Appetite 79 (2014) 42–50

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Food parenting practices and child dietary behavior. Prospective relations and the moderating role of general parenting ☆ Ester F.C. Sleddens a,*, Stef P.J. Kremers a, Annette Stafleu b, Pieter C. Dagnelie c, Nanne K. De Vries d, Carel Thijs c a Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands b TNO, P.O. Box 360, 3700 AJ Zeist, The Netherlands c Department of Epidemiology, CAPHRI School of Public Health and Primary Care, Maastricht University Medical Center+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands d Department of Health Promotion, CAPHRI School of Public Health and Primary Care, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Center+, P.O. Box 616, 6200 MD, Maastricht, The Netherlands

A R T I C L E

I N F O

Article history: Received 27 March 2013 Received in revised form 1 April 2014 Accepted 3 April 2014 Available online 13 April 2014 Keywords: General parenting Food parenting practices Child dietary behavior

A B S T R A C T

Research on parenting practices has focused on individual behaviors while largely failing to consider the context of their use, i.e., general parenting. We examined the extent to which food parenting practices predict children’s dietary behavior (classified as unhealthy: snacking, sugar-sweetened beverage; and healthy: water and fruit intake). Furthermore, we tested the moderating role of general parenting on this relationship. Within the KOALA Birth Cohort Study, in the Netherlands, questionnaire data were collected at 6 and 8 years (N = 1654). Correlations were computed to assess the association between food parenting practices and general parenting (i.e., nurturance, behavioral control, structure, coercive control, and overprotection). Linear regression models were fitted to assess whether food parenting practices predict dietary behavior. Instrumental and emotional feeding, and pressure to eat were found to have associations with undesirable child dietary behavior (increased unhealthy intake/decreased healthy intake), whereas associations were in the desirable direction for covert control, encouragement and restriction. Moderation analyses were performed by evaluating interactions with general parenting. The associations of encouragement and covert control with desirable child dietary behaviors were found to be stronger for children who were reared in a positive parenting context. Future research should assess the influence of contextual parenting factors moderating the relationships between food parenting and child dietary behavior as the basis for the development of more effective family-based interventions. © 2014 Elsevier Ltd. All rights reserved.

Introduction It is well-known that childhood overweight has a tendency to persist into adulthood (Singh, Mulder, Twisk, Van Mechelen, & Chinapaw, 2008) and is associated with multiple adverse health out-

Abbreviations: CFQ, Child Feeding Questionnaire; CGPQ, Comprehensive General Parenting Questionnaire; FFQ, Food Frequency Questionnaire; PFSQ, Parental Feeding Style Questionnaire. ☆ Acknowledgments: We are grateful for the help of the KOALA participants for participating in this study. To our knowledge, no conflict of interest, financial or other, exists. ES, SK and CT designed the research; ES conducted research, wrote the paper and had primary responsibility for final content. All authors read, commented on, and approved the final manuscript. The authors declare that they have no competing interests. This research was funded by the Netherlands Heart Foundation (project number 2008B112). * Corresponding author. E-mail address: [email protected] (E.F.C. Sleddens). http://dx.doi.org/10.1016/j.appet.2014.04.004 0195-6663/© 2014 Elsevier Ltd. All rights reserved.

comes, both in the short term (Daniels, 2009) and longer term (Reilly & Kelly, 2011). While it is generally accepted that parenting has important influences on children’s dietary intake and ultimately on weight status, the exact conditions of its influence are still not well defined. In the feeding domain, previous reviews showed the relationships of parents’ use of food parenting practices (i.e., content-specific acts of parenting (Darling & Steinberg, 1993)) on child eating and weight status (e.g., Clark, Goyder, Bissell, Blank, & Peters, 2007; Faith, Scanlon, Birch, Francis, & Sherry, 2004; Ventura & Birch, 2008; Wardle & Carnell, 2007). Most of the included studies focus on highly controlling food parenting practices (restricting the type and amount of food and using food as a reward), failing to assess other practices such as encouragement and guidance. These (mainly cross-sectional) studies have yielded contradictory results, and have in common that they did not assess the larger context in which these behaviors occurred (i.e. general parenting styles).

E.F.C. Sleddens et al./Appetite 79 (2014) 42–50

A

Food parenting practices (Measured at age 6) Encouragement Control Instrumental feeding Emotional feeding Covert control Pressure to eat Restriction Monitoring

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General parenting Nurturance Structure Behavioral control Coercive control Overprotection C

B

Child dietary behavior (Measured at age 6 and 8) Snacking Sugar-sweetened drinks Fruit

Fig. 1. Hypothesized model of the parenting–child dietary behavior relationship.

