 12). This could indicate that the effects of restriction and EAH are different in normal-weight and at-risk groups or, alternatively, that mothers are responding to their child’s overweight (13). However, these findings have not been replicated in larger, more diverse samples using continuous measures of adiposity to assess weight change across different age ranges. In these studies, parental control has either been associated with lower weight gain (13–15) or shows no association with child weight gain (13, 16–18). For example, in a sample of parents of 204 5–6-y-old and 188 10–12-y-old children, Campbell et al (13) explored longitudinal relations between restriction and change in child body mass index (BMI) SD scores (SDS) 3 y later, with adjustment for baseline BMI. They found that restriction predicted lower BMI SDS change in 5–6-y-olds, but there was no significant association in 10–12-y-olds. Similarly, pressure to eat and monitoring have been associated with lower weight gain (12, 15). In a sample of parent-child dyads, pressure at age 5 y was associated with lower weight gain 2 y later in children of overweight but not of normalweight mothers, whereas monitoring was associated with lower weight gain only in children of normal-weight mothers (12). The aim of the present study was to build on the current literature by examining bidirectional longitudinal relations between a range of parental feeding practices and child adiposity. We used a validated measure of parental feeding and multiple indexes of 1 From the Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, United Kingdom (LW, LC, and JW), and the Department of Psychology, School of Psychology and Clinical Language Sciences, University of Reading, Reading, United Kingdom (CH). 2 The Physical Exercise and Appetite in CHildren Study (PEACHES) is funded by a grant from Cancer Research UK (C1418/A6124). 3 Address correspondence to J Wardle, Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, Gower Street, London, WC1E 6BT, United Kingdom. E-mail:
[email protected]. Received July 9, 2010. Accepted for publication September 7, 2010. doi: 10.3945/ajcn.2010.30112.
Am J Clin Nutr doi: 10.3945/ajcn.2010.30112. Printed in USA. 2010 American Society for Nutrition
Copyright (C) 2010 by the American Society for Nutrition
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adiposity [BMI, waist circumference, fat mass index (FMI)]. The longitudinal design made it possible to examine whether parental feeding predicted change in weight or whether weight predicted change in parental feeding. SUBJECTS AND METHODS
Participants and design Parents of 7–9-y-old London schoolchildren (n = 405) who were taking part in the Physical Exercise and Activity in CHildren Study (PEACHES) were invited to complete the Child Feeding Questionnaire (CFQ), and 213 mothers returned a completed questionnaire. At follow-up, on average 2.9 y later, 113 of the mothers completed a second CFQ, and 302 children were still in the study schools. Children were weighed and measured at school at each time. All applicable institutional and governmental regulations concerning the ethical use of human volunteers were followed during this research. The study received ethical approval from the University College London Committee on the Ethics of Non-NHS Human Research (London, United Kingdom). Measures Trained researchers weighed and measured the children during a school day. Weight and fat mass were measured to the nearest kilogram by using the Tanita TBF-300MA Body Composition Analyzer (Tanita Corporation, Tokyo, Japan), and height was measured to the nearest millimeter by using a stadiometer (Leicester height measure; Seca, Birmingham, United Kingdom). BMI (in kg/m2) and FMI (in kg/m2) were calculated. Waist circumference (WC) was measured by using a Seca 200 measuring tape according to standardized instructions (19). To predict change in adiposity from parental feeding, we used raw BMI, WC, and FMI at follow-up with baseline values controlled for. To predict change in parental feeding from baseline adiposity, we used age- and sex-adjusted waist and BMI SDS (based on UK 1990 growth reference data, using Imsgrowth macro software; Microsoft Excel add-in, version 1.12; Institute of Child Health, London, United Kingdom) and FMI corrected for height (FMIc; fat mass/height5.7), in line with recommendations (20). The CFQ (3) was used to measure 3 feeding behaviors: “pressure to eat” (4 items; eg, “My child should always eat all of the food on his/her plate”) and “restriction’ (8 items; eg, ‘I intentionally keep some foods out of my child’s reach”), which are scaled on a 5-point Likert scale (disagree–agree), and “monitoring’ (3 items; eg, “How much do you keep track of the snack food that your child eats”), which is scaled from “never” to “always” on a 5-point scale. The child’s date of birth and sex were obtained from school records. Mothers reported their ethnicity and educational level. Twenty-five percent (n = 28) of mothers classified their ethnic origin as Middle Eastern (n = 2), black Caribbean (n = 3), black African (n = 6), black other (n = 1), Indian (n = 2), Bangladeshi (n = 5), Chinese (n = 1), or other (n = 7). Because there were too few ethnic subgroups to make meaningful comparisons, these categories were combined to form a nonwhite group at the point of analysis. Five mothers did not report their ethnicity, and so
