Feasibility and impact study of a reward-based mobile application to improve adolescents' snacking habits.

OBJECTIVE: Adolescents' snacking habits are driven by both explicit reflective and implicit hedonic processes. Hedonic pathways and differences in sensitivity to food rewards in addition to reflective determinants should be considered. The present study evaluated the feasibility and impact of a mobile phone-delivered intervention, incorporating explicit reflective and implicit rewarding strategies, on adolescents' snack intake. DESIGN: Adolescents (n 988; mean age 14·9 (sd 0·70) years, 59·4 % boys) completed a non-randomized clustered controlled trial. Adolescents (n 416) in the intervention schools (n 3) were provided with the intervention application for four weeks, while adolescents (n 572) in the control schools (n 3) followed the regular curriculum. Outcomes were differences in healthy snacking ratio and key determinants (awareness, intention, attitude, self-efficacy, habits and knowledge). Process evaluation data were collected via questionnaires and through log data of the app. RESULTS: No significant positive intervention effects on the healthy snack ratio (b=-3·52 (se 1·82), P>0·05) or targeted determinants were observed. Only 268 adolescents started using the app, of whom only fifty-five (20·5 %) still logged in after four weeks. Within the group of users, higher exposure to the app was not significantly associated with positive intervention effects. App satisfaction ratings were low in both high and low user groups. Moderation analyses revealed small positive intervention effects on the healthy snack ratio in high compared with low reward-sensitive boys (b=1·38 (se 0·59), P<0·05). CONCLUSIONS: The intervention was not able to improve adolescents' snack choices, due to low reach and exposure. Future interventions should consider multicomponent interventions, teacher engagement, exhaustive participatory app content development and tailoring.

Parental feeding behavior in relation to children's tasting behavior: An observational study.

Children's eating habits are shaped in part by parental feeding practices. While maladaptive practices have already received a lot of research attention, the effects of adaptive strategies, especially in elementary school aged children of different weight status, are less examined. This study examines how parents (1) model and (2) encourage their child to taste an unknown food. Thereby, attention is paid to the distinction between encouraging what (i.e. adaptive type of encouragement) and the amount (i.e. maladaptive type of encouragement) children eat/drink. Twenty-five families with a child with overweight and 30 families with a child of healthy weight (7-13 years) participated in a taste task. Both the child's tasting behavior and the parents' modelling and encouragement behavior were observed and related to the child's age and weight status. As 94.3% of the children tasted the unknown food, weight status differences between tasters and non-tasters could not be investigated. Only 26.9% of the parents used modelling to enhance tasting behavior; this was unrelated to age and weight status. 77.4% of the parents encouraged their children to taste (encouragement of what children eat/drink), and this was significantly more prevalent in parents of younger children and of healthy-weight children. 21.1% of the parents also encouraged their children to finish the juice (encouragement of amount children eat/drink) and this was also more prevalent in parents of the healthy-weight group. These results evidenced that parental modelling is not often used to enhance tasting behavior in children. In contrast, parental encouragement was frequently observed, especially in parents of younger children and of healthy-weight children. Encouragement, however, seems difficult to measure and more research on adaptive parental encouragement is needed.

The Daily Relation between Parental Rejection and Emotional Eating in Youngsters: A Diary Study.

KEY POINTS  Cross-sectional survey studies have demonstrated significant associations between parental rejection and peer rejection on the one hand and disturbed eating in youngsters, like emotional eating, on the other hand. In this study, we wanted to expand our knowledge on these relationships by investigating the daily fluctuations in these variables. Youngsters completed a 7-day diary to assess daily parental rejection, peer rejection and emotional eating. Using multilevel analyses, our results showed that daily variations in parental rejection were related to daily variations in emotional eating of the youngsters. This highlights the importance of addressing the parent-child relationship in interventions for emotional eating in youngsters. Background: This study investigated the daily relation between parental rejection and peer rejection on the one hand and emotional eating in youngsters on the other hand. Methods: Participants (N = 55) between the ages of 11 and 15 years completed a 7-day diary. A multilevel design was used to examine day-to-day within-person relationships between parental and peer rejection (measured by CHS) and emotional eating (measured by DEBQ-C) of youngsters. Results: The results showed that daily variations in parental rejection were related to daily variations in emotional eating of the youngsters. Daily peer rejection was only marginally significantly related to the emotional eating of the youngsters. Conclusions: These results indicate that especially parental rejection, and to a lesser extent peer rejection, are associated with the emotional eating of youngsters. The findings highlight the importance of addressing the parent-child relationship in interventions for emotional eating in youngsters.

