CROSS-SECTIONAL AND PROSPECTIVE RELATIONSHIPS BETWEEN
MATERNAL FEEDING PRACTICES AND OVEREATING BEHAVIOURS IN
YOUNG CHILDREN
Submitted by
Michelle Noonan
BBSc, PGDipPsych
A thesis submitted in partial fulfilment
of the requirements for the degree of
Doctor of Psychology in Clinical Psychology
School of Psychological Science
Faculty of Science, Technology, and Engineering
La Trobe University
Bundoora, Victoria 3086
Australia
August 2012
CHILD OVEREATING BEHAVIOURS
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Table of Contents
Table of Contents………………………………………………………………………………
List of Appendices…………………………………………………………………………….
List of Tables…………………………………………………………………………………..
List of Figures……………………………………………………………………….................
Abstract…………………………………………………………………………………………
Statement of Authorship……………………………………………………………..................
Acknowledgements……………………………………………………………………………..
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CHAPTER 1: Childhood Obesity: An Overview……………………………….................
General Overview of Research…………………………………………………………….
Overview of Childhood BMI and Obesity …………………………………………………
Aetiology of Obesity in Children……………………………………………………………
Family Feeding Environment……………………………………………………………….
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CHAPTER 2: Maternal Eating, Child Feeding, and Child Eating Behaviours………….
Defining Key Concepts…………………………………………………………………….
Maternal Eating Styles………………………………………………………………….
Emotional Eating……………………………………………………………………
External Eating……………………………………………………………...............
Restrained Eating…………………………………………………………...............
Child Feeding Practices………………………………………………………..............
Instrumental Feeding………………………………………………………………..
Emotional Feeding……………………………………………………….................
Restriction…………………………………………………………………………..
Pressure to Eat………………………………………………………………………
Child Eating Behaviours………………………………………………………………..
Food Approach Eating Behaviours…………………………………………...........
Food Avoidant Eating Behaviours………………………………………….............
Relationships between Maternal Eating and Child Feeding Practices…………………….
Relationships between Maternal Eating Styles and Child Eating Behaviours……………..
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CHAPTER 3: Child Feeding Practices, Child Eating Behaviours, and Child BMI………
Theoretical Underpinnings of Relationships Between Instrumental and Emotional
Feeding………………………………………………………………………………..
Relationships between Instrumental Feeding, Child Eating and Child BMI……………….
Instrumental Feeding and Child Eating …………………………………………………
Instrumental Feeding and Child BMI……………………………………………………
Relationships between Emotional Feeding, Child Eating, and Child BMI…………………
Emotional Feeding and Child Eating…………………………………………………….
Emotional Feeding and Child BMI………………………………………………………
Theoretical Underpinnings of Relationships Between Restriction and Pressure to Eat
Feeding, Child Eating and BMI……………………………………………………….
Relationships between Restriction, Child Eating, and Child BMI………………................
Restriction and Child Eating…………………………………………………................
Restriction and Child BMI……………………………………………………………….
Relationships between Pressure to Eat, Child Eating, and Child BMI…………………….
Pressure to Eat and Child Eating………………………………………………………..
Pressure to Eat and Child BMI………………………………………………………….
Child Eating and Child BMI……………………………………………………………….
Child Feeding, Child Eating Behaviours, and Child BMI…………………………………
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CHAPTER 4: Rationale and Aims for the Present Study………………………………….
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CHAPTER 5: General Method………………………………………………………………
Child and Family Health Study……………………………………………………………..
Participants………………………………………………………………………………….
Assessment Instruments…………………………………………………………………….
Demographic Information……………………………………………………………….
Anthropometric Data……………………………………………………………………
Maternal Eating Behaviours………………………………………………………………..
The Dutch Eating Behaviour Questionnaire (DEBQ)…………………………………..
Child Feeding Practices……………………………………………………………………
Instrumental and Emotional Feeding Practices………………………………...............
The Parental Feeding Style Questionnaire (PFSQ)………………………………….
The Child Feeding Questionnaire (CFQ)…………………………………................
The Preschooler Feeding Questionnaire (PSFQ)……………………………………
Restrictive Feeding Practices…………………………………………………………..
Child Feeding Questionnaire (CFQ)………………………………………………..
Child Eating Behaviours…………………………………………………………………..
The Children’s Eating Behaviour Questionnaire (CEBQ)……………………………….
The Dutch Eating Behaviour Questionnaire – Parent Version (DEBQ-P)……………..
Procedure…………………………………………………………………………………..
Data Analysis……………………………………………………………………...............
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CHAPTER 6: Examination of Scale Properties for Child Feeding and Child Eating
Measures……………………………………………………………………………..
Instrumental and Emotional Feeding……………………………………………...............
Child Eating Behaviour Questionnaire (CEBQ)…………………………………………..
The Dutch Eating Behaviour Questionnaire – Parent Version (DEBQ-P)………………..
Discussion…………………………………………………………………………………
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CHAPTER 7: Study 1 - An Examination of Cross-Sectional Relationships between
Child Feeding Practices and Eating Behaviours in Young Children……………
Introduction………………………………………………………………………………..
Aims and Hypotheses…………………………………………………………………..
Hypotheses 1: Associations with Child Feeding Practices………………………….
Hypotheses 2: Associations with Child Eating Behaviours…………………………
Hypotheses 3: Associations with Child BMI………………………………………...
Method……………………………………………………………………………………..
Participants………………………………………………………………………………
Measures…………………………………………………………………………………
Procedures……………………………………………………………………………….
Data Analysis……………………………………………………………………………
Results………………………………………………………………………………………
Data Preparation………………………………………………………………………….
Data Screening………………………………………………………………………..
Assumption of Parametric Tests……………………………………………………..
Participants Characteristics………………………………………………………………
Child BMI…………………………………………………………………………….
Maternal BMI…………………………………………………………………………
Differences between Gender and Weight Groups……………………………………….
Gender Differences in Children………………………………………………………
Obese and Non-obese Children………………………………………………………
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CHILD OVEREATING BEHAVIOURS
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Obese and Non-obese Mothers……………………………………………………….
Differences Among the Sample on Demographic Variables………………................
Associations between Variables………………………………………………………….
Associations with Child Feeding Practices…………………………………………..
Associations with Child Eating Behaviours………………………………………….
Associations with Child BMI…………………………………………………………
Multivariate Relationships………………………………………………………………
Assumptions for Multivariate Analysis………………………………………………
Hypothesis 1: Predictors of Child Feeding Practices…………………………………
Hypothesis 2: Predictors of Child Eating Behaviours………………………………..
Hypothesis 3: Predictors of Child BMI ……………………………………………...
Discussion…………………………………………………………………………………...
Predictors of Child Feeding Practices……………………………………………………
Predictors of Child Eating Behaviours…………………………………………………..
Predictors of Child BMI…………………………………………………………………
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CHAPTER 8: Study 2 - Mediation Models: Exploring Interrelationships between
Maternal Eating, Child Feeding, Child Eating, and Child BMI...………………...
Introduction…………………………………………………………………………………
Aims and Hypotheses………………………………………………………………………..
Hypothesis 1: Indirect relationships with food approach eating behaviours…………….
Hypothesis 2: Indirect relationships with child BMI…………………………………….
Method………………………………………………………………………………………
Participants………………………………………………………………………………
Measures…………………………………………………………………………………
Procedures……………………………………………………………………………….
Data Analysis……………………………………………………………………………
Overview of Analytic Strategy……………………………………………………….
Results………………………………………………………………………………………
Associations between Variables…………………………………………………………
Child Feeding as a Mediator between Maternal Eating and Child Eating………………
Predictors of Child Emotional Overeating…………………………………………..
Predictors of Child Food Responsiveness……………………………………………
Predictors of Child External Eating………………………………………………….
Discussion………………………………………………………………………………….
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CHAPTER 9: Study 3 - Longitudinal Investigation of Relationships between Child
Feeding Practices and Eating Behaviours in Young Children……………………
Introduction………………………………………………………………………………….
Aims and hypotheses…………………………………………………………………….
Hypothesis 1: Prospective Predictors of Time 3 Child Eating Behaviours.................
Hypothesis 2: Prospective Predictors of Time 3 Child BMI………………. ………..
Hypothesis 3: Prospective Predictors of Time 3 Child Feeding Practices…. ……….
Method………………………………………………………………………………………
Participants………………………………………………………………………………
Attrition………………………………………………………………………………….
Measures…………………………………………………………………………………
Procedures……………………………………………………………………………….
Data Analysis……………………………………………………………………………
Results………………………………………………………………………………………
Descriptive Data…………………………………………………………………………
Data Screening……………………………………………………………………….
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CHILD OVEREATING BEHAVIOURS
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Assumptions of Parametric Tests on Time 1 Variables………………………………
Gender Differences in Time 1 Child Feeding and Child Eating Measures………….
Differences in Time 1 Obese and Non-Obese Children……………………………...
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Stability and Change in BMI, Feeding and Eating Variables………………………..
Cross Lag Associations between Time 1 Predictors of Time 3 outcome Variables…….
Hierarchical Regression Analysis……………………………………………..................
Hypothesis 1: Prospective Predictors of Time 3 Child Eating Behaviours..................
Hypothesis 2: Prospective Predictors of Time 3 Child BMI………………. ………..
Hypothesis 3: Prospective Predictors of Time 3 Child Feeding………….. …………
Discussion…………………………………………………………………………………..
Prospective Predictors of Time 3 Child Eating Behaviours……………………………..
Prospective Predictors of Time 3 Child BMI……………………………………………
Prospective Predictors of Time 3 Child Feeding Practices………………………………
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CHAPTER 10: General Discussion………………………………………………..…………
Summary of Findings……………………………………………………………………….
Study One……………………………………………………………………………….
Study Two……………………………………………………………………. …………
Study Three………………………………………………………………………………
Theoretical Implications of Research Findings……………………………………………..
Instrumental Feeding as Separate Factors……………………………………………….
The Development of Child Feeding Practices…………………………………………..
The Development of Child Overeating Behaviours…………….……………………….
The Development of Overweight……………………………………………………….
Practical Implications of Research Findings………………………………………………..
Research Strengths and Limitations……………………………………………………….
Directions for Future Research…………………………………………………………….
Conclusions………………………………………………………………………………..
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Appendices………………………………………………………………………….................
Appendix A1
Letter of Invitation…………………………………………………………..
Appendix A2
Consent Form………………………………………………………………..
Appendix B1
Demographics……………………………………………………………….
Appendix B2
Maternal Eating Styles……………………..………………………………..
Appendix B3
Child Feeding Practices…………………………………………………….
Appendix B4
Child Eating Behaviours………………………………………....................
Appendix C1
Thank You Letter…………………………………………………………..
Appendix D1
Time 1 factor analysis of instrumental and emotional feeding practice items
Appendix D2
Correlation Matrix of Time 3 Child Eating Behaviour…………………….
Appendix D3
Summary Table of the Significant Associations for Study 1
Appendix D4
Descriptive Data for Time 1 and Time 3 Variables……………………….
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References……………………………………………………………………………………..
