Influences on the dietary intakes of preschool children: a systematic scoping review.

BACKGROUND: Better diet quality of preschool children is associated with many important health outcomes, but there is significant room for improvement in many children's dietary intakes. The determinants of children's dietary intakes are complex and whole systems approaches may be effective tools for changing dietary intake. Collation of all the evidence available on determinants of preschool children's dietary intake is necessary to 'map' the whole system of influence. Therefore, this systematic scoping review of available literature on determinants of dietary intakes in preschool children was undertaken. METHODS: The Joanna Briggs Institute methods for conducting a systematic scoping review were followed. Articles published since 2000 which assessed influences on the dietary intakes of preschool children were identified, yielding a total of 246 papers. Studies of children with clinical conditions (excluding obesity), or those conducted in middle and low-income countries were excluded, due to the different systems of influence in these populations. Data were extracted and information synthesised based on ecological level (child, parent, household, childcare, or wider determinants). RESULTS: Most articles focused on influences at the parental level (n = 118, 48%), followed by those at the child level (n = 73, 30%). Most of the studies were of cross-sectional design (n = 109, 44%). Whilst many studies considered influences at multiple ecological levels (n = 63, 26%) few analyses determined interactions between factors in their relationship with children's dietary intakes, which is needed going forward using systems methods. CONCLUSION: A wealth of evidence exists examining influences on the dietary intakes of preschool children and this information would benefit from analysis using a systems thinking approach in order to assess effective levers for intervention and what works, for whom, under what circumstances.

Parental monitoring may protect impulsive children from overeating.

BACKGROUND: Research has highlighted links between impulsivity and weight in children and adults. Nevertheless, little is known about the nature of this link in very young children or about the underlying mechanism by which impulsivity leads to greater adiposity. OBJECTIVE: The present study aimed to explore relationships between impulsivity, weight and eating behaviour in a sample of 95 2 to 4-year-olds. METHOD: Parent-child dyads visited the laboratory and consumed a meal after which parents completed measures of child impulsivity, eating behaviour and parental feeding, whilst children completed impulsivity tasks measuring the impulsivity facet delay of gratification (Snack Delay task), motor impulsivity (Line Walking task) and inhibitory control (Tower task). RESULTS: Pearson's correlations showed that girls with greater motor impulsivity were heavier. Additionally, monitoring moderated the relationship between impulsivity and food approach behaviour, indicating that monitoring may protect more impulsive children from displaying problematic eating behaviours. CONCLUSIONS: The motor impulsivity facet appears particularly relevant to child weight; parents can modulate the impact of impulsivity on child eating behaviour through their feeding style.

Cortisol metabolism, postnatal depression and weight changes in the first 12 months postpartum.

BACKGROUND & OBJECTIVES: Postnatal depression correlates with postpartum weight retention, and dysregulated cortisol metabolism is evident in depressed individuals. Cortisol metabolism, BMI and metabolic phenotype are robustly associated, but the role of cortisol metabolism in postnatal mental health and weight loss has never been examined. DESIGN: A longitudinal observation. PATIENTS: Forty nine healthy women with uncomplicated pregnancy. MEASUREMENTS: BMI and urinary steroid metabolites at 1 week and 1, 3, 6 and 12 months postpartum. Validated urinary steroid metabolite ratios were measured to determine the activities of 11ß-hydroxysteroid dehydrogenases (11ß-HSD) that interconvert inactive cortisone and active cortisol and the 5α-reductases that clear cortisol to its inactive metabolites. Postnatal depression symptoms were measured at 1, 6 and 12 months. RESULTS: Low 5α-reductase activity was associated with greater weight loss across the first year, independent of demographics, breastfeeding and depression. Postpartum BMI change was unrelated to postnatal depression at any time. Symptoms of postnatal depression were related to higher cortisol metabolite production at 12 months, independent of demographics and breastfeeding. CONCLUSIONS: Greatest weight loss in the postpartum year was associated with lower conversion of cortisone to cortisol and lower conversion of cortisol to its metabolites, supporting previous work that demonstrates the facilitative role of lower 5α-reductase and 11ß-HSD-1 in weight loss. Greater depression symptoms were associated with higher cortisol metabolite production rates. Whilst weight and mental health are both associated with dysregulation of the HPA axis, there may be different pathways towards depressed and obese phenotypes in healthy postpartum samples.