Reward sensitivity and body weight: the intervening role of food responsive behavior and external eating.

BACKGROUND: During the last three decades, the prevalence of childhood overweight and obesity has increased worldwide. It is well established that different child-related factors such as food approach behaviors (i.e. eating behaviors that imply movements towards food) contribute to the development of overweight. However, research is lacking on the underlying mechanisms leading to food approach behaviors, which in turn lead to overweight. SUBJECT/METHODS: Via parent-report questionnaires, we investigated the relation between the personality trait reward sensitivity and body weight in a convenience sample of 211 children aged 2.5-9 years. We further investigated the intervening role of food approach behaviors in the association between reward sensitivity and body weight. RESULTS: Unexpectedly, there was no direct association between reward sensitivity and body weight. Despite the absence of a direct effect, a significant indirect association was found between reward sensitivity and body weight through the intervening food approach variables (i.e. food responsive behavior and external eating). CONCLUSIONS: These results highlight the importance of the focus on eating behaviors as well as trait characteristics in prevention programs for overweight.

The effect of parental rejection on the emotional eating behaviour of youngsters: A laboratory-based study.

Results from survey studies demonstrate a relationship between parental rejection and self-reported emotional eating of youngsters. The aim of the current study was to build on this research by examining the relationship between parental rejection and actual emotional eating, using an experimental laboratory paradigm. Participants were 46 youngsters between the ages of 10 and 17 years old. Participants first completed online questionnaires at home, measuring parental rejection and emotional eating style. At the laboratory, participants were randomly assigned to a neutral condition or negative mood condition, followed by a multi-item snack buffet. The interaction effect maternal rejection × condition on energy intake from savoury food was significant. More maternal rejection predicted more energy intake from savoury food in the negative mood condition, but not in the neutral condition. The results highlight the importance of assessing, and if mandatory, improving the emotional bond between parent and child in the prevention and intervention of emotional eating.

Perceived effective and feasible strategies to promote healthy eating in young children: focus groups with parents, family child care providers and daycare assistants.

BACKGROUND: The aim of the current study is to identify strategies to promote healthy eating in young children that can be applied by caregivers, based on their own perceptions of effectiveness and feasibility. Whereas previous research mainly focused on parental influences on children's eating behavior, the growing role of other caregivers in the upbringing of children can no longer be denied. METHODS: Four focus groups were conducted with three types of caregivers of post-weaning children under 6 years old: parents (n = 14), family child care providers (n = 9), and daycare assistants (n = 10). The audiotaped focus group discussions were transcribed and imported into Nvivo 10.0 for thematic analysis. The behaviors put forward by the caregivers were categorized within three broad dimensions: global influences, general behaviors, and specific feeding practices. RESULTS: Perceived effective strategies to promote healthy eating behavior in children included rewards, verbal encouragement, a taste-rule, sensory sensations, involvement, variation, modeling, repeated exposure, and a peaceful atmosphere. Participants mainly disagreed on the perceived feasibility of each strategy, which largely depended on the characteristics of the caregiving setting (e.g. infrastructure, policy). CONCLUSIONS: Based on former research and the current results, an intervention to promote healthy eating behaviors in young children should be adapted to the caregiving setting or focus on specific feeding practices, since these involve simple behaviors that are not hindered by the limitations of the caregiving setting. Due to various misconceptions regarding health-promoting strategies, clear instructions about when and how to use these strategies are necessary.

Food Approach and Food Avoidance in Young Children: Relation with Reward Sensitivity and Punishment Sensitivity.

It has recently been suggested that individual differences in Reward Sensitivity and Punishment Sensitivity may determine how children respond to food. These temperamental traits reflect activity in two basic brain systems that respond to rewarding and punishing stimuli, respectively, with approach and avoidance. Via parent-report questionnaires, we investigate the associations of the general motivational temperamental traits Reward Sensitivity and Punishment Sensitivity with Food Approach and Food Avoidance in 98 preschool children. Consistent with the conceptualization of Reward Sensitivity in terms of approach behavior and Punishment Sensitivity in terms of avoidance behavior, Reward Sensitivity was positively related to Food Approach, while Punishment Sensitivity was positively related to Food Avoidance. Future research should integrate these perspectives (i.e., general temperamental traits Reward Sensitivity and Punishment Sensitivity, and Food Approach and Avoidance) to get a better understanding of eating behavior and related body weight.