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CHILD OVEREATING BEHAVIOURS
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List of Tables
Table 1
Proportion (%) of Children Classified as Overweight and Obese from Three
Australian Studies…………………………………………………………………
Table 2
Time 3 Demographic Information for Marital Status, Mother’s Country of Birth,
Education Level, Employment Status and Annual Income………………………
Table 3
44
Principle Components Analysis with Forced Three Factor Solution of Emotional
and Instrumental Feeding Items (17 items) ………………………………………
Table 4
2
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Intercorrelations between Instrumental Feeding and Emotional Feeding at Time
3 (N = 138)………………………………………………………………………..
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Table 5
Descriptive Statistics for the Three Factor Structures at Time 3 (N = 138)……....
63
Table 6
Principle Components Analysis of the Child Eating Behaviour Questionnaire
(CEBQ)………………………………………………………………………........
Table 7
Descriptive Statistics for the Original CEBQ Eight Factor Solution by Wardle et
al (2001)…………………………………………………………………………...
Table 8
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Principle Components Analysis of the External Eating Subscale of the Dutch
Eating Behaviour Questionnaire – Parent Version (DEBQ-P)……………………
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Table 9
Means and Standard Deviations for all Measures at Time 3……………………...
83
Table 10
Pearson’s Product Moment Correlations of Maternal Eating Behaviours and
Child Feeding Practices of Time 3 (N = 138) …………………………………….
Table 11
Pearson’s Product Moment Correlations of Maternal Eating Styles, Child
Feeding Practices and Child Eating Behaviours of Time 3 (N = 138)……………
Table 12
97
Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Maternal Eating Styles as Predictors of Child Food Responsiveness (N = 138)….
Table 18
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Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Maternal Eating Styles as Predictors of Child Emotional Eating (N = 138)……
Table 17
95
Summary of Hierarchical Regression Analysis for Maternal Eating Styles as
Predictors of Restriction (N = 138)……………………………………………….
Table 16
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Summary of Hierarchical Regression Analysis for Maternal Eating Styles as
Predictors of Emotional Feeding (N = 138)……………………………………….
Table 15
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Summary of Hierarchical Regression Analysis for Maternal Eating Styles as
Predictors of Instrumental Feeding-behaviour (N = 138)…………………………
Table 14
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Pearson’s Product Moment Correlations between Child BMI and Maternal BMI,
Child Feeding Practices and Child Eating Behaviours (N = 138)………..............
Table 13
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Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Maternal Eating Styles as Predictors of Child External Eating (N = 138)………..
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CHILD OVEREATING BEHAVIOURS
Table 19
Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Maternal Eating Styles as Predictors of Child Satiety Responsiveness (N = 138)..
Table 20
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Summary of Mediation Model for Maternal External Eating, Restriction and
Child External Eating (N = 138)…………………………………………………..
Table 32
130
Summary of Mediation Model for Maternal External Eating, Emotional Feeding
and Child External Eating (N = 138)……………………………………………..
Table 31
128
Summary of Mediation Model for Maternal External Eating, Instrumental
Feeding-behaviour and Child External Eating (N = 138)…………………………
Table 30
127
Summary of Mediation Model for Maternal External Eating, Emotional Feeding
and Child Food Responsiveness (N = 138)………………………………………..
Table 29
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Summary of Mediation Model for Maternal External Eating, Instrumental
Feeding-behaviour and Child Food Responsiveness (N = 138)………………….
Table 28
124
Summary of Mediation Model for Maternal Emotional Eating, Emotional
Feeding and Child Emotional Overeating (N = 138)……………………………..
Table 27
122
Summary of Mediation Model for Maternal Emotional Eating, Instrumental
Feeding-behaviour and Child Emotional Overeating (N = 138)…………………..
Table 26
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Means, Standard Deviation, and Zero-order Correlations of all Proposed
Variables for Mediation Models (N = 138)……………………………………......
Table 25
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Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Child Food Avoidant Eating Behaviours as predictors of Child BMI (N = 138)…
Table 24
102
Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Child Food Approach Eating Behaviours as predictors of Child BMI (N = 138)...
Table 23
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Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Maternal Eating Styles as Predictors of Child Food Fussiness (N = 138)………..
Table 22
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Summary of Hierarchical Regression Analysis for Child Feeding Practices and
Maternal Eating Styles as Predictors of Child Slowness in Eating (N = 138)…….
Table 21
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Paired Samples t-tests for Child and Maternal BMI, Maternal Eating Styles,
Child Feeding Practices, and Child Eating Behaviours from Time 1 to Time 3 (N
= 138)…………………………………………………………………………….
Table 33
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Cross Lag Correlations between Time 1 Maternal Eating Styles and Child
Feeding Practices and Time 3 Child Eating Behaviours and Child BMI-for-age zscores (N = 138) ………………………………………………………………
Table 34
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Cross Lag Correlations between Time 1 Child BMI-for-age Z-scores and Child
Eating Behaviours and Time 3 Child Feeding Practices (N = 138)……………...
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CHILD OVEREATING BEHAVIOURS
Table 35
Summary of Hierarchical Regression Analysis for Time 1 Maternal Eating
Behaviours as Predictors of Time 3 Child Emotional Overeating (N = 138)……..
Table 36
154
Summary of Hierarchical Regression Analysis for Time 1 Child Feeding
Practices as Predictors of Time 3 Child External Eating (N = 138)………………
Table 41
153
Summary of Hierarchical Regression Analysis for Time 1 Child Feeding
Practices as Predictors of Time 3 Child Food Responsiveness (N = 138)………
Table 40
152
Summary of Hierarchical Regression Analysis for Time 1 Child Feeding
Practices as Predictors of Time 3 Child Emotional Overeating (N = 138)………..
Table 39
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Summary of Hierarchical Regression Analysis for Time 1 Maternal Eating
Behaviours as Predictors of Time 3 Child External Eating (N = 138)……………
Table 38
150
Summary of Hierarchical Regression Analysis for Time 1 Maternal Eating
Behaviours as Predictors of Time 3 Child Food Responsiveness (N = 138)……
Table 37
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155
Summary of Hierarchical Regression Analysis for Time 1 Child BMI and Child
Eating Behaviours as Predictors of Time 3 Instrumental Feeding-behaviour (N =
138)……………………………………………………………………………….
Table 42
Summary of Hierarchical Regression Analysis for Time 1 Child BMI and Child
Eating Behaviours as Predictors of Time 3 Emotional Feeding (N = 138)……….
Table 43
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Summary of Hierarchical Regression Analysis for Time 1 Child BMI and Child
Eating Behaviours as Predictors of Time 3 Restriction (N = 138)……………….
158
CHILD OVEREATING BEHAVIOURS
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List of Figures
Figure 1
Ecological Framework of Factors Proposed to be Associated with the
Development of Overweight and Obesity in Children……………………………
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Figure 2
Simple Model of Associations to be Examined…………………………………..
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Figure 3
Simple Model of Associations to be Examined in this Chapter…………………..
8
Figure 4
Simple Model of Associations to be Examined in this Chapter…………………..
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Figure 5
Proportion (%) of Children Classified as Underweight, Healthy Weight,
Overweight, and Obese using the IOFT Age and Gender-Specific Cut-offs (Cole
et al., 2000; Cole et al., 2007) (n = 126)…………………………………………..
Figure 6
84
2
Proportion (%) of Mothers Classified as Underweight (BMI < 18.5kg/m ),
Normal Weight (BMI ≥18.5 to < 25 kg/m2), Overweight (BMI ≥ 25 to < 30
kg/m2), and Obese (BMI ≥30 kg/m2) according to WHO Weight Categories (n =
85
134)……..
Figure 7
The Proposed Mediation Model by Baron and Kenny (1986)………………….....
Figure 8
Mediation Model of Instrumental Feeding-behaviour as a Mediator between
Maternal Emotional Eating and Child Emotional Overeating…………………….
Figure 9
131
Mediation Model of Restriction as a Mediator between Maternal External Eating
and Child External Eating…………………………………………………………
Figure 15
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Mediation Model of Instrumental Feeding-behaviour as a Mediator between
Maternal External Eating and Child External Eating……………………………...
Figure 14
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Mediation Model of Emotional Feeding as a Mediator between Maternal
External Eating and Child External Eating………………………………………..
Figure 13
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Mediation Model of Emotional Feeding as a Mediator between Maternal
External Eating and Child Food Responsiveness…………………………………
Figure 12
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Mediation Model of Instrumental Feeding-behaviour as a Mediator between
Maternal External Eating and Child Food Responsiveness……………………….
Figure 11
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Mediation Model of Emotional Feeding as a Mediator between Maternal
Emotional Eating and Child Emotional Overeating………………………………
Figure 10
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Proportion (%) of Children Classified as Overweight and Obese using the IOFT
Age and Gender-Specific Cut-offs (Cole et al., 2000; Cole et al., 2007) for Time
1 and Time 3 (n = 100)…………………………………………………...
Figure 16
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Proportion (%) of Mothers Classified as Underweight (BMI < 18.5kg/m2),
Normal Weight (BMI ≥18.5 to < 25 kg/m2), Overweight (BMI ≥ 25 to < 30
kg/m2), and Obese (BMI ≥30 kg/m2) according to WHO Weight Categories for
Time 1 and Time 3 (N =
120)………………………………………………………………….
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Abstract
Childhood obesity is a major health concern. Studies have indicated that certain child feeding
practices may be environmental risk factors that contribute to the development of overeating
behaviours in children and consequently increased risk for overweight. The aim of study one
was to examine cross-sectional relationships between maternal eating behaviours, child
feeding practices, child eating behaviours and child BMI. In study two, child feeding
practices were explored as potential mediators between maternal eating and child eating
behaviours. Study three aimed to explore prospective predictors of child eating behaviours
and child BMI that were assessed two years previously. Participants were 138 mothers and
their children aged 4 to 6 years (M = 5.30 years, SD = 0.81). Mothers completed
questionnaires about their own eating styles, child feeding practices, child eating behaviours
and reported their child’s height and weight. Cross-sectional data indicated that instrumental
feeding, emotional feeding and restrictive feeding was associated with child overeating
behaviours and pressure to eat was associated with under-eating behaviours. Neither child
feeding practices nor child eating behaviours were associated with child BMI. Mediation
analyses revealed that child feeding practices partially mediated the relationship between
maternal emotional and external eating and child overeating behaviours. Longitudinal
analyses revealed that child external eating was prospectively predicted by maternal external
eating and restrictive feeding. Child emotional overeating was prospectively predicted by
emotional feeding. Relationships between restrictive feeding and child external eating were
found to be bidirectional. Overall, these findings provide support for the proposed role of
child feeding practices in the development of child overeating behaviours and also that child
eating behaviours may influence child feeding practices. Further research is needed to
replicate the study findings over a longer period of time to determine the long term
implications of child feeding practices on child overeating behaviours and weight.
CHILD OVEREATING BEHAVIOURS
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Statement of Authorship & Ethics Approval
Except where reference is made in the text of the thesis, this thesis contains no material
published elsewhere or extracted in whole or in part from a thesis submitted for the award of
any other degree or diploma.
No other person’s work has been used without due acknowledgement in the main text of the
thesis.
The thesis has not been submitted for the award of any degree or diploma in any other tertiary
institution.
Anna Brozovic and Jane Gregory also contributed to this research by advertising and
recruiting participants during the first year of data collection. No other person’s work has
been used without due acknowledgement in the main text of this thesis.