General parenting is independent of specific socialization content; it has commonly been defined as the approach parents use to raise their child, and is a function of parent’s attitudes, beliefs and behaviors, creating a family emotional climate (Darling & Steinberg, 1993). In a recent review, Sleddens, Gerards, Thijs, De Vries, and Kremers (2011) reported that authoritative forms of parenting (characterized by parental warmth and guidance) were associated with more positive weight-related outcomes than more permissive or coercive forms of parenting. This was confirmed in some recent correlational studies (Fuemmeler et al., 2012; Johnson, Welk, Saint-Maurice, & Ihmels, 2012; Rodenburg, Kremers, Oenema, & Van de Mheen, 2011, 2013; Topham et al., 2011). However, these effects of general parenting on weight-related behaviors were generally indirect and weak compared with the effects of more proximal behavior-specific parenting practices (Cislak, Safron, Pratt, Gaspar, & Luszczynska, 2012). Studies assessing both general parenting and food parenting practices are scarce (e.g., Blissett & Haycraft, 2008; Blissett, Meyer, & Haycraft, 2011; Hennessy, Hughes, Goldberg, Hyatt, & Economos, 2010; Hubbs-Tait, Kennedy, Page, Topham, & Harrist, 2008; Musher-Eizenman & Holub, 2006; Rodenburg et al., 2013; Taylor, Wilson, Slater, & Mohr, 2011; Van der Horst et al., 2007; Vereecken, Rovner, & Maes, 2010), and only few tested whether general parenting influences the impact of food parenting practices (Hennessy et al., 2010; Musher-Eizenman & Holub, 2006; Rodenburg et al., 2013; Taylor et al., 2011; Van der Horst et al., 2007; Vereecken et al., 2010). Two of these studies found that restrictive food parenting was associated with a decrease in sugar-sweetened beverage consumption (Van der Horst et al., 2007) and caloric intake (Musher-Eizenman & Holub, 2006) when parents reported higher levels of authoritative parenting. The contextual influence of general parenting is likely to be more profound than its direct relationship with weight status or related behavior (dietary intake, physical activity, sedentary behavior) (Sleddens et al., 2011). Therefore, general parenting can be considered as a crucial contextual factor in understanding the impact of food related parenting practices. Current interventions to prevent childhood overweight and obesity have been largely ineffective due to a lack of understanding of how family characteristics influence child behaviors (Hingle, O’Connor, Dave, & Baranowski, 2010; O’Connor, Jago, & Baranowski, 2009). Childhood interventions with the best outcomes (i.e., increased healthy eating and physical activity) have engaged parents (Golley, Hendrie, Slater, & Corsini, 2011) and interventions targeting specific parenting practices have improved by being modified to include general parenting skills (Gerards, Sleddens, Dagnelie, De Vries, & Kremers, 2011). In order to develop effective interventions that can incorporate general parenting to tailor information

on optimal parenting practices, we need to further unravel the exact mechanisms of its influence. To our knowledge, the current study is one of the first attempts to assess interactions between general parenting and food parenting practices in shaping children’s dietary behavior applying a longitudinal study design (see Fig. 1). With few exceptions, empirical studies have dealt with one or a few isolated determinants at a time. We investigated the impact of specific food parenting practices on child dietary behavior in the context of broader parent level factors like general parenting, with the aim to execute research that extends beyond isolated associative approaches. The first objective of this study was to examine the extent to which food parenting practices predict child dietary behavior from the child’s age of 6–8 years. The age span encompasses a critical period for the development of overweight among children (e.g., Pryor, Tremblay, Boivin, Touchette, & Dubois, 2011; Ventura, Loken, & Birch, 2009). The second objective was to explore the moderating role of general parenting on the relationship between food parenting practices and children’s dietary behavior. This contextual higher-order moderation approach is advocated to have significant value in understanding the complex process of parent–child interactions in the area of childhood overweight (Kremers et al., 2013). We predicted using foods as rewards and coercing children to eat to be positively related to unhealthy child dietary behaviors and negatively to healthy child dietary behaviors. On the other hand, we predicted encouraging and controlling food parenting practices to be positively related to healthy dietary behaviors and negatively related to unhealthy dietary behaviors. Importantly, we hypothesized that these relationships would be strengthened and/or weakened depending on general parenting. For instance, we hypothesized that the favorable associations would be strengthened for children who were reared in a positive parenting context. The current study takes one of the first steps in unraveling complex environment–behavior interactions in the research area of food parenting. Subjects and methods Respondents and procedure Data were collected within the ongoing KOALA Birth Cohort Study in the Netherlands. The study design has been previously described in detail (Kummeling et al., 2005). Briefly, from 2000 onwards, healthy pregnant women with a conventional lifestyle (N = 2343) were recruited from an existing cohort study on pregnancy-related pelvic girdle pain. In addition, pregnant women with an ‘alternative’ lifestyle (N = 491) with regard to dietary habits (e.g., preferring organic foods), vaccination programs, and/or

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antibiotics use (most often refusal of the latter two) were recruited through several ‘alternative’ circles like anthroposophical physician offices and midwives, and organic food shops. All participants (N = 2834) were enrolled between 14 and 18 weeks of gestation and were asked to complete questionnaires during pregnancy and at regular intervals after birth. Informed consents were signed by all parents, and ethical approval was obtained from the Maastricht University/University Hospital Maastricht medical ethics committee.

Three additional items, not originally in the CFQ, asked parents to report on monitoring of their child’s sugar-sweetened beverage and fruit intake, and the amount of foods their child consumes during breakfast (i.e., ‘How much do you keep track of the sugar-sweetened beverage/fruit that your child consumes’, ‘How much do you keep track of the foods that your child consumes during breakfast’). The response format consisted of a five-point Likert scale from 1 (never) to 5 (always). Cronbach’s α for the pressure to eat and monitoring scales were .53 and .75, respectively in our sample.

