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Research report

Parental perceptions, feeding practices, feeding styles, and level of acculturation of Chinese Americans in relation to their school-age child’s weight status ☆ Q1 Hsiao-Liang Pai, Isobel Contento * Department of Health and Behavior Studies, Teachers College Columbia University, 525 W. 120th Street, New York, NY 10027, USA

A R T I C L E

I N F O

Article history: Received 19 October 2013 Received in revised form 28 April 2014 Accepted 30 April 2014 Available online Keywords: Parental perceptions Parental feeding practices Parental feeding styles Acculturation Chinese American

A B S T R A C T

Parents influence their child’s eating behavior and attitudes directly as food providers and indirectly through their parental feeding styles and feeding concerns and practices. Chinese American parents’ practices are likely influenced by culture. The objective of this study was to explore the relationships between parental perceptions, feeding practices, feeding styles, level of parental acculturation (LPA), and child weight status via a self-administered questionnaire. This survey study involved a convenience sample of 712 individuals who were parents of 5- to 10-year old children attending Chinese language after-school programs. The prevalence of overweight was 11.5% and obesity was 11.1%. LPA was not directly predictive of child overweight in multiple regression but from categorical data, Chinese American parents tended to use indulgent (33.2%) and authoritarian (27.9%) feeding styles, with the former increasing with acculturation and the latter decreasing. Indulgent parents had more than expected overweight and obese children, and authoritarian and authoritative parents, fewer. LPA was negatively predictive of pressure to eat healthy foods (p < .01), which was negatively correlated with child weight status (p < .01). LPA was also independently positively correlated to responsiveness to child needs (p < .01), monitoring of child intake (p < .01), and perceived responsibility for child feeding. Parental perceptions and concerns about child weight were predictors of child weight. Consequently, parental concerns and responsiveness to child needs without also encouragement (demandingness) to eat healthy foods (indulgent feeding style) may promote overweight. The authoritative parental feeding style may contribute to children having healthy weights and therefore healthy lives. © 2014 Published by Elsevier Ltd.

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Introduction Most developed, and increasingly, developing countries are currently plagued by serious health conditions such as overweight and obesity in adults and children (Popkin, 2009). The risk of becoming obese has begun to cross cultural, racial, and socioeconomic backgrounds. Studies show that childhood obesity has been associated with an increased risk for later cardiovascular diseases (Freedman, 2002), type 2 diabetes, metabolic disorders, and increased morbidity and mortality in adulthood (Ogden, Flegal, Carroll, & Johnson, 2002). There is often a marked increase in the level of obesity for children born in the second or third generation compared to the first

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☆

Acknowledgements: The authors would like to thank Dr. Heewon Lee Gray and Mr. Ivo Antoniazzi for statistical support, the Culture Center of Taipei Economic and Cultural Office in New York, and the parents, teachers, and principals of the schools for their participation. * Corresponding author. E-mail address: [email protected] (I. Contento).

67 generation of immigrants to a more developed country (Popkin & 68 Udry, 1998). Estimates of overweight and obesity combined in United 69 States (U.S.) born Chinese American children range from 25% in one 70 study of 4,695 children 6–11 years old (Au, Kwong, Chou, Tso, & 71 Wong, 2009; Tarantino, 2002) to 46% for a sample of those 8–10 years 72 old (Chen, Weiss, Heyman, & Lustig, 2011). The national U.S. average 73 for overweight and obesity combined for children 6–11 years old is Q2 74 31% (Centers for Disease Control and Prevention, 2013). 75 Factors contributing to childhood obesity are numerous, among 76 them genetic factors and behavioral factors such as a high energy 77 density diet, physical inactivity, and social and environmental risk 78 factors. (Barlow, 2007; Berkey et al., 2000). In this context, fami79 lies can be a crucial contributing factor. 80 81 Parental influence on children’s eating behavior 82 83 Parents create a home environment that plays a critical role in 84 shaping children′s food preferences, eating behaviors, and energy 85 intake (Ventura & Birch, 2008). Savage, Fisher, and Birch (2007) note 86 that children learn what, when, and how much to eat based on the 87 transmission of cultural and family beliefs, attitudes, and prac-

http://dx.doi.org/10.1016/j.appet.2014.04.029 0195-6663/© 2014 Published by Elsevier Ltd.