This research was approved by the La Trobe University Ethics Committee (Ethics Approval
Number UHEC 07-64).
____________________________
Michelle Noonan
23rd August 2012
CHILD OVEREATING BEHAVIOURS
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Acknowledgements
There are many people who have supported me through this journey and I cannot express
enough gratitude for their continued support.
I would like to express my sincerest thanks to my supervisor Professor Susan Paxton for her
unrelenting support, guidance, enthusiasm and patience over the past four years. I would not
have made it through this experience without your encouragement. It has been an invaluable
learning experience and I am indebted.
I would also like to extend my thanks to Dr Anna Brozovic and Dr Jane Gregory who
willingly showed me the ropes in the early stages of this project. Your assistance was
invaluable and set the benchmark for me to extend on this project. I would also like to
acknowledge and thank all of the mothers who were involved in this research, without their
contribution this research would not be possible.
Many thanks for the continued support and love from my friends, family, and fellow post
graduate colleagues. I would not have completed this research without you all. In particular,
thank you to my proof reader Amanda Kelly. I am grateful for your contributions and
enthusiasm in supporting me. Lastly, I would also like to thank my Team Manager at work,
Sue Graham, for her warmth and support when things seemed challenging during this
journey.
CHILD OVEREATING BEHAVIOURS
1
CHAPTER 1: Childhood Obesity: An Overview
General Overview of Research
This research explores the development of eating behaviours in young children,
especially behaviours that may increase risk of overweight and obesity. Previous research
suggests that maternal eating styles and child feeding practices may be associated with the
development of unhealthy eating behaviours and potentially excess weight gain among
children. Much of the research in this area has been cross-sectional and few studies have
explored prospective relationships between maternal eating styles and child feeding practices,
and child eating behaviours and body mass index (BMI) in a very young sample. The aim of
this research was to explore these relationships across two time points. Study 1 explored
cross-sectional relationships between maternal eating, child feeding, child eating behaviours
and BMI in a sample of children aged 4 to 6 years old. Study 2 used mediation analyses to
explore the pathway of relationships between maternal eating, child feeding, child eating and
BMI. Study 3 examined prospective predictors of child eating behaviours and BMI assessed
two years previously.
This research is part of a larger longitudinal study, titled the Child and Family Health
Study. Data was collected across three time points, each one year apart. The two contributing
researchers at Time 1 and Time 2 were Dr Anna Brozovic and Dr Jane Gregory. Please refer
to Brozovic (2009), Gregory, Paxton & Brozovic, (2010a), Gregory, Paxton, & Brozovic,
(2010b), and Gregory, Paxton, & Brozovic (2011) for a comprehensive description of their
research. Research findings related to the larger longitudinal study will be referred to as the
Child and Family Health Study throughout the literature review chapters.
Overview of Childhood BMI and Obesity
Childhood obesity is a global public health concern (World Health Organisation
[WHO], 2000) due to its rising prevalence, individual health consequences, and increased
CHILD OVEREATING BEHAVIOURS
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risk of obesity in adulthood (Magarey, Daniels, & Boulton, 2001). Data obtained over a ten
year period between 1985 and 1995 indicated that the prevalence of overweight Australian
boys and girls aged 2-18 years more than doubled, and the prevalence of obesity tripled
(Booth, Chey, Wake, Norton, Hesketh, Dollman, & Robertson, 2003; Magarey et al., 2001).
In 1995 it was estimated that 15% of Australian children were overweight and 5% were obese
(Australian Institute of Health and Welfare [AIHW], 2004; Booth et al., 2003; Margarey,
Daniels, & Boulton, 2001). More recently, the 2007 Australian National Children’s Nutrition
and Physical Health Survey (Department of Health and Ageing [DoHA], 2007) indicated that
the prevalence of overweight and obesity had continued to increase. Table 1 summarises data
from three Australian studies spanning two decades, the 1985 Australian Health and Fitness
Survey (AHFS: Pyke, 1987), the 1995 National Nutrition Survey (NNS: Australian Bureau of
Statistics, 1998) and the 2007 Australian National Children’s Nutrition and Physical Health
Survey (DoHA). Although the increase in prevalence of overweight and obesity appears to
have slowed since the mid 1990’s, they remain major health concerns.
Table 1
Proportion (%) of Children Classified as Overweight and Obese from Three Australian
Studies
AHFS, 1985
NNS, 1995
Children’s Survey, 2007
N =8,492
N = 2,962
N = 4,487
Boys
Girls
Boys
Girls
Boys
Girls
Age (years)
7-15
7-15
2-18
2-18
2-16
2-16
Overweight
9.3
10.6
15.0
15.8
17
18
Obese
1.4
1.2
4.5
5.3
5
6
Note: AHFS: Australian Health and Fitness Survey; NNS: National Nutrition Survey;
Children’s Survey: Australian National Children’s Nutrition and Physical Health Survey.
CHILD OVEREATING BEHAVIOURS
3
It has been estimated that obese children have a 25-50% increased risk of being obese
in adulthood (Must & Strauss, 1999), and it is well documented that obesity can lead to a
range adverse health consequences. For children, overweight and obesity have been
associated with a range of serious health problems such as type 2 diabetes mellitus, asthma,
sleep apnoea, and pulmonary conditions (AIHW, 2004; Crowle & Turner, 2010; Ebbling,
Pawlak, Ludwig, 2002), and risk factors for cardiovascular disease (e.g., hypertension and
dyslipidemia) (Crowle & Turner, 2010). The psychosocial consequences of childhood obesity
are also of considerable concern. Obese children may be targets for social discrimination
(Latner & Stankard, 2003), be negatively stereotyped as unhealthy, and labeled as
academically unsuccessful, socially incompetent, less hygienic, and lazy (Latner & Stunkard,
2003; Staffieri, 1967). Furthermore, obesity has been associated with lowered self-esteem and
body dissatisfaction (Franklin, Denyer, Steinbeck, Caterson, & Hill, 2006), and may be a risk
factor for depression and anxiety (Lostein, Baur, & Uauy, 2004) and eating disorders
(Decaluwe, Braet, & Fairburn, 2003).
In addition to physical and psychological consequences, overweight and obesity
increases pressure on the health care system resulting in economic costs (Crowle & Turner,
2010; DeMattie & Denney, 2008; Norton, Dollman, Martin & Harten, 2006). In 2008 the
economic cost of obesity in Australia was estimated to be $58 billion (Crowle & Turner,
2010). The projected cost of obesity is measured by factors related to direct costs (e.g.,
diagnosis and treatment), intangible costs (e.g., health and quality of life), and indirect costs
(e.g., loss of well-being and economic benefits) (Crowle & Turner, 2010). Taking these
issues into account, an understanding of eating behaviours that may be related to the early
development of excess weight would be valuable to inform early intervention and prevention
strategies.
CHILD OVEREATING BEHAVIOURS
4
Aetiology of Obesity in Children
Obesity among children is a relatively new health concern. While it is known that
obesity develops when the level of energy intake exceeds energy expenditure, the reasons
why some individuals are able to maintain a steady weight compared to others is not well
understood. There is a genetic basis for fat storage patterns demonstrated by the increased
likelihood that children with obese parents are more likely to become obese themselves
(Cutting, Fisher, Grimm-Thomas, & Birch, 1999; Guillame, Lapidus, Beckers, Lamber, &
Bjorntorp, 1995). However, genetic factors alone do not account for the recent rise in
prevalence of overweight and obesity. Davison and Birch (2001) propose that the rise in
childhood overweight and obesity is the combination of a complex interplay of risk factors
from multiple contexts including, child characteristics and behaviours, as well as familial and
societal characteristics.
This notion was conceptualized within the Ecological Systems Theory (EST)
framework, in which human behaviour is considered within all contexts in which the person
is a part (see Figure 1). This model assimilates the results of research assessing risk factors
for childhood overweight (Davison & Birch, 2001). In particular, the model is bidirectional.
That is, the factors on the outer layer influence the inner layers and vice versa. According to
this model, child behaviours such as dietary intake, increased sedentary behaviours and
decreased physical activity are referred to as “risk factors” for overweight. The influence of
risk factors on the development of overweight in children is thought to be moderated by child
characteristics (i.e., age and gender). Child risk factors are proposed to be shaped by
parenting styles and familial characteristics including child feeding practices, parent weight
status, parent dietary intake and activity patterns, types of foods available in the home,
nutritional knowledge, family television viewing, and parent encouragement of child activity.
Community and societal characteristics are proposed to have an overarching influence on
CHILD OVEREATING BEHAVIOURS
5
parenting practices and thereby on child eating patterns and activity levels. These
characteristics may include socioeconomic status, ethnicity, parent work-related demands,
and the availability and accessibility of recreational facilities (Birch & Ventura, 2009; Crowle
& Turner, 2010; Davison & Birch, 2001).
Figure 1. Ecological framework of factors proposed to be associated with the development of
overweight and obesity in children. Source: Adapted from Davison and Birch (2001)
To date, preventative interventions have frequently been aimed at dietary
improvement and increased activity within the school environment, as schools provide a
convenient platform to address the rise in prevalence of overweight and obesity (Ventura &
Birch, 2008). Unfortunately, many of these intervention programs, such as promotion of
nutrition and physical activity, have not produced long term effects in decreasing adiposity
(NHMRC, 2003; Spruijt-Metz, 2011; Ventura & Birch, 2008). Consistent with the model
outlined above, interventions should be implemented across a range of contexts in addition to
schools, including the home environment, community and health care settings (Birch &
CHILD OVEREATING BEHAVIOURS
6
Ventura, 2009), particularly as recent Australian data indicates that almost one in five
children are overweight at the commencement of school (Hardy, King, Hector, & Lloyd,
2012).
Given the fundamental influence that parents have over children during the early
stages of life, a focus of research has shifted towards the home environment and the role
parents have in shaping and influencing child eating behaviour (Campbell, Crawford, Ball,
2006; Rhee, 2008; Ventura & Birch, 2008). In fact, the past decade has seen a rise in research
exploring the association between the family environment and food related behaviours of
parents in relation to childhood overweight (Campbell & Crawford, 2001; Faith, Scanlon,
Birch, Francis, & Sherry, 2004). In particular, the role of parental feeding styles on child
eating behaviours and weight status has received increased attention.
Family Feeding Environment
During the early stages of life, food preferences are shaped by a combination of
genetic and environmental factors (Wardle & Cooke, 2008). Infants have an innate
predisposition towards certain tastes and textures, with a preference toward sweet and salty
tastes and a tendency to reject bitter and sour tastes (Birch, 1999; Wardle & Cooke, 2008).
This is a normal adaptive response to separate good foods from spoiled foods; however,
children have the ability to modify their food preferences by experience, and therefore
environmental factors are likely to be very influential in food preference (Wardle & Cooke,
2008). In particular, the family environmental is likely to provide the primary context for the
child’s early experiences with food, through which the child’s beliefs and preferences for
food develop (Birch & Fisher, 1998; Tiggermann & Lowes, 2002). Feeding is a key
component of parenting that involves significant ongoing interactions between parent/s and
their child (Baughcum, Powers, Johnson, Chamberlin, Deeks, Jain, & Whitaker, 2001).