Measures

General parenting The Comprehensive General Parenting Questionnaire (CGPQ), administered at the child’s age of 8 years, is a recently developed and validated parental-reported measure consisting of 85 items to assess the five key constructs of general parenting: nurturance (e.g., ‘I encourage my child to be curious, to explore, and to question things’), structure (e.g., ‘I use clear and consistent messages when I tell my child to do something’), behavioral control (e.g., ‘I am aware of my child’s choice of friends, who they are, what they are like’), coercive control (e.g., ‘I do not allow my child to question my decisions’) and overprotection (e.g., ‘every free minute I have I spend with my child’) (Sleddens et al., 2014). The first three constructs can be regarded as the more ‘positive aspects’ of parenting, or authoritative behaviors (Sleddens et al., 2014). The measure was developed as consensually identified parenting questionnaires of high quality are currently lacking (e.g., most instruments only assessing limited aspects of parenting) (Sleddens et al., 2014). When completing the CGPQ, parents have to indicate on a five-point Likert scale how much they agree with statements regarding parenting, ranging from 1 (strongly disagree) to 5 (strongly agree). The questionnaire consists of 17 subscales with five items each (Sleddens et al., 2014). Mean scores were computed for each subscale provided that at least 60% of the items were completed. The Cronbach’s α for each of the five higher-order constructs in our sample were .82, .76, .74, .74 and .69, respectively. Based on poor psychometric properties of the construct behavioral control in this study (Cronbach’s α = .53), we decided to delete the newly developed subconstruct of ‘considering child input’ potentially belonging to this construct (Sleddens et al., 2014). Further validation of the CGPQ is necessary to assess the psychometrics of this subconstruct.

When the children were around 6 years old (mean age = 6.61, SD = .65), parents (mostly mothers) completed a questionnaire regarding their food parenting practices and dietary intake. A total of 1828 questionnaires (76%) were returned. After removing the second born of twins (N = 18), removing cases who did not complete any of the food parenting practices scales (N = 1) and cases who did not complete any of the dietary items (N = 156), 1654 cases remained for the analyses. At around age 8 (mean age = 8.60, SD = .66), another questionnaire was administered to parents of the KOALA study, assessing general parenting and children’s dietary intake. A total of 1853 questionnaires (79%) were returned. Of those, 1657 cases also had completed the previous measurement, but only 1654 cases remained for the analyses (see above). Food parenting practices Different validated instruments were used to measure food parenting practices at the child’s age of 6: the Parental Feeding Style Questionnaire (PFSQ) (Wardle, Sanderson, Guthrie, Rapoport, & Plomin, 2002), parental covert control over eating (Ogden, Reynolds, & Smith, 2006), and the Child Feeding Questionnaire (CFQ) (Birch et al., 2001). Mean scores were computed for each subscale provided that at least 60% of the items were completed. The Dutch validated translation of the PFSQ (Sleddens, Kremers, De Vries, & Thijs, 2010) was used to assess the following four subscales: ‘instrumental feeding’ (four items, e.g., ‘If my child misbehaves I withhold his/her favorite food’), ‘emotional feeding’ (five items, e.g., ‘I give my child something to eat to make him/her feel better when he/she is feeling upset’), ‘control over eating’ (10 items, e.g., ‘I decide how many snacks my child should have’), and ‘encouragement to eat’ (eight items, e.g., ‘I encourage my child to enjoy his/her food’). Parents were asked to rate their feeding behavior on a five-point Likert scale from 1 (never) to 5 (always). In our sample, Cronbach’s α for each of the subscales were .65, .82, .72, and .75, respectively. Parental covert control has been defined as forms of control related to eating that cannot be detected by the child (e.g., Ogden et al., 2006). It was assessed using three items adapted from the 5-item covert control scale developed by Ogden et al. (2006) as these items were better suited for our study population. The items, with a five-point Likert scale ranging from 1 (totally disagree) to 5 (totally agree), were: ‘I try not to eat unhealthy food when my child is around’, ‘I avoid buying unhealthy foods at grocery stores’, and ‘I try not to buy foods that I would like because I do not want my child to have them’. The Cronbach’s α was .65 in our sample. The measures of restriction, pressure to eat and monitoring were based on the CFQ (Birch et al., 2001): (1) ‘restriction’ (two items, Pearson’s r = .31), the extent to which parents restrict their children’s access to unhealthy foods, corresponding to the dietary behaviors assessed in the questionnaire (‘I have to be sure that my child does not eat too many unhealthy foods’ and ‘I have to be sure that my child does not drink too many sugar-sweetened beverages’), (2) ‘pressure to eat’ (four items, e.g., ‘My child should always eat all of the food on his/her plate), and (3) ‘monitoring’ (four items, e.g., ‘How much do you keep track of the snacks/sweets that your child eats’).