Beliefs about exercise: relationship to eating psychopathology and core beliefs among young female exercisers.

OBJECTIVE: This study had two objectives. First, to determine links between levels of eating psychopathology and beliefs about exercise among young women. Second, to determine the predictive effects of unhealthy core beliefs on exercise beliefs. METHOD: A convenience sample of 185 young female exercisers completed the Eating Disorders Inventory (EDI), the Exercise Beliefs Questionnaire (EBQ) and the Young Schema Questionnaire (YSQ). RESULTS: The participants' mean scores on the EDI were as follows: drive for thinness=0.69 (SD=0.82); body dissatisfaction=1.30 (SD=0.86); and bulimia=0.33 (SD=0.42). There were significant, positive correlations of all three EDI scales with EBQ social and EBQ appearance subscales. In addition, YSQ Defectiveness/Shame beliefs predicted EBQ social scores, while YSQ Unrelenting Standards predicted EBQ appearance scores. DISCUSSION: Those women with relatively unhealthy eating attitudes are likely to believe that exercise will prevent negative social consequences, and are likely to be motivated to exercise in order to preserve or enhance their physical appearance. These same types of exercise belief (regarding social consequences and appearance) are predicted by feelings of defectiveness and shame and by unrelenting high personal standards.

Cultural differences in parental feeding practices and children's eating behaviours and their relationships with child BMI: a comparison of Black Afro-Caribbean, White British and White German samples.

BACKGROUND/OBJECTIVES: Childhood obesity rates differ between cultural groups in Europe. Parents influence their children's weight status and eating behaviours through feeding practices. We investigated cultural differences in feeding practices and eating behaviours and their relation to child weight in three groups that differed in cultural background and geographical location. SUBJECTS/METHODS: Fifty-two White German (WG) families, in Germany (44 mothers, mean age 33.8 years), 79 White British (WB) families, in the UK (74 mothers, mean age 37.8) and 40 Black Afro-Caribbean (BAC) families, in the UK (34 mothers, mean age 31.8) participated in this study of 2-12-year-old children. Parents completed questionnaires assessing feeding practices and eating behaviours; children were measured and weighed by experimenters. RESULTS: MANCOVAs indicated that BAC parents used the highest levels of restrictive feeding practices and the lowest levels of monitoring, and their children showed the highest levels of food-approach behaviours. WG parents used the lowest levels of pressure to eat. Partial correlations showed that food-approach behaviours were correlated with child BMI in BAC and WG families but not in WB families. Parental restriction was associated with child Body Mass Index (BMI) in BAC families only. CONCLUSIONS: There are both similarities and differences in feeding practices and eating behaviours and their relationships with child weight in different cultural groups. Findings highlight the importance of being aware of cultural differences when carrying out research with multi-cultural samples in Europe.

Stability and continuity of parentally reported child eating behaviours and feeding practices from 2 to 5 years of age.

Previous research suggests that many eating behaviours are stable in children but that obesigenic eating behaviours tend to increase with age. This research explores the stability (consistency in individual levels over time) and continuity (consistency in group levels over time) of child eating behaviours and parental feeding practices in children between 2 and 5 years of age. Thirty one participants completed measures of child eating behaviours, parental feeding practices and child weight at 2 and 5 years of age. Child eating behaviours and parental feeding practices remained stable between 2 and 5 years of age. There was also good continuity in measures of parental restriction and monitoring of food intake, as well as in mean levels of children's eating behaviours and BMI over time. Mean levels of maternal pressure to eat significantly increased, whilst mean levels of desire to drink significantly decreased, between 2 and 5 years of age. These findings suggest that children's eating behaviours are stable and continuous in the period prior to 5 years of age. Further research is necessary to replicate these findings and to explore why later developmental increases are seen in children's obesigenic eating behaviours.

Is being underweight associated with impairments in quality of life in the absence of significant eating disorder pathology?