Parents influence the development of child eating behaviours through this interaction, largely
CHILD OVEREATING BEHAVIOURS
7
because they create the context for the provision of food (Baughcum et al., 2001). For
example, parents decide on the types and amount of food made available, when children are
fed, and what strategies they will use in order to feed their child/ren (Baughcum et al., 2001).
Therefore, parents become the primary role models from which children develop their eating
styles (Rhee et al., 2008). A greater understanding of relationships between familial food
environments and child eating behaviours is needed.
Areas to be specifically targeted in this research are whether maternal eating styles
and child feeding practices predict child overeating behaviours and child BMI. The following
sections will provide an overview of the existing literature. Figure 2 outlines a general model
of relationships to be explored and the sequence in which they will be discussed. Chapter 2
will discuss relationships between maternal eating and child feeding practices (pathway 1),
and relationships between maternal eating and child eating behaviours (pathway 2). Chapter 3
will discuss relationships between child feeding practices and child eating behaviours
(pathway 3), and relationships between child eating behaviours and BMI (pathway 4), and
lastly, relationships between child feeding and child BMI (pathway 5). Chapter 4 will include
a rationale for the present study and aims.
5
1
Maternal Eating
2
Child Feeding Practices
3
Child Eating Behaviours
Child BMI
4
Figure 2. Simple model of associations to be examined. Note: Solid line: the relationships to
be discussed in Chapter 2; dotted line: the relationships to be discussed in Chapter 3.
CHILD OVEREATING BEHAVIOURS
8
CHAPTER 2: Maternal Eating, Child Feeding, and Child Eating Behaviours
A greater understanding of the complex interactions that influence child feeding
practices is important for understanding child weight status and potentially modifiable risk
factors. As discussed in Chapter 1, parents (in Western society, most often the mother) create
the context for how, what, where and when food is provided to their children and help to
shape specific eating behaviours (Baughcum et al., 2001). Therefore, it is reasonable to
assume that a mother’s own perceptions about food, nutritional knowledge, and eating
behaviours are likely to influence strategies used to feed her child, known as child feeding
practices. To what extent a mother’s food choices and eating behaviours impact on her
child’s eating behaviours is unclear (Alderson & Ogden, 1999). However, findings suggest
that there is a familial transmission of obesity, and that a mother’s own eating style and her
beliefs about food influence her child’s eating behaviours and weight (Wardle, 1995). This
chapter will first define the key concepts to be explored in this thesis and then will review
research examining relationships between maternal eating styles and child feeding and child
eating behaviours (pathway 1 & 2) as highlighted in Figure 3.
1
Maternal Eating
 Emotional Eating
 External Eating
 Restrained Eating
2
Child Feeding Practices
 Instrumental feeding
 Emotional Feeding
 Restriction
 Pressure to Eat
5
3
Child BMI
Child Eating Behaviours
 Food Responsiveness
 Emotional Overeating
 External Eating
 Satiety Responsiveness
 Slowness in Eating
 Food fussiness
Figure 3. Simple model of associations to be examined in this Chapter. Note: light dashed
line denotes relationships to be examined in Chapter 3.
CHILD OVEREATING BEHAVIOURS
9
Defining Key Concepts
There is a broad range of maternal eating styles and child feeding practices that have
been proposed to be associated with the development of child eating behaviours. Before
considering interrelationships between maternal eating styles, child feeding practices, and
child eating behaviours, it is important to define the key concepts within the literature.
Maternal eating styles.
A number of eating styles have been linked with the development of obesity in
adulthood including: emotional eating, external eating and restrained eating (van Strien,
Frijters, Bergers, & Defares, 1986; Wardle, 1987).
Emotional eating.
The concept of emotional eating is derived from psychosomatic theory, and is an
eating pattern in which an individual responds to increased arousal states (i.e., anger, fear,
anxiety) by excessive eating (van Strien, Frijters, Bergers, & Defares, 1986). The pairing of
negative emotional states and food is proposed to be established through experiences learnt
during childhood in which the child is either comforted from negative emotional states with
food or it is learnt through observation of parental emotional eating (van Strien, Frijters,
Bergers, & Defares, 1986).
External eating.
The concept of external eating is derived from externality theory and is an eating
pattern in which eating is primarily in response to external food cues such as eating in
response to the sight or smell of palatable food or in the presence of others, regardless of their
internal cues for hunger or satiety (van Strien, Frijters, Bergers, & Defares, 1986).
Restrained eating.
In relation to restrained eating, the restraint theory suggests that some individuals
deliberately restrict intake of specific foods (i.e., by dieting) or cognitively suppress feelings
CHILD OVEREATING BEHAVIOURS
10
of hunger in an attempt to lose or maintain body weight (Herman & Mack, 1975; van Strien,
Frijters, Bergers, & Defares, 1986; van Strien & Oosterveld, 2008).
Child Feeding Practices.
A number of child feeding practices are proposed to be associated with the
development of eating behaviours in children. Commonly used feeding practices include:
instrumental and emotional feeding, which are non-nutritious feeding practices aimed at
shaping eating behaviours; and restrictive feeding and pressure to eat, which are directive
feeding strategies either aimed at limiting access to unhealthy food or encouraging the child
to eat more.
Instrumental Feeding.
Instrumental feeding has been referred to as using food as a reward (Wardle,
Sanderson, Guthrie, Rapoport, & Plomin, 2002). This definition may be further refined by
differentiating between using food as a reward in response to behaviour (i.e., providing food
as a reward for good behaviour or withholding food as punishment for bad behaviour) and
using food as a reward for eating-specific behaviours (i.e., giving dessert as a reward for
eating vegetables) (Baughcum et al., 2001; Wardle et al., 2002). Typically these two types of
feeding styles have been grouped together and defined as one feeding style even though they
appear to relate to different contexts and motivations for feeding. Consequently, a number of
measurement issues have arisen and further refinement of this construct is warranted; this
issue is considered in Chapter 6.
Emotional Feeding.
Emotional feeding refers to the feeding practice of using food to calm the child in
response to emotional distress (Baughcum, Burklow, Deeks, Powers, & Whitaker, 1998;
Wardle et al., 2002). The construct of emotional feeding is a relatively new development.
Items relating to emotional feeding refer to the child being fed when they are feeling
CHILD OVEREATING BEHAVIOURS
11
emotionally distressed (e.g., upset, hurt, bored, worried, angry, and fussy). In review of the
literature it was unclear whether all of these states are indicative of emotional distress (e.g.,
bored). This suggested that examination of the scale properties of this measure in young
children is also warranted and as such, will be considered in Chapter 6.
Restriction.
Restriction has also been described as a “controlling” feeding practice (Birch, Fisher,
Grimm-Thomas, Markey, Sawyer & Johnson, 2001). Restriction refers to the extent to which
parents limit access to food, in particular high energy, palatable foods, through means of
verbally forbidding or physically restricting access to these foods (Birch et al., 2001). An
example item assessing restrictive feeding from the Child Feeding Questionnaire (CFQ) is; ‘I
intentionally keep some foods out of my child’s reach’ (Birch et al). Different types of
restrictive feeding practice have been noted, such as parents being cautious that their child
does not eat excessive high energy dense foods, denying second helpings, not bringing
palatable foods into the home, and telling children that a particular food is off limits or can
only to be eaten on special occasions (Birch et al).
Pressure to Eat.
Pressure to eat is thought to derive from a parents’ desire for their child to eat all the
food on their plate, or an attempt by the parent to increase their child’s consumption of
healthy foods (Francis, Hofer, & Birch, 2001; Wardle et al., 2002).
Child eating behaviours.
Child eating behaviours describe how the child eats, such as eating in the absence of
hunger, eating in response to external cues, showing dietary restraint or disinhibited eating, or
displaying food pickiness (Fisher & Birch, 2000; 2002; Francis, Hofer, Birch, & 2001;
Galloway, Lee & Birch, 2003; Ventura & Birch, 2008).
CHILD OVEREATING BEHAVIOURS
12
Current literature has proposed that different groups of child eating behaviours
contribute to overeating and undereating, namely food approach and food avoidant eating
behaviours, respectively (Carnell & Wardle, 2007; Sleddens, Kremer, & Thjis, 2008;
Webber, Hill, Saxton, Van Jaarsveld & Wardle, 2008). Typically these behaviours are
measured using the Children’s Eating Behaviour Questionnaire (CEBQ; Wardle, Guthrie,
Sanderson & Rapoport, 2001).
Food approach eating behaviours.
Subscales related to food approach eating behaviours thought to be associated with
overeating include: food responsiveness (eating in response to external cues and always
wanting to eat); enjoyment of food (a general appetite and interest in food and eating); and
emotional overeating (eating in response to negative emotions) (Sleddens et al., 2008; Wardle
et al., 2001; Webber et al., 2008). Additionally, external eating, which refers to eating in
response to the sight or smell of palatable foods, has also been proposed to be a key construct
in the association with overeating behaviours (Braet & Van Strien, 1997), and is considered
to be a food approach eating behaviour.
Food avoidant eating behaviours.
Subscales related to food avoidant eating behaviours proposed to be associated with
undereating include: satiety responsiveness (self-regulation of food intake, i.e., to stop eating
when full); slowness in eating (reduced eating from a lack of interest in food or taking over
30 minutes at mealtimes to eat); and food fussiness (rejection of new foods) (Carruth,
Skinner, Houck, Moran, Coletta, & Ott, 1998; Farrow & Blissettt, 2012; Sleddens et al.,
2008; Wardle et al., 2001; Webber at al., 2008).
CHILD OVEREATING BEHAVIOURS
13
Relationships between Maternal Eating and Child Feeding Practices
The following section will examine pathway 1, as shown in Figure 3. This section
will discuss relationships between maternal eating styles and child feeding practices.
The mechanisms involved in the development of both emotional and external eating
styles are unclear (Macht, 2008). An underlying notion is that internal cues of satiety are not
the driving force behind eating and may be misinterpreted or ignored. Therefore, if eating
occurs in response to cues other than hunger, overeating may occur and increase the risk for
becoming overweight (van Strien, Frijters, Bergers, & Defares, 1986). On the other hand, the
restraint theory postulates that restriction of dietary intake eventually leads to overeating
behaviours that are characteristic of disordered eating, such as binge eating, due to a
decreased sensitivity of internal cues for hunger and an increased reliance on external or
contextual cues for hunger (Johnson & Wardle, 2005). That is, for individuals who
cognitively suppress their hunger in an effort to reduce their food intake, are more likely to
overeat in situations where their cognitive control is undermined, resulting in disinhibition
(Johnson, Pratt & Wardle, 2012; Polivy & Herman, 1985; Snoek, van Strien, Janssens, &
Engels, 2007).
Psychosomatic and externality theories for emotional and external eating assume that
the development of these overeating behaviours may be a consequence of eating experiences
in early childhood. Childhood is a time when the brain is still developing and therefore
influences at this time may potentially have a long lasting impact on appetite self-regulation
(Baughcum et al., 2001). Restrained eating, on the other hand, is a behaviour specifically
related to weight management and tends to develop later in adolescence or young adulthood,
when pressure to be thinner is experienced (van Strien, Frijters, Bergers, & Defares, 1986;
Carper, Fisher & Birch, 2000).