Child dietary behavior Dietary behavior of children was assessed using 10 items from a validated Food Frequency Questionnaire (FFQ), administered at the child’s age of 6 and 8 years, designed to accurately assess energy intake of Dutch children aged 2–12 years (Brants, Stafleu, Ter Doest, Hulshof, & Thijs, 2006; Dutman et al., 2010). The 10 items were chosen as we were interested in the consumption of snacks, fruit, sugar-sweetened drinks and water. These dietary behaviors have been found to be related to the development and prevention of childhood obesity (e.g., Daniels & Popkin, 2010; Hu, 2013; Ledoux, Hingle, & Baranowski, 2011; Rosenheck, 2008). Additionally, the participant burden was too high if we administered the total FFQ also assessing other dietary behaviors. The original FFQ (71 items) has been validated using the doubly labeled water method and shows that mean energy intake as calculated from these items did not differ from the mean energy expenditure as assessed with the doubly labeled water method. The Pearson correlation coefficient between energy intake and energy expenditure was .62 (Dutman et al., 2010). For all of the eating and drinking variables the following response categories were used: never, less than 1 day a week, 1 day a week, 2–3 days a week, 4–5 days a week, and 6–7 days a week. Children’s snacking frequency of several sugar-sweetened and energy-dense food products (between meals) was assessed with four items derived from this FFQ. Parents were asked to indicate how many days a week (normal week) their children consumed the

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following snacks in between meals: (1) fried snacks, (2) potato crisps, salted biscuits, and peanuts, (3) cake or large biscuits, and (4) pie, pastry, candy bars, and chocolates. A single score was calculated for the number of snacking occasions (between meals), by adding reported frequency (in days a week) of the different snacks (i.e., range 0–28). Both children’s sugar-sweetened soft drink consumption and water consumption were assessed with two items. Parents were asked to indicate on how many days a week their child consumed these drinks. Additionally, parents were asked to indicate the number of glasses their child consumed of these drinks on such a day. One glass equals 250 ml. Frequency and amount of soft drinks and water consumed were multiplied to obtain an average score of glasses of soft drinks and water consumed a week. Fruit consumption was assessed by asking parents to indicate how many days a week (normal week) their child consumed fruit. Additionally, parents were asked to indicate the number of servings their child consumed on such a day, corresponding with earlier validation studies (Bogers, Van Assema, Kester, Westerterp, & Dagnelie, 2004). One apple or one pear counted as one serving, two mandarins counted as one serving, and one bunch of grapes counted as one serving as well. Multiplying frequency with the reported usual amount computed an average score for the number of fruit servings consumed per week. Parental background characteristics For educational level, seven categories were distinguished which were recoded into three levels (low, medium, and high), in line with international classification systems (Eurostat, 2007). Country of birth was recoded into ‘Netherlands’ versus ‘other country’. In addition, maternal age at birth of the child and recruitment group (conventional versus ‘alternative’ lifestyle) was used in the current analyses. Data analyses Partial correlations were computed for a general assessment of the correlations between food parenting practices and the potential moderating factors (i.e., five general parenting constructs), adjusted for several covariates listed at the end of this paragraph. Thereafter, separate linear regression analyses were performed to examine the relationship between food parenting practices and child dietary behavior (i.e., snacking, sugar-sweetened beverage intake, fruit intake, and water consumption). For each of the four dietrelated outcomes the analyses were performed twice using different dependent variables, one predicting dietary behavior at age 8, the other predicting dietary behavior change from age 6 to 8 (adjusting dietary behavior at age 8 for dietary behavior at age 6). All food parenting practices were entered simultaneously, correcting for potential confounding by the other variables. Finally, in order to examine whether general parenting moderated the association

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between food parenting practices and children’s dietary behavior, we calculated interaction terms between the food parenting and general parenting variables. The interaction terms were added to four different regression models (i.e., in each model one of the four dietary behaviors was set as the dependent variable) in the fourth step using a forward entering procedure. The threshold for including interaction terms in the stepwise regression was set at p < .10, suggested by Stone-Romero and Liakhovitski (2002). For each of the three models, we added all main effects of the potential moderating variables together in the third step. Stratified linear regression analyses were performed, in order to examine the association between food parenting practices and child dietary behavior in the different strata of the moderator variables (i.e., general parenting). For each of the moderators, three groups were created based on half a standard deviation from the mean score (less than −.5 SD, −.5 SD to .5 SD, and higher than .5 SD from the mean), to obtain roughly similar group sizes. All analyses were adjusted for the influence of several potential covariates: recruitment group (conventional versus ‘alternative’ lifestyle), educational level (low, medium, and high; highest educational level attained within a family), country of birth of mother and father (Netherlands versus other), maternal age at birth, and gender and age of the child. The hierarchical multiple regression analyses were additionally controlled for child baseline BMI z-score (at age 6), because parents’ food parenting practices may depend on to their weight perceptions of their child (e.g., Webber, Cooke, Hill, & Wardle, 2010). Results Of the 1654 children eligible for the current study 51.3% were boys and 48.7% were girls. The majority of the mothers (96.8%) and fathers (95.8%) were born in the Netherlands. Moreover, most of the families were characterized by a conventional lifestyle (81.3%) compared with an ‘alternative’ lifestyle (18.7%). Educational level was high for 66.6% of the families, medium for 28.7%, and low for 4.8%. Average maternal age at the time of their child birth was 32.31 years (SD = 3.72). Children consumed snacks 4.93 (SD = 2.83) times a week at age 8. Children’s mean intake of sugar-sweetened beverage and water at age 8 was 2.20 (SD = 4.26) and 9.75 (SD = 8.60) glasses per week, respectively. The mean number of servings of fruit per week at age 8 was 7.75 (SD = 4.32). Associations between general parenting and food parenting (A in Fig. 1) General parenting practices correlated with most of the food parenting practices, although modestly at most (r = .24 or lower, Table 1). Nurturing and structuring parents applied less instrumental and emotional food parenting practices and more encouragement and controlling practices. Parents scoring high on behavioral control more