child ethnicity was used as a proxy, of which one was classified as nonwhite. Educational level was dichotomized at the lowest grade of school qualifications [GCSE (General Certificate of Higher Education) or below] compared with higher-level school or college qualifications (A-levels or above). Statistical analysis Stability of parental feeding practices and child adiposity from baseline to follow-up was tested by using Pearson’s bivariate correlations. Linear regression, adjusted for potential confounders (child sex, child age, maternal education, ethnicity, time at followup), was used to examine associations between 1) parental feeding at baseline and change in child adiposity (follow-up adiposity controlling for baseline value) and 2) child adiposity at baseline and change in parental feeding (follow-up feeding practice with baseline value controlled for). Maternal BMI was available for only 100 cases. It was not significantly correlated with any follow-up feeding practice score, and controlling for this variable in the analyses did not change the results; therefore, to maximize the number of cases for analyses, results without this variable are presented here. There were no significant sex-by-subscale or sexby-BMI interactions. RESULTS
Sample characteristics Characteristics of mothers and children who returned the baseline and follow-up questionnaires are shown in Table 1. As expected from the selection of schools, ethnic diversity was higher than the UK national average (7%; 21) but lower than in London (57.7%) (22). Twenty-five percent (n = 28) of mothers were classified as nonwhite. Maternal educational level was higher than the national average, with 65% in the “A-level or above” group compared with 47% in the UK population (23). More mothers of white than nonwhite children returned a baseline questionnaire (60.6% compared with 39.4%; v2 = 19.17, P , 0.001). This was also true at follow-up (v2 = 29.95, P , 0.001) where 41% of white mothers and only 19% of nonwhite mothers returned the questionnaire. However, there were no significant differences in baseline or follow-up BMI-SDS, waist-SDS, or FMIc between children whose parents returned the CFQ at baseline or follow-up and those who did not (P . 0.20 for all analyses). Of those children whose mothers returned a questionnaire at baseline and follow-up, 11.5% were at or above the 95th percentile (classified as obese), and 23.7% were at or above the 85th percentile (overweight or obese). Obesity prevalence was comparable to the Health Survey for England figures for 2008, which showed that 14.4% of boys and 13.3% of girls in the 2–10-y-old age range were classified as obese (24). Interrater reliability of anthropometric measurements was calculated in a subsample of children (n = 30). Correlations of 1.0, 0.99, 0.99 and 0.89 were found for weight, fat mass, height, and waist circumference respectively. Stability of parental feeding practices and child adiposity Mean CFQ subscale scores at baseline and follow-up are presented in Table 2. Paired-samples t tests showed that there was a significant decrease in pressure (P , 0.011), monitoring
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CHILD ADIPOSITY AND CONTROLLING FEEDING PRACTICES TABLE 1 Characteristics of parents and children at baseline and follow-up and responders at both time points1
Mothers’ characteristics Age (y) Ethnicity (%)3 White Nonwhite Highest educational qualification (%) GCSE/vocational qualifications and below A-level/higher school certificate and above Maternal BMI at baseline (kg/m2)4 Children’s characteristics Sex (%) Female Male Age (y) BMI (kg/m2) BMI SD score Waist circumference (cm) Fat mass index Fat mass adjusted for sample height (kg)
Baseline (n = 213)
Follow-up (n = 136)
Participants with baseline and follow-up data (n = 113)
38.8 6 6.32
40.3 6 6.4
39.9 6 6.2
62.7 37.3
66.2 33.8
74.6 25.4
34.0 66.0 24.2 6 4.5
29.7 70.3 24.0 6 4.3
35.1 64.9 23.9 6 4.3
47.2 52.8 7.8 6 0.67 16.5 6 2.5 0.12 6 1.3 59.7 6 5.8 1.8 6 0.89 1.1 6 0.55
51.0 49.0 10.6 6 0.50 18.1 6 3.3 0.12 6 0.13 65.8 6 8.7 3.7 6 2.5 0.95 6 0.59
50.7 49.3 10.5 6 0.52 — — — — —
1 GCSE, General Certificate of Higher Education (completed at age 16 in the United Kingdom); A-level, Advanced Level (commonly completed from age 16–18 y in the United Kingdom). 2 Mean 6 SD (all such values). 3 Five mothers did not report their ethnicity, and so child ethnicity is used as a proxy for these mothers. 4 Only 184 mothers reported their height and weight at baseline, 106 at follow-up, and 100 at both follow-up and baseline.
