Effect of Parental Feeding Practices (i.e., Responsive Feeding) on Children’s Eating Behavior

Abstract

Child eating behaviors contribute to individual variability in weight status and are influenced by a combination of genetic and environmental factors. Feeding practices have  been identified as a potentially modifiable factor that can influence children’s dietary intake and eating behaviors. However, the majority of research in the field has been cross- sectional whereas more recently a bidirectional relationship between parent feeding and child eating has been proposed. The purpose of this review is to provide a summary of patterns of findings related to feeding practices that may support or undermine children’s eating behaviors. The focus is specifically on eating behaviors related to appetite regulation and obesity risk. Evidence for the potential effect of nonresponsive feeding practices as well as structure-related practices is presented. In sum, there is evidence that parents’ feeding practices do impact on children’s eating behaviors, but children’s eating behaviors also influence the feeding practices parents use. Suggestions for future research in terms of design, measures, and research questions are proposed. Future work in this area will serve to build the evidence base for targeted intervention strategies that can guide parents to feed their children in a way that optimizes child health.
 

Introduction

Child eating behaviors, food preferences, and dietary intake patterns develop early in life and become the foundation for eating behaviors that track into later life [1]. The development of healthy eating behaviors assists children to achieve and maintain a healthy weight status through the effective self-regulation of energy intake whereby children develop the ability to recognize and respond appropriately to internal cues of satiety and hunger [1]. Eating behaviors characterized by high responsiveness to external food cues, eating in response to negative emotions, or poor recognition of satiety cues have consistently shown to correlate with higher BMI and increased obesity risk in children [2, 3]. World- wide it is estimated that 42 million children under the age of 5 years are over- weight. These children are at increased risk of a wide range of health problems, including chronic diseases such as diabetes, cardiovascular disease, cancer, and psychosocial problems [4]. Whilst genetic factors play a role in obesity risk, environmental factors related to nutrition and sedentary/physical activity also influence susceptibility to the development of obesity [5]. Thus, there has been a strong research focus on identifying modifiable factors that may influence the development of children’s eating behaviors to reduce obesity risk.
Parents play a pivotal role in children’s early food environment and eating experiences through food selection, portion size, timing, frequency, structure, and social context of the eating environment [6]. Parental feeding practices have been of interest to researchers and clinicians alike because they constitute modifiable risk factors for problematic child diet-related outcomes and appear to be amenable to intervention [7]. However, evidence from child obesity interventions targeting maternal feeding practices has indicated that whilst significant changes in feeding practices due to intervention can be maintained over a number of years, differences in child eating behaviors and BMI are limited [7, 8]. Furthermore, evidence from twin studies suggests that in childhood some eating behaviors have a significant genetic component [9]; thus, how readily these can be influenced by environmental factors may be less than anticipated. The pur- pose of this review is to examine current evidence for a causal relationship be- tween feeding practices and child eating behaviors related to obesity risk. The aim will be to further understand the etiology of children’s eating behaviors by considering the relationship with responsive and nonresponsive feeding practices.