Table 1 Partial correlations between food parenting practices and general parenting. Mean (SD)

General parenting Nurturance Structure Behavioral control Coercive control Overprotection

4.50 (.32) 4.08 (.37) 4.01 (.39) 1.95 (.41) 2.69 (.52)

Food parenting practices Instrumental feeding

Emotional feeding

Control

Encouragement

Covert control

Pressure to eat

Restriction

Monitoring

−.16*** −.21*** .06* .23*** .02

−.11*** −.19*** .02 .17*** .10***

.15*** .24*** .19*** .05 .03

.31*** .23*** .17*** −.09*** .07**

.08** .08*** .07** .02 .17***

.02 .01 .21*** .18*** .15***

.18*** .18*** .19*** −.04 .04

.18*** .18*** .19*** .02 .14***

Note: n = 1624; Partial rank correlation coefficients, adjusted for recruitment group, parental educational level, country of birth, maternal age at birth, and child gender and age; CGPQ/CFQ answering scale 1–5; *p ≤ .05, **p ≤ .01, ***p ≤ .001.

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between the general parenting and food parenting practices in explaining child dietary behavior at age 8 and change from age 6 to 8, and the results of the stratified analyses. In Fig. 2, we graphically display these stratified analyses only for associations between the food parenting practices and the outcomes that were statistically significant in one or more of the strata of the moderator variable (12 graphs in total). In total, 22 interactions were found between food parenting practices and general parenting in predicting child dietary behavior. Generally, we found that the parenting practices of encouragement (Fig. 2.1) and covert control (Fig. 2.2) had more desirable effects when parents scored higher on positive (i.e., behavioral control) and lower on negative (i.e., overprotection) general parenting constructs, respectively. One exception; for all levels of overprotection, the association between covert controlling parenting and child snacking was desirable. For restriction (Fig. 2.3), more desirable effects were found when parents scored low on behavioral control (more fruit intake) and high on coercive control (more water intake). Instrumental feeding (Fig. 2.4) had stronger relations with undesirable child dietary behavior (i.e., less fruit intake) in less controlled and overprotective home environments. When parents scored intermediate on behavioral control, instrumental feeding was related to lower sugar-sweetened beverage intake, whereas when parents scored high on behavioral control, instrumental feeding was related to higher sugar-sweetened beverage intake. Additionally, the negative relation between instrumental feeding and water consumption was stronger among children of parents who scored high on nurturance. Lastly, pressure to eat (Fig. 2.5) indicated to have an undesirable effect on child dietary behavior (i.e., more sugar-sweetened beverage intake) among children of parents scoring intermediate and high on behavioral control. For the remaining 10 interactions, the stratified analyses were not significant, so they are not considered further.

often used encouraging and controlling food parenting practices. Coercive control was positively related to instrumental and emotional feeding, and overprotection was related to emotional feeding. Overprotective parents more often indicated to keep foods out of reach of their children (covert control). The controlling general parenting constructs (i.e., behavioral control, coercive control, and overprotection) were positively related to pressure to eat. Associations between food parenting and child dietary behavior (B in Fig. 1) We examined the extent to which food parenting practices predict child dietary behavior. The strength of associations was generally low as indicated by the size of the standardized regression coefficients between −.19 and .13 (see Table 2). The associations between food parenting practices and child’s dietary behavior at age 8 were mostly attenuated by controlling for baseline dietary behavior and BMI z-score at age 6 (compare models 1 and 2, Table 2). Instrumental feeding at age 6 was related to less fruit intake at age 8. This association was also present with fruit intake change from age 6 to 8 as an outcome. Emotional feeding was related to increased child snack intake, both cross-sectionally and longitudinally. Encouragement was positively related to fruit intake when not controlling for baseline fruit intake and BMI z-score. Pressure to eat was positively associated with unhealthy behavior (i.e., snacking and consumption of sugar-sweetened beverages). Monitoring was not significantly related to dietary behavior. The results for the controlling food parenting practices (e.g., PFSQ control, CFQ restriction, and covert control) were mixed. Control as measured by the PFSQ was not associated with any of the child eating outcomes. Parental restriction had a desirable effect on the consumption of sugar-sweetened drinks and water (leading to a lower and higher intake, respectively). Parents who kept unhealthy foods out of reach from their children (covert control) were more likely to have children who are eating healthily (i.e., less snacking and sugar-sweetened beverage intake, and more fruit and water intake).