(P = 0.04), and restriction (P , 0.001) from baseline to followup (see Table 2). Correlations for each feeding practice over time ranged from r = 0.31 to r = 0.69 (P , 0.001). Baseline and follow-up BMI (r = 0.93, P , 0.001), WC (r = 0.85, P , 0.001), and FMI (r = 0.91, P , 0.001) were significantly correlated. Baseline parental feeding practices as predictors of change in adiposity Regression analyses examining parental feeding practices at baseline as predictors of change in child BMI from baseline to follow-up, adjusted for maternal education and ethnicity and child age, sex, and baseline BMI, are presented in Table 3. The same analyses were carried out for WC and FMI. No significant associations were observed between any parental feeding practice at baseline and change in child BMI, FMI, or WC.
Baseline anthropometric measurements as predictors of change in adiposity Longitudinal associations between baseline BMI-SDS and each parental feeding practice adjusted for baseline parental feeding practice and for maternal education and ethnicity and child age and sex are presented in Table 4. Higher BMI-SDS at baseline was associated with a larger reduction in parental pressure to eat (B = 20.06, P = 0.04) and a smaller decrease in monitoring (B = 0.10, P = 0.003) at follow-up. Higher baseline BMI-SDS was also associated with a smaller reduction in restriction, but the effect did not reach significance (B = 0.09, P = 0.12). A similar pattern of results was observed for FMIc and waistSDS as indicators of adiposity. Higher waist-SDS at baseline was associated with a smaller decrease in monitoring (B = 0.23, P = 0.003). Associations with pressure to eat and restriction were in
TABLE 2 Child Feeding Questionnaire (CFQ) subscale scores at baseline and follow-up, tests of differences, and Pearson’s bivariate correlations between baseline and follow-up parental feeding scores of mothers who returned a questionnaire at baseline and follow-up Pearson’s correlations CFQ subscale Pressure Monitoring Restriction 1
n 113 112 111
Baseline score 1
2.91 6 0.89 4.26 6 0.84 3.29 6 0.83
Mean 6 SD (all such values).
Follow-up score
P values
r
P
2.62 6 0.86 4.07 6 0.81 2.90 6 0.89
,0.001 0.04 ,0.001
0.69 0.31 0.59
,0.001 ,0.001 ,0.001
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TABLE 3 Linear regression of adiposity measures according to baseline feeding practice1 BMI n Pressure Model 1 Model 2 Monitoring Model 1 Model 2 Restriction Model 1 Model 2
B
Waist circumference
Fat mass index
SE
P
n
B
SE
P
n
B
SE
P
112 112
0.197 0.135
0.134 0.141
0.14 0.34
112 112
0.126 0.024
0.497 0.531
0.801 0.963
110 110
0.044 0.097
0.105 0.107
0.676 0.367
111 111
20.079 20.06
0.138 0.140
0.57 0.66
112 112
0.155 0.320
0.514 0.526
0.764 0.544
111 111
20.015 20.029
0.109 0.108
0.890 0.789
110 110
0.173 0.128
0.153 0.075
0.26 0.09
109 109
0.152 0.162
0.133 0.137
0.254 0.239
109 109
0.093 0.101
0.120 0.115
0.438 0.352
1
Model 1 was unadjusted (controlled for feeding scale score at baseline only to address change in the Child Feeding Questionnaire). Model 2 was adjusted for child age and sex, maternal education and ethnicity, time of follow-up, and baseline parental feeding score.
the same direction as for BMI-SDS but did not reach significance. Higher baseline FMIc was associated with a larger reduction in parental pressure to eat (B = 20.29, P = 0.01) and a smaller decrease in monitoring (B = 0.13, P = 0.002), but it was not significantly associated with restriction (B = 0.15, P = 0.25). DISCUSSION
To our knowledge, this is the first study to examine bidirectional longitudinal relations between parental feeding practices and child adiposity using a validated measure of parental feeding. The results showed that higher child BMI at baseline predicted increased use of monitoring and lower use of pressure to eat over a 3-y period. In contrast, none of the maternal feeding practices at baseline were associated with change in adiposity at follow-up. These results do not support the idea that parental control over feeding increases child adiposity. Instead, child adiposity appeared to “induce” controlling practices—specifically, relatively more parental monitoring and lower pressure. This is consistent with a “child-responsive” model, which suggests that mothers modify their feeding practices in response to their child’s weight (25, 26). The exception was restriction, which showed no significant longitudinal associations in either direction, which is consistent with other cross-sectional and longitudinal findings in this age group (13).