Few studies have compared low-weight individuals with eating disorder (ED) pathology with similar-weight individuals without significant pathology despite the fact that body weight is often used as a key outcome within ED research. This study compared quality of life (QoL) in one group with high levels of ED pathology to a group with low ED pathology, matched by body mass index (BMI). The high ED group reported significantly lower ED-specific quality of life (EDQoL) than the low ED group. These findings suggest that young women with high levels of ED pathology report significantly more impaired QoL than comparable young women with no ED pathology, and that being underweight alone is not a primary contributor to poorer EDQoL.

The role of parenting in the relationship between childhood eating problems and broader behaviour problems.

OBJECTIVE: Previous research has established that childhood feeding and eating problems are often related to other behavioural difficulties. Parenting practices have been implicated in both eating behaviour and broader behaviour problems. The aim of this study was to examine whether the relationship between eating and behaviour problems could be explained in part by parenting style and practices. METHODS: Seventy-seven mothers of 3- to 8-year-old children completed measures of children's eating behaviours, behaviour problems, parenting style and feeding practices. RESULTS: Eating behaviours (food responsiveness, emotional under-eating, fussiness) and behaviour problems (conduct problems, hyperactivity, total difficulties) were significantly correlated, but when parenting style and feeding practices were controlled for, significant associations disappeared. CONCLUSIONS: Although the findings are limited because of a relatively low response rate, in non-clinical groups, the perceived commonality between eating and behaviour problems may be explained by parenting.

Pilot of "Families for Health": community-based family intervention for obesity.

OBJECTIVE: To develop and evaluate "Families for Health", a new community based family intervention for childhood obesity. DESIGN: Programme development, pilot study and evaluation using intention-to-treat analysis. SETTING: Coventry, England. PARTICIPANTS: 27 overweight or obese children aged 7-13 years (18 girls, 9 boys) and their parents, from 21 families. INTERVENTION: Families for Health is a 12-week programme with parallel groups for parents and children, addressing parenting, lifestyle change and social and emotional development. MAIN OUTCOME MEASURES: Change in baseline BMI z score at the end of the programme (3 months) and 9-month follow-up. Attendance, drop-out, parents' perception of the programme, child's quality of life and self-esteem, parental mental health, parent-child relationships and lifestyle changes were also measured. RESULTS: Attendance rate was 62%, with 18 of the 27 (67%) children completing the programme. For the 22 children with follow-up data (including four who dropped out), BMI z score was reduced by -0.18 (95% CI -0.30 to -0.05) at 3 months and -0.21 (-0.35 to -0.07) at 9 months. Statistically significant improvements were observed in children's quality of life and lifestyle (reduced sedentary behaviour, increased steps and reduced exposure to unhealthy foods), child-parent relationships and parents' mental health. Fruit and vegetable consumption, participation in moderate/vigorous exercise and children's self-esteem did not change significantly. Topics on parenting skills, activity and food were rated as helpful and used with confidence by most parents. CONCLUSIONS: Families for Health is a promising new childhood obesity intervention. Definitive evaluation of its clinical effectiveness by randomised controlled trial is now required.

Are parenting style and controlling feeding practices related?

This study examined the relationships between parenting styles, feeding practices and BMI in a non-clinical sample of mothers and fathers of UK preschool children. Ninety-six cohabiting parents of 48 children (19 male, 29 female, mean age 42 months) completed a series of self-report questionnaires assessing parenting style, feeding practices, eating psychopathology and a range of demographic information. There were no relationships between authoritarian parenting and controlling feeding practices. In both mothers and fathers, permissive parenting style was related to lower monitoring of children's unhealthy food intake. Permissive parenting was also associated with increased use of restriction by mothers and pressure to eat by fathers. Authoritative parenting style was also related to lower use of pressure to eat by fathers only. Parenting styles were not related to child BMI in this sample. Higher child BMI was best predicted by lower paternal application of pressure to eat and greater paternal reports of drive for thinness. Parenting style may not have a direct impact on child BMI until child food selection and consumption becomes more autonomous.

The effect of induced stress on the relationship between perfectionism and unhealthy eating attitudes.