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tices surrounding food and eating. Parents shape the development of children′s eating behaviors, not only by the foods made accessible to children (as food providers) but also by their own eating practices (as role models), and their parenting styles, child feeding styles, and perceptions and practices (Rhee, 2008; Ventura & Birch, 2008). General parenting styles has been defined as a constellation of attitudes and beliefs that create a socio-emotional climate within which parenting practices are applied (Darling & Steinberg, 1993). Parenting style is usually classified into one of four categories based on variations in the dimensions of warmth or “responsiveness,” and degree of control or “demandingness” that parents express (Blissett, 2011; Rhee, 2008). The authoritarian style is typified by low warmth or responsiveness and a high degree of demandingness/control while the authoritative parenting style by high warmth and responsiveness and also high demandingness/control. The indulgent-permissive parenting style is characterized by high warmth and low demandingness/control while the neglectful-permissive style by low warmth and low demandingness/control. The relationship between these general parenting styles and child weight or food intake appears to minimal (Vollmer & Mobley, 2013). Parental feeding styles consist of the general parenting styles that have been applied to the food domain (Blissett, 2011; Costanzo & Woody, 1985; Rhee, 2008). They thus consist of the same four typologies. Responsiveness refers to how the parents encourage eating (i.e., the level of nurturance parents use in in directing their child’s eating). Demandingness refers to how much the parent encourages eating (i.e., how demanding they are during the eating experience) (Baranowski, 2013; Blissett, 2011; Hughes, Power, Fisher, Mueller, & Nicklas, 2005). These have been shown to play a contributing role in the weight status of children (Brann & Skinner, 2005; Chen & Kennedy, 2004, 2005; Hughes et al., 2005). Parental feeding practices are embedded in their feeding styles and may vary based on parental concerns and perceptions of the child′s risk for developing a problem in the domain of food (Blissett, 2011; Costanzo & Woody, 1985; Darling & Steinberg, 1993). The most studied to date are concerns and perceptions related to child weight (Birch & Davison, 2001; Johnson & Birch, 1994; Ventura & Birch, 2008). Parental feeding practices are specific techniques parents usually use to facilitate or limit ingestion of foods. The most commonly measured include practices such as pressure to eat healthy food, restriction of less healthful food, monitoring of the child’s food intake, or the use of rewards for food consumption. One widely used instrument is the Child Feeding Questionnaire (Birch & Davison, 2001), that focuses on parental feeding concerns and practices related to child weight, in particular practices related to a controlling or authoritarian feeding style (Birch & Fisher, 2000; Ventura & Birch, 2008). Hughes et al. (2005) expanded theorizing to include parenting practices in relation to the full range of parental feeding styles, and these can be measured with the Caregiver’s Feeding Style Questionnaire (Hughes et al., 2005). Parental feeding practices are often shaped by parents’ own experience with food and eating and concern about their own weight (Johnson & Birch, 1994). They are also likely to be shaped by their cultural group (Arredondo et al., 2006; Hughes et al., 2005; Hughes, Shewchuk, Baskin, Nicklas, & Qu, 2008; Matheson, Robinson, Varady, & Killen, 2006). The Chinese parenting style has often been described as “controlling” or “authoritarian” (Chao, 1994). This is considered acceptable by individuals in Asian sociocultural systems because “the legitimate right and responsibility of parents to exert authority over their children is unquestioned by children and adults alike” (Rohner & Pettengill, 1985, p. 527) and indeed is seen as reflecting “parental concern, caring and loving involvement” (Chen & Kennedy, 2005, p. 113). According to parental feeding style theory, the use of the authoritarian parenting style by Chinese American parents would be expected to be associated with more controlling feeding practices (such as pressure to eat healthy foods and restriction of unhealthy

foods) and should be predictive of an increased risk for childhood obesity (Huang et al., 2012; Hubbs-Tait, Kennedy, Page, Topham, & Harrist, 2008; Hughes et al., 2005). However, it is not known which parental feeding practices and feeding styles are used by the primary caretakers in Chinese American families. Furthermore, these parenting practices and feeding styles may differ by degree of acculturation into mainstream American society (Chen & Kennedy, 2005). The purpose of this study was to examine the relationships between parental perceptions, feeding practices, feeding styles, and level of parental acculturation of Chinese Americans and their schoolage child’s weight status. Methods Participants: inclusion and exclusion critera Parents aged 25 to 56 years old whose children attended bilingual and/or bicultural public elementary schools or Chinese weekend language schools in New York City area were recruited to participate in this study. The participants had to have at least one child aged between 5 and 10 years old. If a family had two or more children, they were invited to complete the questionnaire only for the youngest child within this range. The participants had to have a Chinese ethnicity background but could be either Chinese or English speaking. Cross-cultural marriages were excluded from this study due to the possible impact of multiple cultures on the parenting perceptions, feeding practices, feeding styles, and level of parental acculturation. Procedures The study protocol and instruments were reviewed and approved by the Internal Review Board of the research university. A list of Chinese weekend language schools was obtained from Chinese American community organizations, and 13 out of 15 were selected based on geographic criteria. One public dual language elementary school was also included. When a school’s principal agreed, the principal investigator gave that principal a letter describing the purpose of study, consent forms, and copies of the survey instrument (in both English and Chinese) to distribute to all teachers who had students aged 5 to 10 in their classrooms. Teachers asked the children to bring the research questionnaire home to parents. Parents were asked to complete the questionnaire at home. Teachers collected all the questionnaires back the next school day (or the following weekend). Between September to November 2012, 1,000 parental questionnaires were distributed. Measures The research instrument was a self-report questionnaire constructed from three validated instruments: Suinn-Lew Asian SelfIdentity Acculturation scale, Child Feeding Questionnaire, and Caregiver′s Feeding Style Questionnaire, and demographic information. The questionnaire was translated into traditional Chinese. To ensure that item concepts were comparable for both the English and traditional Chinese versions, back-translations were conducted and the questionnaire revised through two pilots. Examples of questions for each of the constructs in the instrument are shown in Table 1 along with consistency reliability data. The Suinn-Lew Asian Self-Identity Acculturation scale (SL-ASIA) (Suinn, Richard-Figueroa, Lew, & Vigil, 1987) was used to assess level of parental acculturation (LPA) in two ways. Questions asked about language, identity, friendships, and behaviors. A validated nineitem version of the original SL-ASIA provided continuous data (Liou & Contento, 2001). Each question can range from 1 (low acculturation) to 5 (high acculturation). A final acculturation score was cal-

Please cite this article in press as: Hsiao-Liang Pai, Isobel Contento, Parental perceptions, feeding practices, feeding styles, and level of acculturation of Chinese Americans in relation to their school-age child’s weight status, Appetite (2014), doi: 10.1016/j.appet.2014.04.029

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Table 1 Measures used in study: examples of questions and internal consistency reliability (Cronbach’s alpha) coefficients.