Experimental studies have offered compelling evidence of an acute effect of restriction on eating behavior; for example, showing that children eat more of a food that has previously been restricted than an unrestricted food when both are freely available (27, 28). However, support for longer-term effects of restriction on children’s disinhibited eating (using the “eating in the absence of hunger” paradigm) was only seen in children who were already overweight or had overweight parents (10, 12), whereas in a recent study, Campbell et al (13) observed that restriction was associated with lower weight gain in 5–6-y-olds but had no association with weight in 10–12-y-olds. The present study found no evidence that restriction caused any increase in weight. Why experimental and survey studies should produce different results is not clear. Acute effects of restriction, especially when the restricted food is visible but forbidden (as was the case in the experimental studies reported above), may be different from longerterm results of more subtle forms of restriction. Unfortunately, almost nothing is known of the actual behavioral correlates of parental restriction, so it is hard to compare it with the experimental paradigm, but it seems unlikely that a typical parent would put cookies on the table and then not allow the child to eat them. More research is needed to understand the drivers of maternal restriction, the form it takes, and its effects on everyday eating behavior. There was no association between pressure to eat at baseline and change in adiposity, but lower adiposity at baseline was
TABLE 4 Linear regression of parental feeding practices according to baseline adiposity measures1 BMI SD score
Pressure Model 1 Model 2 Monitoring Model 1 Model 2 Restriction Model 1 Model 2 1
Waist SD score
FMIc
n
B
SE
P
n
B
SE
P
n
B
SE
P
113 113
20.10 20.06
0.05 0.03
0.024 0.037
113 113
20.09 20.09
0.06 0.07
0.142 0.171
111 111
20.27 20.29
0.11 0.11
0.014 0.014
112 112
0.16 0.10
0.05 0.03
0.003 0.003
113 113
0.21 0.23
0.07 0.08
0.006 0.003
111 112
0.38 0.13
0.13 0.04
0.005 0.002
111 111
0.08 0.09
0.05 0.06
0.124 0.122
112 112
0.11 0.13
0.07 0.08
0.116 0.089
109 109
0.15 0.15
0.13 0.13
0.254 0.254
FMIc, fat mass index corrected for height. Model 1 was unadjusted (controlled for feeding scale score at baseline only to address change in Child Feeding Questionnaire). Model 2 was adjusted for child age and sex, maternal education and ethnicity, time of follow-up, and baseline parental feeding score.
CHILD ADIPOSITY AND CONTROLLING FEEDING PRACTICES
associated with higher pressure to eat over the 3-y follow-up. This is consistent with the idea that maternal pressuring arises because the child is thinner. Further research might explore whether this is due to the child showing avoidant eating behaviors (eg, fussy eating or satiety responsiveness) or the mother being concerned about her child’s underweight. Monitoring was high at both baseline and follow-up, but again the direction of effect was that higher child adiposity predicted higher monitoring at follow-up. It is possible that monitoring is a form of covert restriction, replacing more overt restriction, particularly at an age when children acquire more control over their own intake. Covert rather than overt control was observed to be the norm among mothers of 4–11-y-olds who perceived their child to be overweight (29). This study did not find any interactions with sex, which suggests that mothers respond to boys and girls similarly. This is consistent both with qualitative studies of the mother-child feeding relation (25) and quantitative studies that have explored sex differences (12, 16). This study has strengths and limitations. The use of a validated measure of parental feeding meant that the results are more widely generalizable, and multiple measures of child adiposity allowed the association between child adiposity to be explored in greater detail than in previous longitudinal studies. Associations with WC were weaker than with BMI or FMI, but the pattern of results was similar, and the difficulty in measuring WC reliably may explain the differences. The longitudinal design is a strength of this study, but it was still a psychometric study, and therefore confounding cannot be entirely ruled out. Causality can only be fully established through intervention designs. There was incomplete participation and considerable loss to follow-up over the 3-y interval of this study: only 53% of mothers of participating children completed a baseline CFQ, and only 38% of mothers of children who were still in the study schools at follow-up completed a follow-up CFQ. Questionnaire respondents were more likely to be white and well educated, which limits the generalizability of the results, although there were no differences in age, sex, or adiposity between children whose mother did and did not complete a CFQ at either time point. The results of this study are consistent with a “child-responsive” model in which the mother’s feeding practices are influenced by her child’s weight status rather than causing subsequent weight gain. This builds on previous studies indicating that mothers modify their feeding practices flexibly in response to the child (25, 26, 30, 31). Rather than blaming parents for feeding their children “incorrectly,” acknowledgment of the interactive nature of the feeding relation could help make child-feeding advice more palatable to parents. We thank the PEACHES families who participated in the study. The authors’ responsibilities were as follows—JW: designed the study and is the principal investigator on the Cancer Research UK grant that supported the work; LW, LC, CH, and JW: drafted the manuscript; LW: analyzed the data supervised by JW; and CH: contributed to the design of the PEACHES study and data collection. All authors contributed to revising and approving the final manuscript. None of the authors had a conflict of interest.
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