Strategies to improve the Willingness to Taste: The moderating role of children's Reward Sensitivity.

The present study investigates the effectiveness of different strategies to improve Willingness to Taste disliked vegetables and the moderating role of Reward Sensitivity. Preschool children (N = 204; age: M = 4.48, SD = 1.01) were randomly allocated to one of four different Willingness to Taste strategies. The findings indicate that first, Willingness to Taste is higher in the modelling and reward strategies compared to neutral instructions. Second, there is a differential effect of Willingness to Taste strategies dependent upon individual differences: children high in Reward Sensitivity were more likely to taste immediately when rewarded, while children low in Reward Sensitivity were more willing to taste when verbally encouraged, but with hesitation. This article thus highlights the roles of both individual differences and behavioral techniques for promoting a healthy diet in children.

Can we link emotional eating with the emotion regulation skills of adolescents?

OBJECTIVE: A recent cross-sectional study showed that maternal rejection is associated with emotional eating of obese youngsters seeking treatment, and that this relation is mediated by maladaptive emotion regulation (ER) of the youngsters. We wanted to build on this study and investigate the relation between parental rejection, maladaptive ER and emotional eating in a community sample using longitudinal data. DESIGN: Participants were 81 youngsters between the ages of 10 and 16 years. Participants completed questionnaires assessing maternal and paternal rejection, ER strategies and emotional eating, at two time moments (M = 71 days between time moments). Latent change models were used to estimate level and change of each variable. RESULTS: Results showed that the levels of maternal rejection, maladaptive ER and emotional eating were related. The indirect effect of the level of maternal rejection on the level of emotional eating through the level of maladaptive ER was marginally significant. On average, maternal rejection showed no change over time, whereas the other variables decreased. The changes in the variables were not related. CONCLUSION: The findings highlight the importance of assessing the emotional bond between mother and youngster and the ER of youngsters with an emotional eating style.

Fat Tissue Accretion in Children and Adolescents: Interplay between Food Responsiveness, Gender, and the Home Availability of Snacks.

The appetitive trait "food responsiveness" is assumed to be a risk factor for adiposity gain primarily in obesogenic environments. So far, the reported results are inconsistent in school-aged children, possibly because these studies did not take into account important moderators such as gender and the food-environment. In order to better inform caregivers, clinicians and the developers of targeted obesity-prevention interventions on the conditions in which food responsiveness precedes adiposity gain, the current study investigated if this relationship is stronger in girls and in children exposed to a higher home availability of energy-dense snacks. Age- and sex-independent Fat and Lean Mass Index z-scores were computed based on air-displacement plethysmography at baseline and after 2 years in a community sample of 129 children (48.8% boys) aged 7.5-14 years at baseline. Parents reported at baseline on children's food responsiveness and the home availability of energy-dense snacks. Food responsiveness was a significant predictor of increases in Fat Mass Index z-scores over 2 years in girls but not boys. The home availability of energy-dense snacks did not significantly moderate the relation of food responsiveness with Fat Mass Index z-score changes. The results suggest that food responsiveness precedes accelerated fat tissue accretion in girls, and may inform targeted obesity-prevention interventions. Further, future research should investigate to which food-environmental parameters children high in food responsiveness mainly respond.

Observation of parental functioning at mealtime using a sibling design.

This study investigates whether parental feeding practices are part of the shared environment or responsive to characteristics of different children from the same family. Thirty-six mothers with two children (4-12 y) of which 10 sibling-pairs were discordant for weight status (healthy weight-overweight), were invited to the lab for a standard meal. Maternal responsive and controlling behaviour was observed and coded. Children's weight status and eating behaviour was assessed. Results indicated that in general, mothers show similar levels of responsiveness and controlling behaviour within families. However, the use of mothers' authoritarian and permissive behaviour and her expressions of involvement at mealtime were consequently related to children's amount of food eaten and their restraining eating style. Thus, the amount of food children eat, both observed and assessed by questionnaire, seems related to more maladaptive parenting practices in mothers. This pleads for more tailor-made guidelines when advising parents of children with eating- and weight problems.

Subtyping children and adolescents who are overweight based on eating pathology and psychopathology.