It has previously been shown that stress situations reveal an association between perfectionism and unhealthy eating attitudes in nonclinical females. The present study aimed to extend these findings by also measuring psychological and physiological reactions to induced stress. Forty-two female university students completed measures of state anxiety, perfectionism and unhealthy eating attitudes on two occasions: an average day and after a task designed to induce stress. Physiological responses to stress were measured before, and immediately after the task. Whilst Body Dissatisfaction was associated with aspects of perfectionism both at baseline and immediately after the stress task, Drive for Thinness was only associated with Concern over Mistakes and Personal Standards after the task. These findings confirm previous work showing that stress encourages a relationship between disturbed eating behaviours and perfectionism and therefore, have implications for prevention and early intervention programmes for eating disorders.

Maternal mental health and child feeding problems in a non-clinical group.

OBJECTIVE: To compare the contribution of symptoms of anxiety, depression and eating psychopathology to reports of child feeding difficulties in a non-clinical group of mothers of male and female children. METHOD: A community sample of 56 mothers of male children and 40 mothers of female children with a mean age of 32 months completed measures of anxiety, depression, eating psychopathology and child feeding problems. RESULTS: In mothers of male children, symptoms of depression and anxiety, but not eating psychopathology, were predictors of difficult feeding interactions. In contrast, in mothers of female children, symptoms of bulimia and depression, but not anxiety, were significant predictors of reported food refusal. DISCUSSION: Different aspects of psychopathological symptomology may be risk factors for reports of feeding problems dependent on the child's gender. Further work should continue to assess the nature and motivation for the controlling of feeding behaviors exhibited by mothers of children of different genders.

Predictors of maternal control of feeding at 1 and 2 years of age.

OBJECTIVE: To establish the best predictors of maternal use of controlling feeding practices at 1 and 2 years of age. DESIGN: A longitudinal study from birth to 2 years. PARTICIPANTS: Sixty-two mothers of 2-year-old children. MEASURES: Infant weight at birth, 6, 12 and 24 months, breastfeeding history, infant temperament and feeding difficulties at 6 and 12 months, maternal demographics at 12 and 24 months, maternal mental health at 6 and 12 months, maternal controlling feeding practices at 12 and 24 months. RESULTS: Controlling feeding practices at 1 year were predicted by perceptions of infant temperament at 6 months, birth weight, length of breastfeeding, mental health at 6 months, and mealtime negativity at 6 months. Parental control over feeding when their child reached 2 years was predicted by the mother's tendency to use that particular strategy at 1 year in combination with the perceptions of infant temperament and feeding problems at 1 year, weight at 1 year, length of breastfeeding in infancy, and/or maternal mental health at 1 year. CONCLUSIONS: Breastfeeding appears to promote subsequent monitoring, and is associated with reduced use of pressurising and restrictive feeding practices. Infant characteristics are important predictors of control at both 1 and 2 years of age. The use of controlling feeding practices is relatively stable from 1 to 2 years.

The development of maternal self-esteem.

Although an important theoretical concept, little is known about the development of maternal self-esteem. This study explores the significance of maternal cognitions, psychopathological symptoms, and child temperament in the prediction of prenatal and postnatal maternal self-esteem. During pregnancy 162 women completed measures assessing their unhealthy core beliefs, psychopathological symptoms, and self-esteem. At 1 year postpartum 87 of these women completed measures assessing their self-esteem and their child's temperament. Overall maladaptive maternal core beliefs and psychopathological symptoms during pregnancy explained 19% of the variance in prenatal maternal self-esteem. Forty-two percent of the variance in maternal self-esteem at 1 year could be explained by a combination of prenatal maternal self-esteem, mental health symptoms, maternal core beliefs, and more unsociable infant temperament. Underlying maternal cognitive structures may be important in determining the development of maternal self-esteem.

Breast-feeding, maternal feeding practices and mealtime negativity at one year.

This paper explores whether breast-feeding, mediated by lower maternal use of controlling strategies, predicts more positive mealtime interactions between mothers and their 1 year old infants. Eighty-seven women completed questionnaires regarding breast-feeding, assessing their control over child feeding and mealtime negativity at 1 year of infant age. Seventy-four of these women were also observed feeding their infants solid food at 1 year. Mediation analyses demonstrated that the experience of breast-feeding, mediated by lower reported maternal control over child feeding, predicted maternal reports of less negative mealtime interactions. The experience of breast-feeding also predicted observations of less conflict at mealtimes, mediated by observations of maternal sensitivity during feeding interactions. The implications of these findings are discussed.