CHILD OVEREATING BEHAVIOURS
14
Maternal emotional, external and restrained eating styles have been proposed to be
associated with child feeding practices (Wardle et al., 2002). Parents frequently attempt to set
up standards of eating behaviour for their children through the use of different feeding
strategies (Moore, Tapper, & Murphy, 2007). These strategies are typically related to foods
that parents consider being part of a well-balanced diet (Moore, Tapper, & Murphy).
However, it has been suggested that mothers who engage in emotional, external or restrained
eating themselves may be more likely to use particular feeding strategies that may lead to the
development of unhealthy eating behaviours among children (Wardle et al., 2002). The
feeding strategies of interest in this research include: instrumental feeding, emotional feeding,
restriction, and pressure to eat (Wardle et al.; Birch et al., 2001). These strategies have been
proposed to interfere with the child’s self-regulatory ability, such that the child may associate
eating with cues other than hunger (Wardle et al.). This will be discussed in greater depth in
the following section.
A small number of cross-sectional studies have examined how maternal emotional,
external, and restrained eating styles are related to these specific child feeding practices (e.g.,
Robinson, Kiernan, Matheson, & Haydel, 2001; Wardle et al., 2002). For example, Wardle
and colleagues (2002) compared each of these child feeding practices in a sample of obese
and normal weight mothers. Although there were no significant differences in child feeding
practices between obese and normal weight mothers, a mother’s own eating style matched her
feeding practice for emotional and external eating styles but not for restrained eating (Wardle
et al., 2002). In particular, mothers who were emotional eaters tended to use food to calm
their child (emotional feeding) and use food rewards (instrumental feeding). Additionally,
mothers who were external eaters tended to use food as a reward (instrumental feeding).
However, no association was found between mothers who were restrained eaters and any
child feeding practice.
CHILD OVEREATING BEHAVIOURS
15
Conversely, Birch and Fisher (2000) examined restrained eating in a sample of
mothers and their 5 year old daughters. Specifically maternal control in feeding was
examined as a predictor of child eating and weight. Maternal weight was shown to be a
significant predictor of daughter’s weight. Additionally, in a feedback loop such that child
feeding is in response to child eating and weight, it was found that mothers who were
controlling their own weight (restrained eating) combined with the perception that their
daughter was at risk for overweight, were more likely to use restrictive feeding practices
(Birch & Fisher, 2000).
Of the limited research examining the association between mothers’ eating style and
child feeding practices, findings suggest that mothers’ use feeding strategies that are similar
to their own eating style. It seems likely that mothers who eat to manage negative emotions
or in response to palatable foods may naturally respond to their child in the same manner.
The studies noted above were cross-sectional, and therefore the direction of this relationship
cannot be assumed. However, findings from the Birch and Fisher (2000) study above provide
support that that mothers’ feeding practices may be in response to child eating patterns rather
than originating from a mother’s eating style. Further longitudinal research is needed to
clarify relationships between mothers’ eating styles and child feeding practices.
Relationships between Maternal Eating Styles and Child Eating Behaviours
The following section will examine pathway 2 (as shown in Figure 3). This section
will review the relationship between maternal eating styles and child eating behaviours.
Some maternal eating styles (emotional, external and restricted eating) do not appear
to be associated with hunger, but may be associated with overeating behaviours (van Strien,
Frijters, Bergers, & Defares, 1986; Wardle, 1987). It has been proposed that maternal
emotional and external eating styles may commence in childhood as a consequence of early
learning experiences about food, in which appetite self-regulation is disrupted or
CHILD OVEREATING BEHAVIOURS
16
misinterpreted (van Strien, Frijters, Bergers & Defares, 1986). To what extent a mother’s
food choices and eating behaviours impact on her child’s eating behaviours is not clear. That
said, the home environment as outlined earlier is the primary context for children to learn
about food, and mother-child interactions during meal times are likely to influence and shape
child eating behaviours (Baughcum et al., 2001; Tiggermann & Lowe, 2002). Consequently,
through modeling children may learn to eat in similar ways to their mother. To date, very few
studies have examined relationships between maternal eating styles and child eating
behaviours (e.g., Contento, Zybert & Williams, 2005; Cutting et al., 1999; Francis & Birch,
2005b).
Eating behaviours, as previously described (pages 11-12), are argued to emerge early
in development and remain stable throughout childhood (Ashcroft et al., 2008; Farrow &
Blissettt, 2012). Research has supported this hypothesis. Ashcroft and colleagues (2008)
examined the stability of subscale scores from the Children’s Eating Behaviour Questionnaire
(CEBQ) in children at aged 4 and again at aged 10. Subscale scores were significantly
correlated across the two time points, which suggested that eating behaviours were stable
across time. In another study supporting Ashcroft’s findings, Farrow and Blissett (2012) also
examined the stability and continuity of child eating behaviours in early childhood using
subscales from the CEBQ, and found that eating behaviours remained stable among children
aged between 2 to 5 years.
A few studies have explored the extent to which maternal eating styles predict child
overeating behaviours through the use of food approach eating items; namely food
responsiveness, emotional eating, and external eating (Brozovic, 2009); Jahnke &
Warschburger, 2008). A cross-sectional study by Jahnke and Warschburger (2008) utilised a
sample of boys and girls (n = 142) and their mothers who predominately came from lower
socioeconomic backgrounds. Maternal emotional eating was found to be a significant unique
CHILD OVEREATING BEHAVIOURS
17
predictor of emotional eating in boys but not in girls, maternal restrained eating was
associated with food responsiveness in boys but not in girls, and maternal external eating was
positively associated with external eating in both boys and girls (Jahnke & Warschburger).
The reasons for the gender differences are unclear but it may be hypothesized that as there is
greater social pressure for women to be thin, mothers who are emotional eaters may be more
cautious and avoid such eating behaviours when their daughters are around them, and perhaps
be less concerned about their sons developing such eating behaviours (Brozovic, 2009).
In contrast, other studies have found conflicting results in relation to gender
differences between maternal eating and child eating behaviours. For instance, research by
Cutting and colleagues (1999) revealed a positive association between maternal eating and
child eating in girls but not boys. This study assessed maternal dietary restraint and
disinhibited eating as predictors of child eating in preschool-aged children. Disinhibited
eating (similar to external eating) relates to the extent eating is triggered by emotional, social
or environmental cues. In this laboratory study, child eating was assessed using a free access
protocol method to measure eating in the absence of hunger. This method records the extent
children eat or overeat when given free access to palatable snack foods for ten minutes. This
exercise followed a normal lunch and children indicated they were not hungry. Maternal
disinhibition (external eating) was significantly associated with eating in the absence of
hunger in daughters aged 3 to 6 years. Neither maternal eating style was found to be
associated with eating in the absence of hunger in sons (Cutting et al).
Relationships between maternal eating and child eating behaviours were examined
prospectively in the Child and Family Health Study of mothers and their children aged 2 to 4
years (Brozovic, 2009). Maternal external eating was shown to be a significant prospective
predictor of child external eating at one year follow-up; however neither maternal emotional
eating nor restrained eating predicted child eating behaviours (Brozovic). Contrary to the
CHILD OVEREATING BEHAVIOURS
18
Jahnke and Warschburger (2008) study, there were no significant gender differences in any of
these relationships.
In a longitudinal study of 3 to 5 year old children, when parents exhibited higher
levels of both restrained eating and disinhibition, children were found to have had a greater
increase in body fat over a six year period compared to children whose parents had lower
levels of restraint and disinhibited eating (Hood, Moore, Sundarajan-Ramamurti, Singer,
Cupples, & Ellison, 2000). The authors suggest that parents who exhibit both of these eating
behaviours may inadvertently model inappropriate eating behaviour and undermine the
child’s autonomy in food selection through excessive control over their food intake (Hood et
al).
One mechanism by which eating behaviours may be transmitted from parent to child
could be through the consequences of feeding practices. This hypothesis was examined in the
Child and Family Health Study (Brozovic, 2009). Analyses suggested that emotional feeding
was a partial mediating variable between maternal emotional eating and child emotional
overeating, and between maternal external eating and child external eating. Moreover,
emotional feeding was shown to fully mediate the association between maternal external
eating and food responsiveness (Brozovic).
In summary, few studies have explored relationships between maternal eating and the
consequence on child eating behaviours. There is some evidence to support the hypothesis
that children eat in a similar way to their mothers. However, research has tended to be crosssectional and few studies have prospectively explored these relationships in young children.
Further research is needed to explore whether maternal feeding practices mediate the effect of
maternal eating on child eating behaviours. It will be important to understand potentially
modifiable risk factors that may be contributing to overeating behaviours in children in order
to develop effective treatment to minimise overweight and obesity.
CHILD OVEREATING BEHAVIOURS
19
CHAPTER 3: Child Feeding Practices, Child Eating Behaviours, and Child BMI
An important focus of the present research is to explore relationships between child
feeding practices, child eating behaviours, and child weight. In addition to genetic factors, the
development of overeating behaviours may be learnt through experiences of feeding practices
that are not related to hunger (Wardle et al., 2002). This will be discussed in greater depth in
the following sections. A review of research examining relationships between instrumental
and emotional feeding practices, child eating behaviours, and child weight will be considered,
followed by a review of the research examining relationships between restriction and pressure
to eat feeding practices, child eating behaviours and child weight (pathways 3, 4 & 5) as
highlighted in Figure 4.
1
Maternal Eating
 Emotional Eating
 External Eating
 Restrained Eating
2
Child Feeding Practices
 Instrumental feeding 5
 Emotional Feeding
 Restriction
 Pressure to Eat
4
Child BMI
3
Child Eating Behaviours
 Food Responsiveness
 Emotional Overeating
 External Eating
 Satiety Responsiveness
 Slowness in Eating
 Food fussiness
5
Figure 4. Simple model of associations to be examined in this Chapter. Note: light dashed
line denotes the relationships that were explored in Chapter 2.
CHILD OVEREATING BEHAVIOURS
20
Theoretical Underpinnings of Relationships Between Instrumental and Emotional
Feeding, Child Eating Behaviours and BMI
Instrumental and emotional feeding practices are non-nutritious feeding styles that are
proposed to interfere with the child’s ability to recognize when they are full and associate
eating with factors other than hunger, thereby increasing the likelihood of eating more than
physiologically required (Rhee, 2008; Wardle et al., 2002). While parents employ these
feeding strategies with the aim of reducing emotional distress and to reward positive
behaviour, they may actually promote eating in the absence of hunger. As a result, eating is
refocused to aspects of the environment rather than internal satiety cues. Consequently, it has
been proposed that the child’s self-regulatory ability to reduce food intake to match satiety is
in effect ignored and may lead to overeating (Baughcum et al., 2001; Wardle et al., 2002).
These feeding patterns become problematic as they are not confined to mealtimes and often
involve foods high in fats and sugar, which may increase the likelihood of excess weight gain
(Wardle et al., 2002).
Relationships between Instrumental Feeding, Child Eating and Child BMI
Instrumental feeding and child eating.