Child Eating Behaviors

Eating behaviors have been found to influence energy intake and weight status through the individual child’s choice of the amount and type of food they consume [3]. Child eating behaviors have been measured using both observational and questionnaire-based methods. An observational method that has been used is the eating in the absence of hunger (EAH) paradigm. Eating in the absence of hunger is defined as a heightened response to food cues (even after a meal has just been eaten). It is characterized by the inability of the child to self-regulate their energy intake, and hence the child’s propensity to eat will be reinstated in the presence of palatable foods [10, 11]. Cross-sectional and prospective re- search has indicated that overweight children eat significantly more than children of normal weight in the EAH paradigm [12].
One of the most commonly used questionnaire methods to measure child eating behavior is the Children’s Eating Behavior Questionnaire (CEBQ) [2]. The CEBQ was developed to aid the investigation of how individual differences in eating style contribute to the development of underweight and over- weight in children. The CEBQ assesses 2 main dimensions of children’s eating behaviors: food approach and food avoidance behavior. Food approach behaviors include: food responsiveness (child is always asking for food or eats too much if allowed), emotional overeating (child consumes more food when annoyed, anxious, worried, or bored), enjoyment of food (child loves food or enjoyment of eating), and desire to drink (child always wants a drink or constantly asks for one). Food avoidance behaviors include: satiety responsiveness (child gets full easily or cannot eat a meal if a snack has been consumed prior), slowness in eating (child takes longer than 30 min to eat a meal), emotional undereating (child consumes less food when tired, angry, upset, or happy), and food fussiness (child is highly selective about the range of foods they will accept) [2]. The CEBQ has been shown to have good reliability and validity [2, 9, 13].
Research using the CEBQ has shown that food approach traits correlate positively with BMI in children, and food avoidance (except food fussiness) traits negatively correlate with BMI [2]. A longitudinal study of children from the Twins Early Development Study found that the characteristic ways in which children interact with their food environment may be moderately stable over time [13]. However, it was also noted that eating behavior traits may vary with age: food avoidance behaviors decrease over time, whereas food responsiveness behaviors increase over time [13]. These variations may be reflective of changes in children’s food environments or as a result of children eating in environments that are less controlled by family members as they get older.
Some eating behaviors measured via the CEBQ have been shown to have a strong genetic underpinning. Low satiety responsiveness and high food responsiveness, for instance, appear to have a substantive genetic basis in childhood that contributes to a higher rate of weight gain [14, 15]. In contrast, both emotional overeating and emotional undereating were found to have minimal genetic basis and are likely to be learned responses to negative affect [16]. Thus, variations in children’s eating behaviors are, in part or predominantly, influenced by environmental factors. Culture, social and economic status, accessibility to food resources, family practices, and environmental factors, all contribute to obesity-related behaviors [5]. One specific environmental factor may be the feeding practices parents use with their children [6].

Feeding Practices

Feeding practices are defined as content-specific goal-directed strategies or behaviors used by parents in an attempt to control or modify their child’s diet and eating behaviors [6]. Historically, in times of famine, foods were often low in nutrients, energy, and palatability. As such, the use of feeding practices that aimed to increase children’s food intake was likely to be adaptive for survival. However, in the current obesogenic environment of many developed and developing countries where there is an abundance of energy-dense, palatable, inexpensive foods that are conveniently available for consumption [1], the use of “coercive” or “controlling” feeding practices that aim to encourage consumption of food are potentially problematic and may contribute to the development of child obesity. One of the most widely used self-report instruments to measure maternal feeding practices is the Child Feeding Questionnaire (CFQ) [17]. The CFQ assesses parental beliefs, attitudes, and controlling practices (monitoring, restriction, and pressure to eat) with a focus on the risk of obesity.
More recently, many of the feeding practices referred to as controlling have been similarly described in the literature as nonresponsive and include pressure to eat (pressuring a child to eat), instrumental feeding (using food to reward children’s behavior), and emotional feeding (using food to soothe or calm children). Restriction is another feeding practice that was originally conceptualized as controlling [17] and is often grouped with these nonresponsive practices; however, rather than encouraging food intake, this practice involves the parent attempting to limit the child’s access to “unhealthy” foods.
DiSantis et al. [18] proposed that nonresponsive feeding practices may interfere with a child’s ability to self-regulate their energy intake, i.e., to adjust their eating in response to internal feelings of fullness or satiety. It is proposed that when parents fail to recognize or respond appropriately to children’s internal cues of hunger or fullness, the child’s ability to self-regulate may be disrupted [18]. Thus, the way in which feeding is responsive to the child is an important element of the caregiver-child interaction. Similarly, Black and Aboud [19, p. 492] proposed that responsive feeding can be conceptualized as a component of responsive parenting which is a process that reflects “reciprocity between the child and caregiver.” Within the context of child weight, responsive feeding has been defined as developmentally appropriate (not intrusive or controlling), prompt, and contingent responses to infant and child hunger and satiety. Also integral to responsive feeding are: establishing routines around mealtimes (eat- ing at the same place and times), modeling appropriate behavior (making healthy choices), and ensuring children are seated [19].