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3

Measurement categories and scales Level of parental acculturation • Survey (9 items; range of scores: 1 = only Chinese, 3 = both equally, 5 = only English) • Categorical data

Example of questions • • • •

What language(s) do you read, speak, and think in? If you can choose a family doctor or other health professional, whom do you prefer? What kind of food do you prefer − at home, and restaurant(s)? Rate yourself on how much you believe in Chinese values (e.g., about marriage, families, education, work)? Rate yourself on how well you fit when with other Chinese of the same ethnicity:

.90

• •

Your childhood (5 to 10years old), adolescence, 20s, present weight status Your child during the first year of life, as a toddler, preschooler, kindergarten through 2nd grade, and 3rd through 5th grade

.67 .82

•

How often are you concerned about your child eating too much when you are not around her? How often are you responsible for deciding what your child’s portion sizes are, eating the right kind of foods?

.87

• Parental perceptions of weight (1 = markedly underweight, 5 = markedly overweight) • Perception parent weight (4 items) • Perception child weight (5 items)

Q11

Parental feeding perceptions (Range of scores 1–5) • Concern about child weight (3 items) • (1 = unconcerned, 5 = very concerned) • Perceived responsibility (3 items) • (1 = never, 5 = always) Parental feeding practices (Range of scores: 1 = disagree, 5 = agree) • Restricting unhealthy foods (8 items) •

Monitoring child intake (3 items)

• Pressure to eat healthy foods (4 items) Feeding styles Continuous data (range of scores: 1 = never, 5 = always) • Demandingness (calculated with 19 items)

•

Child-centered (calculated with 7 items)

Reliability Cronbach’s alpha

•

• • •

• • • •

You have to make sure that your child does not eat too many sweets, high-fat foods, and favor foods? How much do you keep track of the snack foods (potato chips, Doritos, cheese puffs) that your child eats? Your child should always eat all of the food on her plate.

.82

.78 .94 .71 .88

Say to the child “Hurry up and eat your food.” Warn the child that you will take away something other than food if he or she doesn’t eat (e.g., “If you don’t finish your meat, there will be no play time after dinner”). Reason with the child to get him or her to eat (e.g., “Milk is good for your health because it will make you strong”) Allow the child to choose the foods he or she wants to eat for dinner from the foods already prepared

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culated by the dividing the total value by 9. Thus a low score (low acculturation) reflects high Asian identification, and a high score (high acculturation) reflects high Western identification. These data were used to examine variables by level of acculturation. Because acculturation is not linear and mono-dimensional but multi-dimensional and orthogonal, the instrument developers added four additional questions to the original SL-ASIA scale to capture this aspect (Suinn, 1998). These questions asked respondents to rate themselves on how much they believed in Chinese values or felt they fit when with other Chinese or with non-Asians (Westerners). These questions were used to classify the participants into categories: Asian identified, Bicultural, and Western identified. These categorical data were used in some analyses. The Child Feeding Questionnaire (CFQ) (Birch & Davison, 2001) was used to assess parents’ concerns about child weight and use of controlling or demanding feeding practices. Eighteen questions examined seven factors placed into three categories: parental perceptions about weight (child’s and parent’s own weight); feeding concerns (perceived responsibility for child feeding and concern about child weight); and parental feeding practices (monitoring what the child eats, restricting less healthy foods, and pressuring the child to eat healthy food). Caregiver’s Feeding Styles Questionnaire (CFSQ) is a validated measure that assesses parental feeding styles (Hughes et al., 2005). The CFSQ consists of 19 questions describing verbal and physical feeding strategies. Caregivers indicate how often they engage in various behaviors with their child during mealtime. A five-point Likert scaled response category (never = 1 to always = 5) was used for each item. Seven of these 19 reflected child-centered practices. The CFSQ uses a typology approach: two scores are created – demandingness and responsiveness. To create a score for demand-

ingness, a total mean score is calculated across all 19 items; to create a score for responsiveness, a ratio of the seven child-centered items over the total score is calculated. These scores can be used as continuous variables in analyses. Median splits (Hughes et al., 2012) (calculated from the data as demandingness = 2.82, responsiveness = 1.07) were used to categorize the sample participants into the four parental feeding styles: high, high; and high, low; low, high; and low, low on the categories of demandingness and responsiveness, respectively. The values of the median splits were very similar to those found in other studies (Hughes et al., 2012). These categorical data were used in some analyses. Demographic information included the children’s and caregiver’s gender, age, body weight, and height. In addition, the caregivers reported their educational attainment, employment, marital status, participant’s role for child, hometown, length of residence in the U.S., person in charge of shopping and meal preparation, grandparents living with family or not, and family annual income. One variable was added: language used for answering research questions. Child BMI percentile for age and gender. Child’s body weight and height were based on self-reported information. Child’s BMI percentile lower than the 5th percentile was defined as underweight, BMIs between 6 and 84th percentile were defined as normal weight, BMIs between 85th and 94th percentile were defined as overweight, and BMI above 95th percentile were defined as obese, based on the growth charts developed by United States Centers for Disease Control and Prevention (2014). Adult BMI. Adult height and weight were self-reported, from which BMI was calculated for each person. BMIs for adults below 18.5 were defined as underweight, BMIs between 18.5 and 24.9 were defined as normal weight, BMIs between 25.0 and 29.9 were defined as overweight, and BMIs above 30 were defined as obese.