One aspect of instrumental feeding is the use of food rewards to encourage the child
to eat a preferred food. However, it is proposed that this feeding strategy may in fact increase
the child’s liking for the food that was given as a reward and decrease the liking of the
encouraged food (Birch, Marlin & Rotter, 1984; Newman & Taylor, 1992). Commonly,
rewards for eating-specific behaviours tend to be another food item, to encourage the child to
eat a desired, usually healthy food (Benton, 2004; Newman & Taylor, 1992; Wardle et al.,
2001), for example, “Unless you eat all your vegetables you will not have dessert”. As noted
though, this strategy is proposed to increase the child’s preference for the reward food.
CHILD OVEREATING BEHAVIOURS
21
Consistent with this hypothesis, a change in food preferences was demonstrated in an
experimental study by Newman and Taylor (1992). In this study, children aged 4 to 7 years
old neutrally rated two different snack foods, and were then assigned to one of three different
experimental conditions. In one condition children were told they could have a second snack
if they ate the first one (means-end condition), whilst in the second condition children were
given the second snack after the first one was eaten (temporal order condition). Moreover, in
the control condition children were shown both snacks and allowed to eat them in any order
(mere exposure condition). In the means-end condition it was found that preference for the
snack that was given as a reward increased, and preference for the initial snack decreased. No
differences were found in the temporal order or mere exposure conditions. One possible
implication of using rewards to encourage the child to eat the preferred food (i.e., vegetables),
may be that children’s intrinsic value of this food is altered. That is, being promised a reward
may devalue the preferred food when given a choice (Newman & Taylor, 1992; Rhee, 2008).
Recent research indicates that when a reward is paired in a positive context, such as
for achievement or praise, it can enhance the liking of that food. For example, Lowe, Horne,
Tapper, Bowdery, and Egerton (2004) conducted a school-based study over a 16 day period
with children aged 4 to 11 years old. This study included an intervention phase where
rewards such as stickers and pencils were given to children who ate the target amounts of
fruit and vegetables offered to them. It was found that reward-based intervention not only
increased the consumption of fruits and vegetables but also the liking of these foods (Lowe,
et al., 2004).
Very few studies have explored the influence of instrumental feeding practices on
child eating in terms of food approach (i.e., food responsiveness, emotional overeating, and
external eating) and food avoidant (i.e., satiety responsiveness, slowness in eating, and food
fussiness) eating behaviours. Carnell and Wardle (2008a) found robust positive correlations
CHILD OVEREATING BEHAVIOURS
22
between instrumental feeding and food responsiveness (i.e., eating in response to external
cues) in large samples of children from various age ranges, including 3 to 5 year olds (n =
541) and 9 to 11 year olds (n = 348). However, no associations between instrumental feeding
practices and other food approach eating styles were observed.
Other research that has supported a positive relationship between instrumental feeding
and food approach eating behaviours includes findings from the Child and Family Health
Study of mothers and their 2 to 4 year old children (Brozovic, 2009). While instrumental
feeding was shown to have robust correlations with food approach eating behaviours, when
entered into a regression analysis with other feeding practices it did not uniquely predict
variance in any child eating behaviour (Brozovic).
Brozovic (2009) also examined whether instrumental feeding predicted child eating
behaviours one year later (after controlling for time 1 of the relevant eating behaviour).
Instrumental feeding-eating was found to have predicted food responsiveness at one year
follow-up.
Instrumental feeding and child BMI.
Other studies have examined the relationship between instrumental feeding and child
BMI. Findings from experimental research noted above by Newman and Taylor (1992)
suggests that instrumental feeding may increase a child’s preference for unhealthy food,
which could potentially lead to overeating and weight gain. No studies to date, however, have
found an association between instrumental feeding and child BMI (Baughcum et al., 2001;
Brozovic, 2009; Carnell & Wardle, 2007; Wardle et al, 2002).
Two commonly used questionnaires to assess instrumental feeding include the
Instrumental Feeding subscale of the Parental Feeding Style Questionnaire (PFSQ: Wardle et
al., 2002) and the Pushing the Child to Eat More subscale of the Preschooler Feeding
Questionnaire (PFQ: Baughcum et al., 2001). Wardle and colleagues (2002) found no
CHILD OVEREATING BEHAVIOURS
23
association between instrumental feeding and BMI using a twin sample aged 4 to 7 years;
however, obese mothers were significantly more likely to use instrumental feeding compared
to normal-weight mothers. Additionally, Baughcum and colleagues (2001) found no
significant association between instrumental feeding and child BMI in a younger sample
children aged 2 to 5 years.
More recently, a study by Carnell and Wardle (2007) compared associations between
instrumental feeding and child BMI z-scores on scales from the two aforementioned
questionnaires (Instrumental Feeding and Pushing the Child to Eat More) in a sample of 3 to
5 year olds (n = 439). A significant correlation was found between the Pushing to Eat
subscale and lower child BMI; nevertheless post-hoc analysis revealed no significant
differences between the groups (child adiposity groups). In response to this finding, the
authors suggested that this feeding practice may not as of yet impacted on children’s weight.
The Child and Family Health Study (Brozovic, 2009) was the first to examine
instrumental feeding as two separate factors (feeding to reward good behaviour versus
feeding to reward particular eating behaviours) in a sample of 2 to 4 year old children and
their mothers using a longitudinal study design. Cross-sectional data and data from a one year
follow-up revealed no associations between instrumental feeding for rewards to shape
behaviour (i.e., giving sweets for good behaviour) and child BMI z-scores, or for
instrumental feeding for eating-specific behaviour (i.e., desserts provided as a reward for
eating vegetables) and child BMI z-scores (Brozovic).
The proposed impact of instrumental feeding on child eating and weight needs further
clarification. Whilst instrumental feeding has been examined in a small number of
observational settings (e.g., Newman & Taylor, 1992) and cross-sectional research (e.g.,
Baughcum et al., 2001; Wardle et al., 2002) over the past two decades, only one study has
explored instrumental feeding longitudinally (e.g., Brozovic, 2009). This may account for the
CHILD OVEREATING BEHAVIOURS
24
overall lack of research support for the hypothesis that using food as a reward is implicated in
the development of overeating behaviours and child overweight. Further refinement of the
instrumental feeding construct is warranted. The long-term implications of this feeding
strategy have not yet been clarified, as many of these studies have been cross-sectional and
have focused on preschool-aged children. Longitudinal research would therefore assist to
understand the implications of this feeding strategy.
Relationships between Emotional Feeding, Child Eating and Child BMI
Emotional feeding and child eating.
A small number of studies have explored the relationships between emotional feeding
and food approach eating behaviours. However, no studies have explored associations
between emotional feeding and food avoidant eating behaviours. Typically emotional feeding
is assessed by either The Preschooler Feeding Questionnaire (PFQ) by Baughcum et al.
(2001), which includes the factor structure labelled Using Food to Calm the Child, or The
Parental Feeding Style Questionnaire (PFSQ) by Wardle et al. (2002), which includes the
component of Emotional Feeding.
In a large sample of children, robust positive correlations were found between
emotional feeding and food responsiveness (i.e., eating in response to external cues) (Carnell
& Wardle, 2008a). No association between emotional feeding and other food approach eating
styles were observed in this study.
Moreover, other studies also report positive relationships between emotional feeding
and food approach eating behaviours. Cross sectional research in the Child and Family Health
Study of Australian mothers and their 2 to 4 year old children (Brozovic, 2009) found
emotional feeding to be a significant unique predictor of food responsiveness, emotional
overeating, and external eating. Additionally, Brozovic (2009) also examined if emotional
CHILD OVEREATING BEHAVIOURS
25
feeding predicted child eating behaviours one year later (after controlling for time 1 of the
relevant eating behaviour). Emotional feeding predicted emotional overeating at one year
follow-up; however, neither food responsiveness nor external eating was associated with
emotional feeding.
Emotional feeding and child BMI.
It is proposed that emotional feeding may contribute to the development of
overweight. Feeding to alleviate emotional distress is thought to encourage eating in response
to cues other than hunger and therefore it is contended that overeating may occur. Few
studies have examined the relationship between emotional feeding and child BMI. To date,
no studies have found a significant relationship between emotional feeding and child
overweight (e.g., Baughcum et al., 2001; Carnell & Wardle 2007; Wardle et al., 2002).
Studies have explored relationships between emotional feeding and child BMI in relation to
differences in maternal weight status. Wardle and colleagues (2002) found that in a
community sample of mothers and their children aged 3 to 5 years, obese mothers were no
more likely than non-obese mothers to use food to calm the child in response to emotional
distress. Furthermore, other studies have also explored differences in child weight in relation
to emotional feeding and child overweight. Baughcum et al. (2001) identified that mothers of
overweight children (aged 2 to 5 years) more often used the feeding style of using food to
calm the child compared to mothers of non-overweight children, however this difference was
not significant.
Finally, the Child and Family Health Study (Brozovic, 2009) examined the
relationship between a refined measure of emotional feeding and child BMI z-scores of
children aged 2 to 4 years. Items from the using food to calm the child subscale and the
emotional feeding subscale were combined and examined in an exploratory factor analysis for
item integrity (Brozovic). No associations were found between emotional feeding and child
CHILD OVEREATING BEHAVIOURS
26
BMI irrespective of mother’s weight status in a cross-sectional analysis (Brozovic). Brozovic
also examined emotional feeding as a prospective predictor of child BMI at 12 months
follow-up. However, results revealed no significant association.
The impact of emotional feeding on overeating and overweight requires greater
examination. Emotional feeding has not been explored experimentally, and the Child and
Family Health Study (Brozovic, 2009) appears to have been the first study to examine this
feeding style longitudinally. One explanation for the lack of association with child BMI could
be that child characteristics, such as eating behaviours, may mediate this relationship; this
will be considered in greater depth in a later section (p. 36). Alternatively, the lack of
association could be related to study limitations. For example, emotional feeding may have
not yet impacted on child weight and therefore any change in weight may take longer than 12
months to become apparent and as such may require longitudinal studies with periods of
greater than 12 months. On the other hand, there may be no impact from emotional feeding
on child weight in young children. Further longitudinal research is needed to explore the
relationships between emotional feeding and the impact on child eating and weight over time.
Theoretical underpinnings of Relationships Between Restriction and Pressure to Eat
Feeding and Child Eating and BMI
Restriction and pressure to eat are considered directive feeding practices. Earlier
research referred to these feeding practices as “controlling” feeding practices; however,
subsequent research has conceptualized these feeding strategies as separate concepts (Birch et
al., 2001). It is contended that overly controlling feeding practices may negatively impact on
child eating and increase the risk for overweight (Costanzo & Woody, 1985; Farrow, Blissett
& Haycraft, 2011).
CHILD OVEREATING BEHAVIOURS
27
Similar to non-nutritious feeding practices, restricting access to energy dense foods is
also proposed to promote overeating by interrupting the child’s self-regulating mechanism of
food intake (Birch et al., 2001; Faith & Kerns, 2005; Webber, Cooke, Hill, Wardle, 2010b).