Evidence for Associations between Feeding Practices and Child Eating Behaviors

 Pressure to Eat
Pressure to eat is a nonresponsive feeding practice whereby the child is coerced to eat particular foods or to eat more. However, associations between pressure to eat and child outcomes including eating behaviors and BMI are mixed. In line with predicted deleterious effects of this practice on child eating behavior, a cross-sectional Australian study (n = 560) of 5- to 6-year-old children found pressure to eat was associated with higher estimated daily energy intake and higher consumption of both sweet and savory snack foods [20]. However, cross-sectional and longitudinal studies have reported higher pressure to eat to be associated with lower child BMI [21, 22] and positively associated with food avoidance eating behaviors, such as food fussiness, slowness in eating, and child satiety responsiveness, and negatively associated with food enjoyment [23]. Together, these findings suggest that pressure to eat may be associated with higher consumption of discretionary/snack foods but may be a practice that is used in response to parental concerns about the child being/becoming under-weight or displaying food-avoidant eating behaviors such as food fussiness.

Instrumental and Emotional Feeding Practices
Feeding practices such as instrumental feeding and emotional feeding that pro- mote the use of food as a reward or as a source of comfort have been suggested to influence child BMI via their potential to teach children to eat for reasons other than hunger. Findings from Rogers et al. [22] study of mother-child dyads (n = 222) reported maternal instrumental feeding to be associated cross-section- ally with emotional eating and a tendency to overeat in children (mean age = ± 0.37 years). Instrumental feeding was also found to be prospectively associated with higher child BMI. Rogers et al. [22] suggested when parents use food as a reward to decrease negative affect in children, dysfunctional eating patterns and weight gain may occur. Another cross-sectional study of children aged 6–7 years (n = 135) [24] also found instrumental and emotional feeding to be positively associated with the snacking behavior of children. In a longitudinal study (n = 623) [25], it was shown that use of food as a reward (instrumental feeding) in children 6 years of age predicted higher food responsiveness at age 8 years. While these feeding practices may provide short-term solutions to man- age children’s behavior or mood, evidence indicates poor outcomes for children’s eating behaviors in the longer term.

Restriction
Restrictive feeding practices have been thought to result in greater preference for restricted food and poor self-regulation of eating [26]. Restrictive feeding practices have been positively associated with increased intake of restricted foods when these are made available and heightened food responsiveness [23, 27]. A longitudinal study of maternal feeding practices found that girls of over- weight mothers who reported restricting their daughter’s food intake at 5 years of age showed greater EAH across the age of 5–9 years [26]. However, this finding did not apply to girls with mothers who were not overweight; rather, restriction had no effect on EAH [26]. Similarly, another longitudinal study with mother-child dyads (n = 323) found restriction of child’s food for the purpose of weight control to be prospectively associated with food approach behaviors and overeating [22]. Nevertheless, these studies do not address the issue of whether mothers who are concerned about their child’s risk of overweight/obesity or who perceive their child as being overweight/obese are prompted to more rigorously attempt to restrict their child’s access to unhealthy food. Further research is needed to better understand the effects of restrictive feeding practices and what factors may moderate these effects (such as child gender and obesity risk). Furthermore, how restriction may be used in conjunction with other feeding practices needs to be considered given that the foods most likely to be restricted may also be used in instrumental or emotional feeding as re- wards or comfort foods, respectively.