Please cite this article in press as: Hsiao-Liang Pai, Isobel Contento, Parental perceptions, feeding practices, feeding styles, and level of acculturation of Chinese Americans in relation to their school-age child’s weight status, Appetite (2014), doi: 10.1016/j.appet.2014.04.029

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Internal consistency Internal consistency reliability was calculated for each of the scales using Cronbach’s alpha and the data are shown in Table 1. Except for parental perception of own weight, the values are all at an acceptable level (>.70) of internal consistency.

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Statistical analyses All data including continuous and categorical data were statistically analyzed by SPSS Version 22 (2014) software. Descriptive analysis for continuous data included means, Q3 standard deviation, percentages, and residual, which were used to describe the age and gender of participants and their children, the family annual income, the length of residence in the U.S., the level of education, and the language used to answer research questionnaire. Descriptive analysis for categorical variable data was conducted by cross tabulation. The categorical variable data groups included (1) child weight status as underweight, normal weight, overweight, and obesity; (2) parental feeding styles of uninvolved, authoritarian, indulgent, and authoritative; and (3) acculturation groups as Asian identified, bicultural, and Western. Pearson correlations and multiple linear regressions were used to determine the relationships among (1) level of parental acculturation, (2) child BMI percentile, (3) parental perceptions about weight (parent and child), (4) feeding perceptions (concern child weight and perceived responsibility), (5) feeding practices (monitoring, restriction, and pressure to eat), (6) feeding styles dimensions (demandingness and responsiveness), (7) parents’ BMI. Multiple linear regression analysis was used to determine the relationship separately for child BMI percentile and level of parental acculturation separately as dependent variables with the independent variables found to be significant in correlations studies. Level of parental acculturation was not significantly correlated with age or gender of the caregiver but was significantly correlated with educational level (p < .001, r = .482), and family annual income (p < .001, r = .362). Consequently, all multiple liner regression analyses were conducted with parental education level and family income as covariates.

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Table 2 Characteristics of participants. Characteristics Gender of caregiver Male Female Age of caregiver (years) 30 or younger 31−40 41−50 Above 50 Caregiver’s relation to child Mother Father Grandparents or other Caregiver’s education level Less than high school High school graduate Some college College graduated or more Family annual income Under $50,000 $50,001−$80,000 $80,001−$100,000 More than $100,000 Unknown Language used in answering questions Chinese English Length of residence in the U.S. (Mean ± SD) Up to 5 years 6 to 10 years 11 to 20 years 21 years more Person who prepares meals Mother Father Grandparents or others Caregiver weight status (BMI) Underweight (BMI < 18.5) Normal weight (18.5 ≤ BMI ≤ 24.9) Overweight (25 ≤ BMI ≤ 29.9) Obese (BMI>30) Unknown Gender of child Boy Girl

N = 615

Percent

106 509

17.3% 82.7%

26 360 218 11

4.2% 58.5% 35.4% 1.8%

509 98 8

82.8% 15.9% 1.3%

79 108 70 349

12.9% 17.6% 11.4% 56.8%

209 107 73 198 28

33.98% 17.40% 11.87% 32.20% 4.55%

304 311 1–49 (18.26 ± 8.85) 18 105 290 191

49.4% 50.6%

437 56 116

71.1% 9.1% 18.9%

39 428 105 12 31

6.3% 69.6% 17.1% 2.0% 5.0%

390 324

47.1% 52.7%

2.93% 17.07% 47.15% 31.06%

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A thousand questionnaires were distributed. Out of 712 who participated (response rate 71.2%) in the study, 97 participants were excluded from the data analysis for the following reasons: (1) participant’s age was under 25 years or older than 56 years (n = 16), (2) missing age data (n = 40), (3) children’s age being younger than 4.7 years (n = 6), and (4) children′s age being older than 10.5 years (n = 35). The mean of participants’ children’s age was 7.42 ± 1.47 years, and 52.7% of the children were female. The mean age of the caregivers was 39.4 ± 5.12 years (range 25 to 56 years). Of the participants, 82.7% were the mother of the child. Most of the participants’ (95%) had an education level of high school or above, and 56.8% of caregivers had a college degree or higher. The participants’ family annual income ranged from below $50,000 (34%), $50,000–$100,000 (29.3%), to more than $100,000 (32.2%). Half of the participants chose the English version questionnaire and the other half chose the Chinese version. 80% of participants had been residents of the U.S. for over 10 years, and 31.1% of participants for more than 20 years. As shown in Table 2, the caregivers’ weight status was 17.1% overweight and 2.0% obese. The prevalence of child overweight was 11.5%, and obesity was 11.1%. Boys had higher (15.3%) prevalence of obesity than girls (7.4%).

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Results Demographic characteristics of participants

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The correlation of parental perceptions and child BMI percentile Parent’s perception of their own weight (PPW) was correlated with their own BMI (r = .40, p < .001) and with perception of their child′s weight (PCW) (r = .23, p < .001) (data not shown) but not with child’s weight status measured as BMI percentile. The child′s BMI percentile was positively and significantly correlated with parents’ own BMI, parents’ perception of child weight (PCW), and concern about child weight (shown in Table 3).