Discussion Many studies on food parenting fail to consider the larger family context. The present study provides evidence for effective and ineffective food parenting practices, as well as for child- and parentrelated contexts that moderate their impact. The relatively weak main effects could be summarized as follows: instrumental and emotional feeding, and pressure to eat were found to have detrimental associations with child dietary behavior (i.e., increased unhealthy intake/decreased healthy intake), whereas covert control,

General parenting constructs moderating the food parenting–child dietary behavior relationship (C in Fig. 1) We explored the moderating role of general parenting on the relationship between food parenting practices and children’s dietary behavior. In Table 3 we provide all significant interaction terms

Table 2 Associations between food parenting practices and child dietary behavior. Mean (SD)

Child dietary behavior Snacking

BMI z-score Baseline eating Food parenting Instrumental feeding Emotional feeding Control Encouragement Covert control Pressure to eat Restriction Monitoring

Sugar-sweetened drinks

Fruit

Model 1 n = 1390 Beta

Model 2 n = 1378 Beta

Model 1 n = 1159 Beta

Model 1 n = 1159 Beta



−.05 −

−.05* .54***



1.72 (.57) 1.42 (.46) 4.36 (.36) 3.88 (.47) 2.93 (.93) 3.51 (.75) 4.52 (.62) 4.31 (.56)

.01 .13*** −.03 −.02 −.19*** .07* −.04 −.05

−.01 .07* .01 −.03 −.09*** .03 .00 −.04

−.01 .02 −.05 −.01 −.08* .11** −.13*** .04

.03

Model 2 n = 1044 Beta .00 .49*** −.01 −.01 −.03 −.03 −.02 .07* −.07* .05

.04 − −.09* .04 −.02 .08** .09*** −.05 .06 .03

Water Model 2 n = 1078 Beta .01 .61*** −.09** .05 −.01 .05 .04 .00 .02 .03

Model 1 n = 1108 Beta .07* − −.03 −.05 −.02 .06 .12*** −.05 .10** −.02

Model 2 n = 982 Beta .04 .64*** .03 −.05 .00 −.02 .04 −.01 .04 .00

Note: Beta, standardized linear regression coefficient; Model 1, dependent variable is child dietary behavior around the age of 8 years which is additionally adjusted for child BMI z-score at age 6; Model 2, dependent variable is additionally adjusted for baseline child dietary behavior (snacking or sugar-sweetened drink intake or fruit intake or water intake) at age 6 and child BMI z-score at age 6; both models adjusted for recruitment group, parental educational level, country of birth, maternal age at birth, and child gender and age; food parenting practices answering scale 1–5; *p ≤ .05, **p ≤ .01, ***p ≤ .001.

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Table 3 Interaction terms and stratified analyses food parenting–child dietary behavior relationship. Dietary behavior

Year

Snacking

6–8

Sugar-sweetened beverage

8 6–8 8

Fruit

6–8 8

Water

6–8 8

Interaction term (general parenting × food parenting)

Behavioral control × Encouragement* Structure × Pressure to eat Overprotection × Covert control* Behavioral control × Instrumental feeding* Behavioral control × Encouragement* Behavioral control × Pressure to eat* Behavioral control × Encouragement Behavioral control × Control Nurturance × Monitoring Behavioral control × Instrumental feeding* Behavioral control × Monitoring Behavioral control × Emotional feeding Behavioral control × Restriction* Overprotection × Instrumental feeding* Overprotection × Encouragement* Nurturance × Instrumental feeding Overprotection × Monitoring Nurturance × Instrumental feeding* Coercive control × Encouragement Coercive control × Restriction* Overprotection × Covert Control* Overprotection × Pressure to eat

Groups Low

Intermediate

High

Beta

P

Beta

P

Beta

P

Beta

P

−.62 .53 −.27 .77 −.91 .82 −1.16 .96 .89 .52 1.25 .66 −.69 .85 −.52 −.70 −.41 −1.10 −.55 .47 −.34 .53

.034 .045 .099 .007 .009 .018 .005 .054 .034 .049 .004 .027 .086 .031 .091 .024 .070 .004 .047 .083 .062 .014

.02 .03 −.14 −.04 .03 .03 .07 −.07 −.05 −.16 −.04 −.05 .15 −.02 .14 .01 .03 .06 .09 .05 .17 −.06

.624 .533 .005 .509 .539 .578 .218 .221 .344 .003 .444 .439 .012 .800 .011 .874 .536 .416 .112 .459 .003 .320

.00 −.02 −.21 −.11 .01 .15 −.01 −.07 .05 −.08 .03 .07 .10 −.13 .06 .08 .00 .02 .07 .10 .07 −.09

.994 .641 .000 .048 .788 .003 .899 .149 .308 .080 .553 .220 .064 .028 .231 .067 .977 .709 .157 .047 .170 .091

−.11 .08 −.19 .12 −.14 .13 −.08 −.02 .07 −.01 .08 .09 −.05 −.14 .06 −.04 −.04 −.15 −.01 .16 .09 .02