Structure of the Mealtime Environment
Although the provision of structure in terms of the timing and setting of meals is central to Black and Aboud’s [19] concept of responsive feeding, limited research has considered the role of the structure of the mealtime environment until recently. The emerging evidence supports structure as integral to positive child feeding. In a recent report by Powell et al. [28], the structure of a typical mealtime was studied within the family setting of 75 mothers of children aged 2–4 years. The children of mothers who ate the same foods as their children  (at the same time as their children) were found to be easier to feed and refused less food than children of mothers who did not. Children displayed less fussy eating  behaviors  when  mealtimes  were  free  of  distractions  (television and toys), and when children were allowed to have input into portion size and food choice.
The Feeding Practices and Structure Questionnaire [29] was developed specifically to expand the measurement of child feeding to include structure-related practices. Initial validation of the questionnaire included examination of cross-sectional associations with child eating behaviors. Three practices related to the timing of meals, setting of meals, and eating meals as a family were associated with less food fussiness, more enjoyment of food, and less emotional (over- and under)eating in a sample of 2-year-old children of first-time mothers. These initial studies into the influence of structure on the mealtime environment suggest that it may contribute to promoting healthier eating behaviors of children and is of interest to consider in future research.

The Reciprocal Relationship between Child Eating Behavior and Maternal Feeding Practices

To date, the vast majority of research investigating the relationship between maternal and child eating behaviors is cross-sectional in nature, and, therefore, inferences about causality cannot be made. Furthermore, until recently, longitudinal studies have assumed feeding practices as the independent variable and child eating as the dependent variable. However, some recent studies in the field have moved toward considering the parent-child feeding relationship as reciprocal and have tested bidirectional parent → child and child → parent effects. A study by Steinsbekk et al. [25] tested for bidirectional relationships between nonresponsive feeding practices (instrumental feeding, encouragement to eat, and control over eating) and a range of child eating behaviors but only identified a parent → child effect (instrumental feeding leading to increased food responsiveness). None of the child → parent effects were significant. However, other similar studies have produced evidence of bidirectional effects.
The study by Rogers et al. [22] (n = 323) of mothers and their 2-year-old children assessed parental feeding practices and child eating behaviors at baseline and again 1 year later. Controlling for baseline feeding practices, a child’s tendency to overeat at baseline predicted greater maternal instrumental feeding 1 year later, and emotional eating of a child at baseline predicted greater maternal emotional feeding 1 year later. Another longitudinal study [30] that used con- current assessments of child eating behavior (satiety responsiveness and food responsiveness) and parental nonresponsive and structure-related feeding practices tested for bidirectional effects across child ages of 2, 3.7, and 5 years. Covert restriction and use of food as a reward for behavior (instrumental feeding) at 2 years predicted greater food responsiveness at 3.7 years. However other nonresponsive feeding practices (persuasive feeding and reward for eating – conceptually similar to pressure to eat) were not predictive of child eating behaviors. Interestingly, child food responsiveness did not influence parental feeding whereas higher satiety responsiveness was predictive of an increase in (overt and covert) restriction and more structured timing of meals [30].

Limitations, Future Research Directions, and Conclusions

This review provides a snapshot of the state of the field with regard to feeding practices and their potential effects on children’s eating behaviors. The primary limitations within the field include the over-reliance on cross-sectional designs, often with small samples of highly educated, Caucasian mothers. The use of various self-report measurement tools in many studies is also a limitation due to potential reporting bias as well as limited validity testing of self-reported practices against observed feeding practices. The CFQ [17] is one of the most widely used tools for measuring feeding practices. However, it does not consider potentially key nonresponsive feeding practices such as instrumental and emotional feeding nor the role of structure in the mealtime environment (such as family management, timing, and setting) which may assist in understanding the relationship between feeding practices, child eating behavior, and obesity risk [30].
Future research in this field that utilizes a longitudinal design, assesses feeding practices and child eating concurrently, and attempts to ensure the validity of such measures is needed. Validation of questionnaire measures is critical to the accurate interpretation of study findings and has generally been limited to statistical validation of questionnaires in this field of research. Observational data that can complement self-report measures of both feeding practices and child eating behavior are one option for ensuring the validity of study findings. In conclusion, it is anticipated that greater understanding of the complex associations between these child eating-parental feeding constructs can assist in improving our knowledge of the modifiable factors that contribute to the development of childhood obesity. These findings may be used in the design of future interventions targeting the prevention of childhood obesity.

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