114 115 116 117 118 119 120 121 122 123

The correlation of parental feeding practices and child BMI percentile Table 2 shows pressure to eat healthy foods was negatively and significantly correlated with child’s BMI percentile while restriction of less healthy foods was not.

124 125 126 127 128 129

The correlation of parental feeding styles dimensions to parental perceptions and feeding practices Demandingness in terms of parental feeding style was significantly positively correlated with perceived responsibility for child feeding perceptions, and with the practices of restriction of less healthy foods, monitoring, and pressure to eat healthy foods, but

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Table 3 Correlation of child’s BMI and level of parental acculturation (LPA) with parental feeding perceptions, practices, and feeding styles dimensions. Variables

Child’s BMI percentile

4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

5

LPAg

Demandingnessf

Responsivenessf

−.023 .004

−.039 −.146**

.082* .119**

Pearson correlation (r) (A) Parental perceptions and feeding practices (1) Parental perception about weight • Perception parent weighta (PPW) • Perception child weighta (PCW) (2) Parental feeding perception • Concern child weightb • Perceived responsibilityc (3) Parental feeding practices • Monitoringd • Restriction of less healthy foodse • Pressure to eat healthy foodsd (B) Parental feeding styles • Demandingness • Child-centered • Responsiveness (C) Parent’s BMI Child’s BMI percentile

.08 .242** .171** .055

.055 .122**

.042 .082*

.060 .114**

−.020 .061 −.140**

.124** −.053 −.201**

.176** .286** .408**

.052 −.130** −.350**

−.175** −.141** .068 .168**

−.056 .032 .15** .063 −.026

−.085* −.175**

.132** .068

*** Significant at the .001 level (2-tailed). ** Significant at the .01 level (2-tailed). * Significant at the .05 level (2-tailed). Scale: 1–5: a Response options: 1 (markedly underweight), 2 (underweight), 3 (normal), 4 (overweight), 5 (markedly overweight). b Response options: 1 (unconcerned), 2 (a little concerned), 3 (concerned), 4 (fairly concerned), 5 (very concerned). c Response options: 1 (never), 2 (seldom), 3 (half of time), 4 (most of time), 5 (always). d Response options: 1(never), 2 (rarely), 3 (sometimes), 4 (mostly), 5 (always). e Response options: 1 (disagree), 2 (slightly disagree), 3 (natural), 4 (slightly agree), 5 (agree). f Response options: 1 (never), 2 (rarely), 3 (sometimes), 4 (most of the time), 5 (always). g Response options: 1 (low acculturation) – 5 (high acculturation).

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was significantly negatively correlated with perception of child weight and with child’s BMI percentile (Table 3). Responsiveness was positively and significantly correlated with parental perception of own weight and child weight and with perceived responsibility for child feeding, and negatively and significantly correlated with restriction of less healthy foods and pressure to eat healthy foods (Table 3). The correlation of level of parental acculturation, parental feeding perceptions, feeding practices, feeding styles dimensions, and child BMI percentile Based on analyses of continuous data, the level of parental acculturation (LPA) was not related to child BMI percentile. However,

as shown in Table 2, LPA was positively correlated with responsiveness in terms of feeding style (p < .01), perceived responsibility in child feeding (p < .01), and the practice of monitoring child food intake (p < .01). LPA was negatively related to the pressure to eat healthy foods (p < .01). The description of child weight status, parental feeding styles, and level of parental acculturation relationships based on categorical data Analyses based on categorical feeding style data showed that Chinese American parents more often used the indulgent (33.2%), authoritarian (27.9%), and uninvolved (21.3%) feeding styles, and less often the authoritative (17.6%) feeding style (see Table 4). The ma-

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Table 4 Cross tabulation of child weight status and level of parental acculturation (LPA) with parental feeding styles. Child weight status

52

Uninvolved

53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69

Feeding styles

Underweighta Normal weightb Overweightc Obesityd Total (% of total) LPA Asian identified Bicultural Western Total (% of total)

Authoritarian

Indulgent

Authoritative N (%)

Total

N (%)

Residual

N (%)

Residual

N (%)

Residual

Residual

N (% of total)

22 (4.3) 58 (11.5) 14 (2.8) 14 (2.8) 108 (21.3)

4.3 −8.0 1.6 2.0

20 (4.0) 106 (20.9) 13 (2.6) 2 (0.4) 141 (27.9)

−3.1 19.9 −3.2 −13.6

23 (4.5) 92 (18.2) 24 (4.7) 29 (5.7) 168 (33.2)

−4.6 −10.6 4.7 10.4

18 (3.6) 53 (10.5) 7 (1.4) 11 (2.2) 89 (17.6)

3.4 −1.3 −3.2 1.2

83 (16.4) 309 (61.1) 58 (11.5) 56 (11.1) 506

81 (13.2) 41 (6.7) 3 (0.5) 125 (20.4)

9.0 −9.4 .3

111 (18.1) 65 (10.6) 2 (0.3) 178 (29.0)

8.5 −6.7 −1.8

97 (15.8) 98 (16.0) 7 (1.1) 202 (33.0)

−19.3 16.6 2.7

64 (10.4) 43 (7.0) 1 (0.2) 108 (17.6)

1.8 −.5 −1.3

353 (57.6) 247 (40.3) 13 (2.1) 613

(− Residual): The observed cell had a lower than expected count. (+Residual): The observed count in the cell in higher than the expected count. a BMI < 5%. b 5% ≤ BMI < 85%. c 85% ≤ BMI < 95%. d 95% ≤ BMI.