.010 .053 .000 .036 .005 .021 .135 .688 .081 .785 .169 .163 .437 .043 .312 .467 .445 .013 .881 .013 .184 .712

Note: *Interactions for which the association between the food parenting practice and the outcome was statistically significant in one or more groups of the moderator variable; Beta: standardized regression coefficient from linear regression analysis, stratified for the moderator (i.e., low, intermediate, high), model adjusted for recruitment group, parental educational level, country of birth, maternal age at birth, child gender and age, child BMI z-score at age 6 and all other food parenting practices (note that there were two different models: (1) dependent variable is additionally adjusted for baseline child dietary behavior at age 6 and adjusted for child BMI z-score at age 6, (2) dependent variable is child dietary behavior at age 8, adjusted for child BMI z-score at age 6.

encouragement and restriction were found to have favorable associations with child dietary behavior (i.e., increased healthy intake/ decreased unhealthy intake). This is confirming our hypotheses and most of these relationships have been demonstrated previously (e.g., Brown, Ogden, Vögele, & Gibson, 2008; Gubbels et al., 2009; Murashima, Hoerr, Hughes, & Kaplowitz, 2012; Rodenburg et al., 2013; Sleddens et al., 2010; Van der Horst et al., 2007). These associations were stronger for some subgroups of the moderating variables, as expected. The associations of encouragement and covert control with desirable child dietary behaviors were found to be stronger for children who were reared in a positive parenting context. Associations between food parenting and general parenting The more ‘positive’ constructs of general parenting (i.e., nurturance and structure) (Sleddens et al., 2014) were associated with lower use of instrumental and emotional feeding. Reversed associations were found for the more firmly controlling parents. Thus, those parents tend to give their child more foods in response to good behavior and to soothe their child. The other scales, except pressure to eat, were positively related to the authoritative aspects of parenting. For pressure to eat, we found positive associations with controlling parenting styles. This finding is partially supported by previous studies (Hennessy et al., 2010; Hubbs-Tait et al., 2008). Associations between food parenting and child dietary behavior We confirmed some of the results of previous studies in which nondirective child-centered food practices were related to consuming healthier diets (Murashima et al., 2012; Vereecken et al., 2010), and parental reward of food was related to unhealthy food (Kröller & Warschburger, 2009; Sleddens et al., 2010) and soft drink intake (Kröller & Warschburger, 2009). Parental restriction was negatively related to sugar-sweetened beverage intake and positively related to water intake, in contrast to previous studies that showed that high

levels of restriction can lead to increases in calorie intake and liking for the restricted food (e.g., Fisher & Birch, 1999; Jansen, Mulkens, & Jansen, 2007). However, the latter types of studies were mainly experimental looking at what the child eats when the parent is not around with free access to food. In line with a previous study within the KOALA birth cohort by Gubbels et al. (2009) we failed to confirm the paradoxical effect of increased intake of unhealthy foods following parental restriction, although we should be cautious in interpreting these findings as parent-reported child dietary intake only accounts for the dietary behaviors that parents see and are aware of. Coercing children to eat was associated with unhealthy eating. Higher levels of pressure in child feeding could have detrimental effects on children’s change in healthy dietary behavior, as children are focused away from internal cues to hunger and satiety (Francis, Hofer, & Birch, 2001), leading to decreases in preference and intake of the healthy foods and subsequent increases in consumption of unhealthy foods. General parenting constructs modifying the food parenting–child dietary behavior relationship Moderating effects of general parenting on the relationship between food parenting practices and child eating behavior were found. For children who were reared in a positive parenting context, encouragement and covert control were found to work better (i.e., increased healthy intake/decreased unhealthy intake). However, some conflicting findings were found. The one concept standing out most was pressure to eat, which was related to sugar-sweetened beverage intake for children of parents scoring high on behavioral control. Pressure to eat often occurs when parents feel that their child is eating insufficient amounts of food or in response to their child’s underweight (Francis et al., 2001). Secondary analyses confirmed this assumption, as we found that parents of children who were underweight scored significantly higher on pressure to eat compared with parents of children who were overweight or obese (data

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E.F.C. Sleddens et al./Appetite 79 (2014) 42–50

Snacking

Sugar sweetened beverage

6-8 yr

6-8 yr

0,2

Fruit 8 yr

*

0,15 0,1 0,05

n.s. n.s. n.s.

0

n.s. n.s.

n.s.

-0,05 -0,1 **

-0,15

**

-0,2 -0,25

Behavioral control

Behavioral control

8 yr

0,2 0,15 0,1

n.s.

0 -0,05 -0,1 -0,15

**

-0,2 ***

6-8 yr

0,2 0,15 0,1

Fig. 2.2. Food parenting practice ‘covert control’.

*

* n.s.

* n.s.

0,05 0 -0,05

n.s.

-0,1 -0,15 -0,2 -0,25

Behavioral control

0,25

Sugar sweetened beverage

Fruit

Fruit

Water

0,2

6-8 yr

6-8 yr

8-yr

8 yr

0,15

Low (left bar), Intermediate (middle bar), High (right bar)

n.s.

0,05

n.s.

0 n.s.

-0,05

n.s.