Children and adolescents who are overweight can differ on dimensions measuring dietary restraint and psychopathology. Classifying clinical obese children and adolescents based on these psychological characteristics is shown to be useful in making differential prognoses. The present study aimed to research the validity of subtyping children and adolescents with overweight (N = 138) in a non-clinical sample. Using cluster analysis, results revealed three subtypes: a dietary restraint/internalizing group (DR + IN; n = 41), a pure internalizing group (IN; n = 20) and a non-symptomatic group (NS; n = 77). The DR + IN group outscored both other groups on measures of eating pathology, whereas the IN group outscored both other groups on measures of negative offect. Interestingly, the three groups did not differ on degree of overweight. The results seem to suggest that different psychological mechanisms can be observed in subgroups of young overweight adolescents. Further research should explore how individual psychological characteristics can be helpful when stipulating weight loss treatment programmes.

Training parents of overweight children in parenting skills: a 12-month evaluation.

BACKGROUND: The origins of childhood obesity invariably need to be looked at within a family context and several reviews have concluded in favour of parental involvement in the treatment of paediatric obesity. However, there is little consensus on the format, and next to weight outcomes behavioural outcomes also merit more attention when assessing program effectiveness. METHOD: In this pilot study, a total of 50 families with overweight children (aged 6-12) were randomly allocated to a parent-led intervention group (cognitive behavioural training) or to a waiting list control group (Study 1). Afterwards, the parents of the waitlist control group also followed the intervention. All children were included in a follow-up study and were compared with a reference group (Study 2). RESULTS: The intervention group as well as the waitlist group (who had not yet received treatment) showed a decrease in adjusted BMI over a 6-month period, although the decrease was only significant for the intervention group (Study 1). All children showed a decrease of 7% in adjusted BMI from pre to one-year follow-up measurement (Study 2), while the reference group showed an increase in adjusted BMI over that period. Parents reported significant positive changes in children's eating behaviour and a significant positive increase in familial health principles. CONCLUSIONS: Weight and behavioural outcomes suggest potential for intervention effectiveness. Long-term follow-up is needed to reveal residual benefits of enhanced parenting skills on environmental lifestyle changes.

How is reward sensitivity related to bodyweight in children?

Previous research assumes that there are two seemingly opposing hypotheses for the relation between reward sensitivity (RS) and bodyweight: hyper-responsiveness model and Reward Deficiency Syndrome (RDS), leading to the proposition of a feed forward process of weight gain. High RS may contribute to overeating and weight-gain among normal weight individuals. Over time the excessive food-intake may evolve in a down-regulation of dopamine (RDS), resulting in overeating as a form of self-medication and the progression to obesity. This process was evidenced in adults showing a curvi-linear relationship between self-reported RS and BMI. The aim of the current study was to investigate the association between self-reported RS and BMI in children (10-15 years). The results confirm the non-linear relationship between RS and bodyweight and support the suggestion of the same feed forward process in children. These findings imply that it is crucial to reduce the intake of high palatable foods in high RS children to prevent the decrease in RS and reduce the risk for future weight gain.

An 8-year follow-up of treated obese children: children's, process and parental predictors of successful outcome.

OBJECTIVE: This study presents an 8-year outcome of overweight children who were treated in an outpatient program and aims to identify child and familial variables associated with long-term weight regulation. METHODS: A total of 90 children participated with a mean age of 10.1 years +/- 2.6 at baseline and a mean adjusted BMI (actual BMI/50th percentile of BMI for age and gender x 100) of 153.1 +/- 20.7% at baseline participated in the 8-year follow-up (retrieval rate 71%; response rate 89%). Children's and parental factors, administered at baseline and at follow-up were related to the success of the treatment. RESULTS: The children obtained a mean reduction of 8% in adjusted BMI at the 8-year follow-up. A total of 59 children (66%) were successful in obtaining weight control (i.e. maintaining their original % adjusted BMI); 40% even decreased their adjusted BMI by 10% or more. Analyses revealed that the child's age, the degree of overweight at baseline and the child's global self-worth were positive predictors of long-term weight loss 8 years after treatment, whereas psychopathology in the mother was a negative predictor. The total explained variance was R(2) = 35%. DISCUSSION: Treatment of childhood obesity by means of a multidisciplinary cognitive-behavioural program enables the majority of children to control their weight in the long term. In order to predict the success of the treatment, it is recommended to take into account the child's age, its degree of overweight, its global self-worth and the occurrence of maternal psychopathology.