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Table 5 Regression analysis predicting children’s BMI from feeding perception, feeding practices, and feeding styles dimensions

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Dependent variables

Child BMI percentile

4 Q12

Predictors

Std. β|

5 6 7 Q13 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

(A) Parental Perceptions and Feeding Practices (1) Parental perception about weight • Perception parent weighta (PPW) • Perception child weighta (PCW) (2) Parental feeding perception • Concern child weightb • Perceived responsibilityc (3) Parental feeding practices • Monitoringd • Restriction of less healthy foodse • Pressure to eat healthy foodsd (B) Parental feeding styles • Demandingness • Child-centered • Responsiveness (C) Parent’s BMI Child BMI percentile R2 change Adjusted R2 df1 df2

Level of parental acculturation t

P-value

Std. β|

t

P-value

−.033 .180

−.674 3.829

.501 .000

−.020 .010

−.445 .227

.656 .821

.135 −.050

2.813 −1.059

.005 .290

.063 .050

1.430 1.157

.154 .248

−.069 .130 −.092

−1.311 2.475 −1.745

.191 .014 .082

.076 −.137 −.133

1.568 −2.844 −2.772

.117 .005 .006

−.093 −.015 .030 .124 – .129*** .104 11 452

−.285 −.046 .163 2.529 –

.775 .963 .870 .012 –

.120 −.083 .061 .058 −.010 .052** .264 12 449

.407 −.288 .360 1.300 −.231

.684 −.773 −.719 .194 .817

26 Q14 Std. β|: regression standardized coefficients. Family annual income and parent educational level were controlled for as a continuous variable. 27 *** Significant at the .001 level (2-tailed). 28 ** Significant at the .01 level (2-tailed). 29 * Significant at the .05 level (2-tailed). 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

jority of children for all parenting styles were normal weight, reflecting the overall rate of 61.1% normal weight (see Table 4). However, 31% of children of indulgent feeding style parents were overweight or obese and 54% normal weight (below the group mean). Indulgent parents had 15.1% more overweight and obese children than expected and 15.2% less underweight and normal weight than expected. Another way to look at it is that 51.8% (5.7% out of 11.1%) of obese children had indulgent style parents. Among uninvolved feeding style parents, 26% of children were overweight or obese (which was 17% more than expected) and 54% normal weight. On the other hand, 11.1% of children of authoritarian feeding style parents were overweight or obese (which was 16.8% less that expected) and 75.2% were normal weight. For authoritative feeding style parents, 31% of their children were overweight or obese and 59.6% normal weight (the second highest among the groups) (Table 4). Analyses based on categorical data from the acculturation scale show that Asian identified parents used all four parenting styles somewhat evenly while more acculturated parents practiced a more indulgent parenting style, increasing from 27.5% for Asian identified, to 39.7 % for bicultural to 53.8% for Western identified parents (Table 4). They also used the authoritarian feeding style less, decreasing from 31.5% for Asian identified, to 26.3% for bicultural, to 15.4% for Western identified.

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Relationship of child BMI percentile and parental feeding perceptions, feeding practices, feeding styles dimensions, and level of parental acculturation from multiple regression analysis Multiple linear regression analysis was used to determine the relationship separately for child BMI percentile and level of parental acculturation separately as dependent variables and the independent variables found to be significant in correlations studies: parental perceptions about weight (parent self and child), feeding perceptions (concern about child weight and perceived responsibility), feeding practices (monitoring, restriction, and pressure to eat), feeding style’s dimensions (demandingness and responsiveness), and parents’ BMI.

Table 5 shows that parental perception of child weight, parental concern about child weight, the practice of restriction of less healthy foods, and parents’ own BMI were significantly related to child BMI percentile as the dependent variable. The practices of restriction of less healthy foods and pressure to eat healthy foods were significantly related to level of parental acculturation as dependent variable.

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Discussion This was the first research study to our knowledge to examine the relationship of parental perceptions, feeding practices, feeding styles, and level of acculturation of parents or caregivers to their school-age child’s weight status all on the same group. Several studies have examined parenting practices and styles in some minority groups (Huang et al., 2012; Hughes et al., 2005; Matheson et al., 2006) or acculturation and child weight (Chen & Kennedy, 2005). This study focused sought to find relationships among accultura- Q4 tion, parenting variables, and child weight. Given the increasing presence of immigrants in many countries, an examination of the role of acculturation is important. This is also the first to examine these variables in Chinese Americans, a fast growing group that is understudied. This study found that level of parental acculturation was not directly related to weight status of their children in multiple regression analysis. The findings from the categorical data, however, show that the higher the level of acculturation the more parents used the indulgent feeding style. Children of parents who used an indulgent feeding style were more likely to be overweight or obese than children of parents using other styles. At the same time, multiple regression analysis showed that the higher the level of acculturation the less parents used the practices of restriction of unhealthy foods and pressure to eat healthy foods. Separately, the less that parents restricted their children’s eating of unhealthy food the more the children weighed. These results are consistent with the categorical data and suggest that indulgent parents were neither restricting nor encouraging their children in terms of food. Although