However, the proposed mechanism that disrupts the child’s natural ability to self-regulate
their energy intake differs. It is contended that parental attempts to limit access to energy
dense foods in an effort to reduce overconsumption of unhealthy foods may essentially be
counterproductive, in that it actually increases the child’s focus on restricted foods (Faith &
Kerns, 2005). It has been demonstrated that when parents restrict access to palatable foods it
actually makes these foods more appealing to children, and therefore, when children are no
longer in the restricted environment overconsumption of the restricted foods has occurred
(Birch, Fisher & Davison, 2003; Fisher and Birch, 1999a, 2000, 2002; Jansen, Mulkens, &
Jansen, 2007). Consequently, restriction has been associated with eating in the absence of
hunger, and an increased risk of overweight (Fisher & Birch 1999b; Fisher & Birch, 2002).
Pressure to eat on the other hand, is likely to be a response to child weight. It was
originally contended that this feeding practice interfered with the child’s self-regulatory
ability. By requiring the child to eat all food on their plate regardless of portion size, parents
inadvertently taught children to ignore feelings of satiety and overeat (Birch, McPhee, Shoba,
Steinberg, & Krehbiel, 1987). However, more recently it has been proposed that pressure to
eat is associated with undereating, which may be related to the range of food the child
consumes or actual weight status (Birch et al., 2001; Carnell & Wardle, 2007; Montgomery,
Jackson, Kelly, & Reilly, 2006; Spruijt-Metz, Li, Cohen, Birch, & Goran, 2006). One
possible interpretation is that pressure to eat is protective against weight gain, in that this
feeding practice actually leads to eating less. On the other hand, it is more likely that parents
who perceive their child as underweight or eating too slowly exert pressure to eat, while
mothers of already overweight children tend to use less pressured feeding practices (Francis,
CHILD OVEREATING BEHAVIOURS
28
Hofer, & Birch, 2001; Keller, Pietrobelli, Johnson, & Faith, 2006; Kroller & Warschburger,
2008; Spruit-Metz, Lindquist, Birch, Fisher, & Goran, 2002).
Relationships between restriction, child eating and child BMI
Restriction and child eating.
Recent studies have explored the association between food restriction and food
approach and food avoidant eating behaviours as measured by the Children’s Eating
Behaviour Questionnaire (CEBQ: Farrow, Galloway & Fraser, 2009; Van Strien & Brazelier,
2007; Webber, Cooke, Hill & Wardle, 2010a). If eating is thought to be in response to
palatable foods (i.e., external food cues), it might be expected that restriction would be
positively associated with food approach eating behaviours (i.e. food responsiveness and
enjoyment of food), and be negatively associated with food avoidant eating behaviours (i.e.,
satiety responsiveness, and food fussiness).
Partial support has been found for this proposition. Some cross-sectional studies have
supported a positive relationship (Gregory, Paxton & Brozovic, 2010a), and other studies
have found no relationship between greater restriction and food approach eating behaviours
(Farrow, Galloway, & Fraser, 2009; McPhie et al., 2011; Webber et al., 2010a). For example,
a positive relationship between greater levels of restrictive feeding and food responsiveness
has been found in a preschool aged sample of 2 to 4 year old children in the Child and Family
Health Study (Gregory, Paxton & Brozovic) and in a primary school aged sample of 7 to 9
year old children (Webber, et al., 2010a). Gregory, Paxton and Brozovic (2010a) reported
that food responsiveness positively predicted restrictive feeding and was partially mediated
by maternal concern about their child becoming overweight in a sample of 2 to 4 year old
children. Put another way, this finding suggested that children who are perceived to be
overweight and who have a tendency to eat in response to external cues are more likely to
CHILD OVEREATING BEHAVIOURS
29
have parents who restrict access to certain foods. On the other hand, no association has been
found between restriction and enjoyment of food (Farrow, Galloway, & Fraser, 2009; McPhie
et al., 2011; Webber et al., 2010a) and between restriction and emotional overeating (Farrow,
Galloway, & Fraser, 2009). However, given these studies are cross-sectional the direction of
relationships between food responsiveness and restriction cannot be assumed. It could be that
mothers respond to children who tend to overeat in the presence of palatable food by
restricting access to these foods, or it could be that as a result of these foods being prohibited
that children tend to overeat when they become freely available.
Longitudinal research has tended to explore the latter proposal. Three studies from the
Birch group followed a sample (n = 197) of 5-year old girls across two time points – at age 7
years and again at age 9 years ( Fisher & Birch, 2002; Birch, Fisher & Davison, 2003; Francis
& Birch, 2005a). Laboratory research was conducted to explore if restrictive feeding
promoted eating in the absence of hunger (i.e., external eating) and was associated with
overweight (Birch, Fisher, & Davison, 2003; Fisher & Birch, 2002; Francis & Birch, 2005a).
Eating in the absence of hunger (EAH) was measured using a free access protocol method.
Higher levels of restriction at age 5 were found to predict greater eating in response to the
presence of palatable foods at age 7 and at age 9, when in the laboratory setting (Birch,
Fisher, & Davison 2003; Fisher & Birch, 2002). Greater eating in the absence of hunger was
also associated with higher BMI from age 5 to age 9 (Birch, Fisher, & Davison; Fisher &
Birch, 2002; Francis & Birch, 2005a).
In contrast to laboratory findings by the Birch group, the Child and Family Health
Study (Gregory, Paxton, & Brozovic, 2010b) prospectively explored if restrictive feeding
positively predicted food responsiveness (i.e., eating in response to external cues) one year
later in a sample of 2 to 4 year old children (N = 156). Restriction was not a unique predictor
of food responsiveness over time (Gregory, Paxton & Brozovic). The Birch et al. studies
CHILD OVEREATING BEHAVIOURS
30
included an older sample and a different measure to assess child eating behaviours. It will be
important to understand the impact of restrictive feeding practices at a more formative stage
of development where it is thought that these eating behaviours are formed. Further
longitudinal research is needed to validate if restriction may indeed promote overeating
behaviours as proposed by Birch et al.
Restriction and child BMI.
Cross-sectional studies examining the relationships between restrictive aspects of
control (i.e., “limiting access to foods”) and child BMI have also yielded mixed results. In
support of a relationship between restriction and child overweight, Birch and colleagues
(2001) who developed the scale of restriction in the Child Feeding Questionnaire, found that
higher restriction was positively associated with child BMI in a sample of 5 to 9 year olds,
albeit weakly (r = .13, p = .06).
A small number studies have replicated this finding. Among a mixed sample of white
and African American children aged 7 to 14 years (N = 74) it was found that restriction was
associated with higher fat mass in children (Spruijt-Metz, et al., 2002). Furthermore, support
was found in a longitudinal study that compared children at high and low risk for overweight
(Faith, Berkowitz, Stallings, Kerns, Storey, & Stunkard, 2004). Level of risk refers to
maternal weight status prior to their child’s birth, in which maternal overweight is a marker
for children at greater risk for overweight. Among high risk families, higher restriction of
child eating at age 5 predicted an increase in BMI of children at aged 7. No association was
found between restriction and change in child BMI two years later in low risk families,
however (Faith, Berkowitz, et al., 2004).
In contrast, several studies have found no association between restriction and child
weight (e.g., Crouch, O’Dea & Bassisti, 2007; Gregory, Paxton & Brozovic, 2010b; Keller, et
al., 2006; Saelens, Ernst & Epstein, 2000). Research has investigated this relationship across
CHILD OVEREATING BEHAVIOURS
31
a range of cross-sectional and longitudinal studies that include various age ranges, cohorts,
ethnic diversity and socioeconomic backgrounds, with limited support.
In fact, several studies have found an inverse relationship between restrictive feeding
and child BMI (Campbell et al., 2010; Farrow & Blissett, 2008; Robinson, et al., 2001). For
example, Robinson, Kiernan, Matheson and Haydel (2001) investigated the association
between controlled feeding and child BMI in a large sample (n = 792) of third grade children
from diverse ethnic and socioeconomic backgrounds. Controlled feeding was inversely
related to overweight in girls, and no relationship was found in boys (Robinson et al). The
authors suggested that the inverse relationship may be a reflection of sample characteristics in
previous research, in which samples have tended to be white middle-class families (Robinson
et al.). Furthermore, it is also noteworthy that the measure of control in this study appears to
be a combination of restrictive items and pressure to eat items, which may explain the inverse
finding, as the majority of other studies have used Birch’s CFQ, which measures these
concepts separately. Notwithstanding this, current longitudinal research also supports an
inverse relationship between restriction and child BMI (Campbell et al., 2010; Farrow &
Blissett, 2008). This was apparent in a young sample, which found that higher restriction at
age 1 predicted lower BMI at age 2 (Farrow & Blissett, 2008), and in a sample of school-age
children (aged 5 to 6 years), in which higher restriction predicted lower child BMI at three
years follow-up (Campbell et al., 2010).
Inconsistent findings suggest that this construct needs further investigation. As noted
earlier, other than support in experimental studies where the short-term effects of restriction
are robust, there is limited support for a long-term effect of restriction on child BMI.
Longitudinal studies that have found an association between restriction and higher BMI have
been with children already at high risk for overweight (Faith, Berkowitz et al., 2004). In
contrast, two studies using community samples, with children aged 7 to 9 years and 2 to 4
CHILD OVEREATING BEHAVIOURS
32
years respectively, have found no association (Gregory, Paxton, & Brozovic, 2010b; Webber,
Cooke, Hill, & Wardle, 2010b). The lack of support between restriction and higher child
weight is not clear. It may be possible that restriction is associated with children who have a
genetic vulnerability to overweight or it could be that overeating of energy-dense, palatable
foods when in an unrestricted environment occurs irregularly, and therefore may not imply a
continuous pattern of overeating. As the majority of research in this area has been crosssectional, the extent to which restrictive feeding is a prospective predictor of higher child
BMI has not yet been established. It has been suggested that this relationship may be
bidirectional, such that restriction may be in response to overweight, or is influenced by
children’s eating behaviours and weight status (Birch & Fisher, 2000). This therefore makes
it difficult to provide useful advice to parents regarding appropriate feeding strategies for
managing children’s consumption of energy dense foods. Further longitudinal research is
required to resolve this issue.
Relationships between Pressure to Eat, Child Eating and Child BMI
Pressure to eat and child eating.
Cross-sectional and longitudinal studies have frequently supported an inverse
association between pressure to eat and child weight status (Birch et al., 2001; Powers, et al.,
2006; Spruit-Metz, et al., 2002). An association with lower weight status therefore suggests
that this feeding practice may to be linked to undereating behaviours rather than overeating
behaviours. This hypothesis was supported across four separate cross-sectional studies, in
which pressure to eat was positively associated food avoidant eating behaviours including
slower eaters, more fussiness, and being full easily (e.g. Farrow, Galloway, & Fraser, 2009;
McPhie et al., 2011; Powell, Farrow, & Meyer, 2011; Webber, Cooke, Hill &Wardle, 2010a).
This finding is robust across childhood, including studies of preschool-aged children
CHILD OVEREATING BEHAVIOURS
33
(Gregory, Paxton, & Brozovic, 2010a; McPhee et al., 2011; Powell, Farrow & Meyer, 2011)
and children in late childhood (Webber et al., 2010a). Furthermore, food fussiness has been
found to predict pressure to eat and maternal concern of the child being underweight partially
mediated this relationship (Gregory, Paxton, & Brozovic, 2010a).
Pressure to eat and child BMI.