-0,1

n.s.

n.s. *

-0,15

* **

-0,2 Behavioral control

Behavioral control

*

Overprotection

* Nurturance

Low (left bar), Intermediate (middle bar), High (right bar)

Fig. 2.3. Food parenting practice ‘restriction’.

Association (standardized regression coefficient)

*

0,1

-0,25

Coercive control

0,25

Overprotection

Low (left bar), Intermediate (middle bar), High (right bar)

Association (standardized regression coefficient)

Association (standardized regression coefficient)

Water

8 yr

***

Overprotection

Fig. 2.1. Food parenting practice ‘encouragement’.

Fruit

n.s.

0,05

Low (left bar), Intermediate (middle bar), High (right bar)

0,25

8 yr

**

-0,25

Overprotection

Water

Snacking

0,25

Association (standardized regression coefficient)

Association (standardized regression coefficient)

0,25

Fig. 2.4. Food parenting practice ‘instrumental feeding’.

Sugar sweetened beverage 8 yr

0,2 **

0,15

*

0,1 0,05

n.s.

0 -0,05 -0,1 -0,15 -0,2 -0,25

Behavioral control

Low (left bar), Intermediate (middle bar), High (right bar)

Fig. 2.5. Food parenting practice ‘pressure to eat’. Fig. 2. Stratified analyses: the food parenting–child dietary behavior relationship moderated by general parenting. Note: Red bars represent significant associations between food parenting and undesirable behavior (i.e., increased unhealthy intake/decreased healthy intake), green bars represent significant associations between food parenting and desirable behavior (i.e., increased healthy intake/decreased unhealthy intake), white represent nonsignificant associations between food parenting and child dietary intake; bars within each cluster represent the stratified levels of the moderator (i.e.,general parenting constructs); *p ≤ .05, **p ≤ .01, ***p ≤ .001.

E.F.C. Sleddens et al./Appetite 79 (2014) 42–50

not reported). Low weight status has been proven to be related with more food avoidant behaviors (Jansen et al., 2012; Sleddens, Kremers, & Thijs, 2008). As a result, parents could apply coercing food parenting practices trying to increase their child’s calorie intake, and probably also increasing their child’s unhealthy dietary behavior (i.e., snacking and sugar-sweetened beverage intake). Our moderation results should be interpreted with caution and more studies are needed before drawing definite conclusions. Study strengths and limitations This study benefitted from a longitudinal design, with measures of child dietary behavior repeated at age 6 and 8. The included variables (food parenting practices and general parenting) were measured with instruments validated for the Dutch context (Bogers et al., 2004; Brants et al., 2006; Dutman et al., 2010; Sleddens et al., 2010, 2014). Moderation analysis was possible thanks to a large sample size and sufficient diversity within the study. We confirmed the operation of higher-order moderation processes, implying that parenting factors at higher, more distal, levels alter the impact of food parenting practices at more proximal levels. We recommend future studies to include the theory-based examination of possible moderation effects and ensure sufficient study size to do so; or examine specific hypotheses in smaller scale studies with careful selection of the contextual situation. There were also some limitations that need special attention. Highly educated parents and parents with an ‘alternative’ lifestyle were overrepresented in our sample, partially due to the choice of recruitment methods (Gubbels et al., 2009), although mean values for the parenting variables (i.e., general parenting and food parenting) were comparable with previous studies (e.g., Sleddens et al., 2010, 2014). We therefore adjusted all analyses for highest education level attained and recruitment channel. Additionally, all of the measured variables were reported by parents. This may evoke social desirability. The associations between food parenting practices and children’s dietary behavior should therefore be interpreted with caution. Cronbach’s alpha for the pressure to eat scale of the CFQ was quite low, although this finding is in accordance with some previous studies using this scale (e.g., Boles et al., 2010; Gregory, Paxton, & Brozovic, 2010). In spite of the longitudinal analysis, causality is difficult to establish, since part of the associations (and interactions) may be modified by parental adaptations to unwanted behavior. Snacking and intake of sugar-sweetened drinks were studied as unhealthy behaviors, and fruit and water intake as healthy behaviors. Of course, other behaviors such as breakfast and vegetable consumption are important as well to determine dietary intake. Finally, any choice of single food groups as healthy or unhealthy is deemed to be debatable due to complexities such as substitution (e.g., between fruit, natural fruit drinks, sweetened fruit drinks and soft drinks, tea, water and milk drinks), and the ambiguities of relations with specific health indicators such as nutritional imbalances, dental health, and overweight development. Further studies are needed with specific health outcomes to evaluate whether moderation by contextual factors as shown in our study with health behaviors as outcome also translate to health outcomes such as overweight development. Conclusion Our results show that food parenting practices are important determinants in explaining child dietary behavior, and that general parenting behaviors moderate this association. Future research efforts should continue to focus on testing the influence of factors (e.g., general parenting, but also child characteristics such as temperament and eating style) impacting on the food parenting–child eating and/or weight relationship in order to gain insights into relevant con-

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Food parenting practices and child dietary behavior. Prospective relations and the moderating role of general parenting.

Research on parenting practices has focused on individual behaviors while largely failing to consider the context of their use, i.e., general parentin...
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