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the correlation data show that such parents did also perceive responsibility for their child’s eating, monitored their intake, and were responsive to them, these perceptions and practices were not related to child weight. These findings suggest that the indulgent feeding style is problematic. This result is similar to two studies of multi-ethnic (white, Latino and, African-American) low-income populations that found a robust association of indulgent feeding style with higher child weight even after controlling for variables known to be related to child weight, demographics, and psychosocial characteristics (Hughes et al., 2005, 2008). A study of mother–child dyads in a recent immigrant population from South America also found that indulgent style was associated with higher weight of their child (Tovar et al., 2012). Unlike these studies, the sample in the present study had a wide range of incomes and was highly educated. Because level of acculturation was highly correlated to family income and education, it means that the more highly educated and those with higher incomes used the indulgent style more and had more overweight and obese children. Thus observed relationships for the indulgent style may apply more broadly. This would be consistent with the findings of a comprehensive review of parenting which found that although feeding style studies had inconsistent results, the majority of feeding style studies showed a significant, positive relationship between the indulgent feeding style and child weight status (Vollmer & Mobley, 2013). It could also be that engagement with a different social environment, not examined in this study, is a contributing factor. Though not directly related to the purpose of this study, studies have also found that the indulgent feeding style is associated with Q5 poorer quality of children’s diets (Chen & Kennedy, 2005, Hoerr et al. Q6 2009, Hughes et al., 2009, Vollmer & Mobley, 2013). This is not surprising considering that parents with the indulgent feeding style cater to child food preferences and do not place boundaries on their child’s food intake (Hughes et al., 2005, 2008). The higher the level of acculturation, the less parents used the authoritarian feeding style in the current study. Parents using the authoritarian feeding style, however, had the highest percentage of normal weight children, and the least overweight and obese children, of all parent categories. Such parents had more normal weight children than would have been expected, and fewer overweight and obese than expected. There have been concerns that authoritarian feeding styles may lead to eating problems (Birch & Fisher, 2000; Birch, Fisher, & Davison, 2003; Savage et al., 2007). About 4% of children of authoritarian style parents in this study were underweight. According to standard child growth charts (United States Centers for Disease Control and Prevention, 2014) 5% of any large sample would be expected to be underweight. This suggests that use of this parenting style in this sample was not leading to undesirable negative outcomes in terms of weight. In support of these categorical data, correlational data show that demandingness, a key feature of the authoritarian feeding style, was related to child weight. Demandingness was also correlated with concern about child weight and feeling responsible for their child’s eating, and also the practices of restricting unhealthy foods, pressuring to eat healthy foods, and monitoring intake. These data show that in this ethnic group, Chinese Americans, the authoritarian feeding style, with its associated parenting practices, appears not to be problematic in terms of weight and may indeed be helpful. This is in contrast to studies with some mainstream samples, where the authoritarian feeding style has been considered to be the primary problematic parental issue (Birch & Fisher, 2000; Birch et al., 2003). However, these studies were conducted primarily with young white girls. The findings in this study are consistent with the Chinese view Q7 of demanding parenting as positive (Chen & Kennedy, Wong 2010). However, the authoritarian style has also been found to be associated with lower weight for children in low-income Hispanic and

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African-American families as well (Hughes et al., 2008), suggesting that this style is helpful in other cultural contexts. It could be that these findings apply more generally. Researchers have pointed out that in the current obesigenic food environment, some degree of conscious monitoring of intakes is commonly needed (Peters, Wyatt, Donahoo, & Hill, 2002). Independent of level of parental acculturation, multiple regression analysis shows that there is a positive relationship of parents’ perception of child weight, concern about child weight, and restriction of intake of less healthy food to child BMI percentile. The crosssectional nature of this study does not permit knowing the directionality of the relationship. It has been hypothesized by researchers that such controlling practices as restriction of unhealthy foods disrupt children’s ability to self-regulate, which could then lead to various eating-related issues, such as eating in the absence of hunger, which could be related to child overweight (Birch & Davison, 2001; Birch & Fisher, 2000; Birch et al., 2003; Fisher & Birch, 1999). However, it has been pointed out that these studies examined the short-term and negative effects of highly directive and specific feeding practices on self-regulation and child weight status (Hughes et al., 2005). Such highly demanding or controlling practices, measured for example by the Child Feeding Questionnaire, form only one end of a continuum of feeding practices and do not take into consideration the broader range of parenting practices and how they are carried out, whether with or without warmth. The use of a more complete feeding styles framework, as used in this study, provides for an examination of the full spectrum of styles and their impacts. Thus it could be that in this study when their child weighed more, parents recognized that their child weighed more, were more concerned, and restricted their child’s intake of less healthy food. Indeed, in a study that used meditational analysis, results showed that restriction appears to be a consequence of mothers’ concern about their child becoming overweight rather than a cause of children’s weight gain. The authors concluded that “pressure to eat may be a more complex response that is influenced by the desire to encourage consumption of healthy foods as well as ensure adequate energy intake and appropriate weight gain” (Webber, Hill, Cooke, Carnell, & Wardle, 2010, p. 259). The authoritative parental feeding style was least used by this sample and was used about equally by Asian and bicultural parents and used much less by Western identified parents. Authoritative parents are demanding of their children in terms of eating but are also responsive or aware of their child’s needs and show warmth and caring, in contrast to the authoritarian parents who were also highly demanding but not very responsive to their children’s needs. Authoritative parents in the current study had the same high proportion of children who were normal weight and the same low proportion of overweight and obese children as the authoritarian parents, suggesting that in terms of weight, both styles are associated with lower weight in this population. However, given previous studies showing that the authoritative feeding style is likely to lead to more healthful eating overall (Blissett, 2011; O’Connor et al., 2010; Patrick, Nicklas, Hughes, & Morales, 2005; Vollmer & Mobley, 2013), the authoritative style seems preferable. It is typified by noncontrolling practices that encourage healthful eating but do not force consumption, accompanied by moderately restrictive practices about eating less healthful foods and snacks, all in a climate of emotional warmth and sensitivity to the child (Blissett 2011; Hughes et al., 2005; Vollmer & Mobley, 2013). Previous research has proposed that parents’ controlling practices also reflect their perceptions and concerns about their own weight (Birch & Fisher, 2000; Ventura & Birch, 2008). For example, one study also showed that parents’ perception of their own past and current weight was related to how they perceive their child’s weight and their parenting practices (Davison, Francis, & Birch, 2005).