Unfavourable family characteristics and their associations with childhood obesity: a cross-sectional study.

OBJECTIVE: This cross-sectional study explores the influence of multiple familial factors on children's weight status and the interaction between parenting stress and unfavourable family characteristics. METHODS: A total of 197 families with children between 6 and 14 years participated in this study. Of this group, 97 families had a child with normal weight and 100 families had a child with overweight. Parents reported on seven family factors (maternal BMI, number of children, family structure, socioeconomic position, life events, parental psychopathology and parenting stress). RESULTS: Families with overweight children experience more parenting stress. A regression analysis revealed that familial factors explain 27% in the variance in child's weight status. The hypothesis that a combination of familial factors will be more able to explain child's adiposity could not be confirmed. CONCLUSIONS: Familial factors have moderate ability to predict children's weight status. There is a need to identify other familial mechanisms taking into account developmental and temporal evolutions over the past decade.

Differences in eating style between overweight and normal-weight youngsters.

Differences in eating styles between overweight and normal-weight youngsters were investigated with a child version of the Dutch Eating Behavior Questionnaire (DEBQ). Subjects were children (n=1458; M: 10.1; SD=1.3) and adolescents (n=1016; M: 14.9; SD=1.5). Overweight adolescent girls scored high on emotional eating while overweight adolescent boys displayed more external eating. In overweight children, already 10.5 per cent displayed emotional eating and 38.4 per cent reported external eating. All overweight youngsters reported restrained attitudes. Eating styles were positively associated with indicators of eating pathology. The results suggest the use of appropriate norms that take into account the child's age, gender and overweight status.

Thought suppression in obese and non-obese restrained eaters: piece of cake or forbidden fruit?

OBJECTIVE: This article examines thought suppression tendencies in restrained eaters. Furthermore, the dynamics between failing thought suppression and thought control strategies are explored. METHODS: One hundred and five overweight and normal-weight boys and girls (12-18 years) participated in a cross-sectional questionnaire-based study. A distinction was made between disinhibited restrained eaters (high restraint/high disinhibition), inhibited restrained eaters (high restraint/low disinhibition) and unrestrained eaters (low restraint) in both weight-groups. The Dutch Eating Behaviour Questionnaire (DEBQ) was used to select the different groups of (un)restrained eaters. The White Bear Suppression Inventory (WBSI) was employed to measure thought suppression and intrusions. The Thought Control Questionnaire (TCQ) was used to measure thought control strategies (distraction, punishment, reappraisal, worry, social control). RESULTS: The disinhibited restrainers obtained meaningfully higher scores on WBSI-total, WBSI-thought suppression and WBSI-intrusion than the inhibited restrainers and unrestrained eaters in both weight groups. Those who scored high on WBSI-total, obtained significantly higher scores on the TCQ subscales distraction, worry and punishment, than those who scored low on WBSI-total. DISCUSSION: The findings suggest that disinhibited restrainers, irrespective of their weight status, report a high tendency to suppress thoughts. Given Wegner's theoretical account, this may be associated with preoccupations and self-control difficulties.

Are two informants better than one? Parent-child agreement on the eating styles of children who are overweight.

AIM: It is currently unknown to what extent the view of a child with overweight on its' own eating behaviour converges with parental perception regarding this behaviour and how parent-child agreement is influenced by overweight status and age. METHOD: Youngsters (N = 498; range 7-15 years; 37% boys) referred for weight treatment to an outpatient University centre filled in the Dutch Eating Behaviour Questionnaire-child version (DEBQ-child version; Van Strien & Braet, unpublished work), prior to treatment, while their parents reported on their child's eating behaviour by completing the DEBQ-parent version (Braet & Van Strien, 1997). RESULTS: Parents scored significantly higher when reporting on the emotional eating and external eating behaviour of their child, while they scored lower for restrained eating (all p < 0.001). Comparisons between the subscales of the DEBQ-parent version and the DEBQ-child version revealed significant positive correlations of r = 0.45 for emotional eating, r = 0.35 for external eating and r = 0.36 for restrained eating (all p < 0.01); convergence is lowest for the age group younger than 10 (p < 0.05). Both versions of the DEBQ displayed low correlations with the degree of overweight of the child. DISCUSSION: Parents and children displayed moderate to good agreement with regard to emotional eating, external eating and restrained eating. However when only one perspective can be assessed, possible biases must be taken into account. In that case, the use of appropriate age-specific norms is indicated.