Is cognitive behavior therapy developmentally appropriate for young children? A critical review of the evidence.

This paper questions the extent to which developmental considerations have been incorporated into the theory and practice of cognitive behavioral therapy (CBT). It focuses on children aged between 5 and 8 years because Piagetian developmental theory places them at a prelogical cognitive level, and thus, the use of a therapeutic approach that is based on a rationalist paradigm would be considered inappropriate. The cognitive demands made upon 5- to 8-year-old children by CBT are outlined, and the current developmental literature is reviewed in the light of this to evaluate the cognitive abilities of this age group. The models underpinning CBT are examined for evidence of the influence of developmental psychology, and the outcome literature of CBT techniques is then scrutinized to evaluate the efficacy of these techniques with young children. Conclusions are reached regarding the appropriateness of current cognitive-behavioral approaches with young children, and the implications for alternative approaches are briefly considered.

The relationship between parental eating problems and children's feeding behavior: a selective review of the literature.

This review describes the research evidence linking parental eating problems with processes that affect children's food selection and rejection, including child feeding difficulties, and child dieting practices and attitudes. First, studies that assess the relationship between parental eating disorder and child feeding are reviewed. Secondly, research that examines the relationship between parent and child dieting behavior and attitudes is reviewed. Finally, the eating characteristics of parents whose children have feeding difficulties are discussed. There is no consensus in the literature about the relationships between parent and child feeding and eating disturbance, and mechanisms for the intergenerational transmission of these behaviors have yet to be established.

A behavioural intervention in a child with feeding problems.

AIM: This case study aimed to describe an intervention with a 2-year-old child with growth problems and moderately severe feeding difficulties. METHOD: The intervention was based on cognitive behavioural principles and psycho-physiological techniques, and focused on reducing parental anxiety and returning the control of feeding to the child. RESULTS: The child's feeding behaviour considerably improved over a 6-month period, and growth and weight were significantly increased. These positive changes have been maintained for a 3-year subsequent period. CONCLUSION: The principles described can be applied to children with a wide range of feeding problems with multivariate causes.

Sexual orientation and eating psychopathology: the role of masculinity and femininity.

OBJECTIVE: Previous research suggests that eating disorders are related to homosexuality in men, although links with female sexual orientation are less clear. Appearance factors have generally been implicated in this relationship. However, previous studies have failed to consider the role of femininity, even though evidence suggests that this is a more critical factor than sexual preference. The aim of this study was to consider the relationship between gender-role orientation and eating psychopathology in nonclinical men and women of different sexual orientations. METHOD: One hundred university students (40 homosexual; 60 heterosexual) completed the Bem Sex Role Inventory and the Eating Attitudes Test. RESULTS: For the group as a whole, there were links between femininity and high levels of eating psychopathology, whereas masculinity was associated with relatively healthy eating-related attitudes and behaviors. When considering the role of sexual orientation, these links were specific to homosexual men and women. CONCLUSIONS: In relation to homosexual men and women, the results support a model where femininity might be seen as a specific risk factor for eating disorders, whereas masculinity is likely to be a protective factor. Methodological and conceptual implications are discussed.

Feeding problems in Silver-Russell syndrome.

In order to identify the prevalence and severity of feeding problems in children with Silver-Russell syndrome (SRS) the feeding difficulties of 32 children with SRS and 32 age- and sex-matched control children were assessed using the Feeding Assessment Questionnaire (Harris and Booth 1992). Children's ages ranged from 2 to 11 years, with 19 male and 13 female pairs. In a subset of matched pairs, parent-child interaction at mealtimes was examined using video recording; food intake was also assessed over a 3-day period using weighed food diaries. Children with SRS experienced significantly more feeding problems than children without growth disorders. Common feeding problems for children with SRS were poor appetite, fussiness, slow feeding, and problems associated with oral-motor dysfunction. Feeding problems did not significantly affect intake of kilocalories, protein, fat, or carbohydrates. Mealtime interaction between children with SRS and their parents was significantly more negative than interactions between control-group children and their parents. The focus of intervention packages in SRS should be to reduce negative parent-child interactions and reduce parental anxiety about feeding, growth, and weight.