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In this study, parental perceptions and concerns about their own weight were unrelated to the weight of their child. The fact that parental BMI is significantly associated with child BMI percentile suggests that shared genes or shared environment or both may also be operating. Note, however, that the rate of obesity among parents in this sample is only 2% and that of overweight, 17%. The prevalence rate of obesity among Chinese adults has been found to be in a similar range: 2.92% (Wang, Wang, & Li, 2001). In sum then, the indulgent feeding style, with its associated parental feeding practices, was the most problematic for this population, as is increasingly being seen for others (Vollmer & Mobley, 2013). The authoritarian feeding style did not appear to have an undue negative impact on the weight status of children. The more acculturated they were, the more likely these parents were to use the authoritarian style of feeding their children. While authoritarian feeding style parents had the fewest overweight and obese children, the authoritative feeding style parental group was a close second. Since the authoritative feeding style has been shown in other studies to have the most beneficial in terms of healthier diets overall (Vollmer & Mobley, 2013), it seems prudent to encourage this feeding style. The study has a number of strengths. The study had a large final sample (n = 615) of participants with a high response rate (72.1%) and participants displayed a very wide range of characteristics (family income, parental education level, length of residence in U.S., living location – urban, semi-urban, and suburban – and level of parental acculturation) so that the results are more generalizable to the Chinese American population. Our study used a combination of three validated and widely used instruments. The combined instrument was available in two languages (participants in this study could choose either a Chinese/Mandarin or English version) and about half chose each of the languages. Independent t-tests showed that there was no difference in terms of people’s responses to the two versions of survey, indicating no systematic difference in response due to language. This study also had a number of limitations. This research used a cross-sectional design, which cannot identify the direction of a cause-and-effect relationship. All data were self-reported, including height and weight of parent and child. Although this study had a large number of participants, the level of parental acculturation tended toward Asian and bicultural identified; only a small proportion of subjects were fully acculturated or Western identified.

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Q8 Implications for research and practice This study has demonstrated the complicated nature of the relationships among level of acculturation, parental feeding styles, parental perceptions and practices, and child weight. Most of the studies to date are cross-sectional in nature and the literature has not generated hypothesized structural relationships among these variables. Some variables may be mediators and others moderators (Wen & Hui, 2012). Future longitudinal or experimental studies can build on the results of this study to systematically examine the direction of the influences on child weight and possible structural relationships among them. The finding that the indulgent feed style is the most problematic needs to be explored in other population groups, to determine how widespread is its use and its impact on weight and eating patterns of children. Most studies have involved mothers or grandmothers, as in this study. Future studies can explore the role of fathers or others in the family. One such study for example found that the indulgent style of fathers, but not mothers, was related to child obesity (Wake, Nicholson, Hardy, & Smith, 2007). The child’s experience is likely influenced by the combination of parenting styles within the family structure.

Future studies with Chinese American families should seek to include parents with a better spread of levels of acculturation to see whether these findings are robust enough to apply to such a sample as well. Studies with other ethnic groups that examine the role of acculturation in feeding styles and practices should include a wide range of acculturation levels, income, and education. The weight status of children should be based on objective measures and not be self-reported. The study also has some implications for practice. The study found that higher levels of parent acculturation were associated with greater use of an indulgent feeding style, along with greater responsiveness to child needs, less pressure to eat more healthy foods and less restriction of unhealthy foods, and higher weight of their child. However, acculturation was also related to parents’ sense of responsibility for their child. Therefore indulgent parents can build on their sense of responsibility to encourage their child’s intake of healthy foods and also provide clear expectations for their children’s behaviors and set clear boundaries. While fewer children of those with the authoritarian parenting style were overweight and obese, and demandingness was associated with lower child weight, this approach does not involve the warmth and responsiveness of parenting that may be essential for development of healthy eating patterns and reduction of obesity risk for the long run (Blissett, 2011). Indeed, the evidence in this study suggests that being childcentered but also demanding is associated with better weight status. This represents the authoritative style that involves encouraging, but not forcing, healthful eating, and moderately restricting eating less healthful foods and snacks, in a climate of responsiveness to child needs (Blissett, 2011; Rhee, 2008; Vollmer & Mobley, 2013). The authoritative parental feeding style in Chinese Americans, as for other groups, may contribute to children having healthy weights and therefore healthy lives. Uncited reference Wong, O. L. (2010). Childhood obesity in a Chinese family context. Contemporary Family Therapy, 32, 335–347.

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