Overall, longitudinal evidence suggests that parents more commonly use pressure to
eat feeding practices for children who are perceived as underweight or are eating too slowly
(Gregory, Paxton, & Brozovic, 2010a; Webber et al., 2010a). For example, in a preschool
sample of children aged 2 to 4 years, higher child BMI was shown to predict less pressure to
eat at one year follow-up (Gregory, Paxton, & Brozovic, 2010b). A similar result was found
in 7 to 9 year old children by Webber and colleagues (2010b), in which higher BMI predicted
lower use of pressure to eat over a three year period. Neither study found pressure to eat at
baseline to be associated with change in BMI at follow-up (Gregory, Paxton, Brozovic,
2010b; Webber et al., 2010b). Whilst these two studies support an inverse relationship, other
longitudinal research has found no association between pressure to eat and child BMI
(Montgomery et al., 2006; Spruijt-Metz et al., 2006). Further longitudinal research is required
to explore this relationship.
Generally, robust findings have supported a positive relationship between pressure to
eat and food avoidant eating behaviours. Specifically, research has frequently shown that
parents are more likely to promote eating in leaner children. Nevertheless conclusions
regarding causality and the direction of this relationship require further investigation.
Potentially, the long term use of pressure to eat, regardless of child weight, may lead to
overeating behaviours and increased weight in the long-term. Longitudinal design research
with longer follow up periods may help to shed light on the bidirectional nature of the
relationship between pressure to eat, child eating behaviours and relative weight.
CHILD OVEREATING BEHAVIOURS
34
Child Eating Behaviours and Child BMI
The final area to be explored is the direct association between child eating behaviours
and child BMI. The past decade has seen a marked rise in research examining the differences
in appetite traits and the association with weight status. Evidence relating to food cue
responsiveness, emotional eating, external cue responsiveness (food approach) as well as
satiety responsiveness, speed of eating, and food fussiness (food avoidant) will be reviewed.
Laboratory research using a preload paradigm has produced significant evidence
related to appetite and overweight (e.g., Carnell & Wardle, 2009). The preload paradigm
assumes that individuals will adjust their intake of a meal according to the energy content
consumed in a previous meal (Carnell & Wardle, 2008a). Jansen and colleagues (2003) used
a preload method to explore responsiveness to internal satiety cues in a sample of obese and
normal-weight children aged 8 to 12 years. Whereas obese children who were presented with
a meal after a preload showed no adjustment or down-regulation of intake, normal-weight
children showed reduced consumption. This indicated greater satiety responsiveness in leaner
children (Jansen et al., 2003). Differences between obese and normal-weight children have
been demonstrated in other experimental studies in which obese children demonstrated a
greater intake of energy dense foods in the absence of hunger (Birch & Fisher, 2000; Johnson
& Birch, 1994).
Several cross sectional studies have supported associations between child weight and
food approach and food avoidant eating traits as measured using the CEBQ (Parkinson,
Drewett, Couteur & Adamson, 2010; Sleddens, Kremers & Thijs, 2008; Viana, Sinde &
Saxton, 2008; Webber et al., 2008). Specifically, positive associations with child weight have
been found for food responsiveness, enjoyment of food, and emotional overeating.
Additionally, negative associations with child weight have been found for satiety
responsiveness, slowness in eating, and food fussiness (Carnell & Wardle, 2008b; Sleddens,
CHILD OVEREATING BEHAVIOURS
35
Kremers & Thijs, 2008; Viana, Sinde & Saxton, 2008; Webber et al., 2008). Notably, the
majority of this research has used samples of primary school-aged children and used cross
sectional designs, which therefore does not exclude reverse causality.
Mixed results have been found when eating behaviours have been explored in
younger samples. The Child and Family Health Study of 2 to 4 year olds found no association
between BMI and any child eating behaviours as measured by the CEBQ subscales
(Brozovic, 2009; Gregory, Paxton, Brozovic, 2010a). In contrast, higher BMI was associated
with lower satiety responsiveness and higher food responsiveness in a sample of 3 to 5 year
olds (Carnell & Wardle, 2008b).
Child external eating and emotional eating have also been examined using a different
instrument; namely the Dutch Eating Behaviours Questionnaire – parent version (DEBQ-P;
Braet & Van Strien, 1997). The external eating subscale was explored in a preschool-aged
sample of 2 to 4-year olds, however no significant association was found with BMI
(Brozovic, 2009). External and emotional eating have also been explored using different
weight indices. Among a pre-adolescent sample of obese and normal-weight 9 to 12 year
olds, scores for obese children were significantly higher than in leaner children (Braet & Van
Strien). Contrary to this finding, other studies have reported no significant differences in
external and emotional eating behaviours between obese and normal-weight groups in a
similarly aged sample (Caccialanza, Nicholls, Cena, Maccarini, Rezzani, Antonioli et al.,
2004).
To date, there is very little longitudinal data exploring the relationship between eating
behaviours and weight status. The Child and Family Health Study examined the CEBQ and
BMI in a sample of 2 to 4 year-olds and found no relationship between child eating
behaviours and changes in weight one year later (Brozovic, 2009). In contrast, a longitudinal
study by Parkinson, Drewett, Couteur, and Adamson (2010) demonstrated that higher
CHILD OVEREATING BEHAVIOURS
36
emotional overeating at age 5 to 6 years (n = 506) was significantly associated with higher
BMI (p = .006) in children aged 6 to 8 years; and higher satiety responsiveness at ages 5 to 6
years was significantly associated with lower BMI (p = .029).
In summary, whilst a number of studies have found relationships between child eating
behaviours and overweight (Carnell & Wardle 2008a; Sleddens, Kremers & Thijs, 2008;
Viana, Sinde & Saxton, 2008; Webber et al., 2008), many of these studies have used samples
of primary school-aged children. The onset of such eating behaviours is unclear but the
evidence proposes that overeating behaviours may develop at a much younger age (Wright,
Cox & Couteur, 2011). It is suggested that children may begin responding to external food
cues from toddler years or perhaps earlier (Carnell & Wardle, 2008a). However, relatively
few studies have investigated overeating traits in these younger age groups.
The literature presented has shown consistent cross-sectional evidence that an
association exists between particular eating traits and overweight in primary school-aged
children. This includes eating in the absence of hunger, poor compensation after a preload,
interest in food, emotional eating, and eating in response to external cues. Additionally,
results largely indicated that obese children differ from leaner children in eating style. It has
been contended by Carnell and Wardle (2008a, 2009) that individual differences in appetitive
traits may be explained by the susceptibility model of obesity, in which children who are
genetically more vulnerable to overeating behaviours may have a greater susceptibility to
environmental influences than their low-risk counterparts. Nonetheless, these cross-sectional
studies cannot infer a causal relationship. Longitudinal studies will be important to examine if
overeating traits precede or predict weight gain, or conversely if eating behaviours may be
secondary to changes in weight status (Carnell & Wardle, 2009). If weight-related appetite
traits can be recognized earlier, targeted interventions could potentially modify their impact
(Carnell & Wardle, 2008a).
CHILD OVEREATING BEHAVIOURS
37
Child Feeding Practices, Child Eating Behaviours and Child BMI
In the research described above, it has been shown that parents may be influential in
the development of childhood overweight as they establish and shape the immediate eating
environment of the child. It is likely that parental feeding influences child eating and weight,
but it is also possible that child eating and weight may influence parental feeding. However,
the cross-sectional nature of the majority of studies prohibits assumptions to be made of the
direction of this relationship (Ventura & Birch, 2008). Furthermore, it is reasonable to assert
that parental feeding may not have a direct effect on child weight. Ventura and Birch (2008)
argue that the influence of parental feeding on child weight is likely to be mediated by child
eating behaviours such as food approach eating behaviours, as they have been found to have
an impact on food intake (Stang & Loth, 2011). Moreover, it seems logical to examine child
feeding with both outcomes - child eating and child weight outcome (Ventura & Birch 2008);
nevertheless very few studies have explored interrelationships between child feeding, child
eating and child weight.
Observational research has explored restriction, eating in the absence of hunger and
child adiposity (as measured by skin folds) (Fisher & Birch, 1999a; Fisher & Birch, 1999b).
For girls, child adiposity predicted greater restrictive feeding, with higher levels of restriction
predicting greater levels of eating in the absence of hunger (Fisher & Birch, 1999b). Two
recent cross-sectional studies investigated parental feeding with both outcomes in a
preschool-aged sample (Gregory, Paxton, & Brozovic, 2010a; Mcphie et al., 2011). Both
studies failed to find an association between parental feeding (restriction and pressure to eat),
child eating behaviours (subscales from CEBQ), and child BMI. Additionally, the Child and
Family Health Study was the first to explore instrumental and emotional feeding as a
predictor of child eating, including food responsiveness, emotional overeating and external
CHILD OVEREATING BEHAVIOURS
38
eating, and child BMI (Brozovic, 2009). Likewise, neither child feeding practices nor child
eating behaviours were associated with BMI.
Additionally, in previous longitudinal research, mothers with overweight daughters at
age 5 who used higher levels of restriction predicted higher levels of eating in the absence of
hunger (EAH) at age 7 and 9 years (Birch, Fisher & Davison, 2003). In a similar study,
overweight and normal-weight mothers’ restriction was examined as a predictor on daughters
EAH and BMI from ages 5 to 9 years (Francis & Birch, 2005a). Overweight mothers who
used higher restriction predicted greater increases in EAH, which in turn predicted greater
changes in BMI from ages 5 to 9 years.
The Child and Family Health Study explored child feeding practices in children aged
2 to 4 years as predictors of child eating and BMI at one year follow-up. No significant
relationships were found with child BMI across time (Brozovic, 2009).
Whilst weight differences were found in relation to eating behaviours and weight
change in observational studies, few studies have found associations when explored in a
younger sample. Parents influence child weight directly through genetics (Birch & Ventura,
2009), but it could be that the effects of child feeding practices and eating styles on weight
are minimal at this age and may not emerge until later in childhood. It seems plausible that
child eating behaviours may act as a mediator between child feeding and child BMI. A
research design that includes all three constructs is needed to explore this proposition.
Longitudinal research would assist to identify bidirectional pathways between parental
feeding, child eating and child weight. This would also help to further establish if parental
feeding both influences, and is influenced by, child eating and child weight.
CHILD OVEREATING BEHAVIOURS
39
CHAPTER 4: Rationale and Aims for the Present Study
The review of literature in this chapter suggests that there may be a number of familyfood environment factors related to the development of eating behaviours and BMI in young
children. It also highlighted that there are a number of inconsistencies and gaps in the current
literature regarding relationships between maternal eating behaviours, child feeding practices,
child eating behaviours, and child weight status.
To summarise the findings, there is evidence to support positive associations between
instrumental and emotional feeding, and eating in response to environmental food cues and
interest in food (external eating and food responsiveness), and to reduce emotional distress
(emotional eating). No associations have been found between instrumental feeding and
emotional feeding, and child BMI. However, research related to restrictive feeding has
revealed mixed results. Restriction has been positively associated with eating in response to
environmental food cues (food responsiveness) and BMI in some studies, and no association
has been found in others. Pressure to eat, on the other hand, has been the most consistent
feeding behaviour across studies and was shown to be associated with food avoidant eating
(slower eaters, more fussiness, and being full easily) and lower weight status.
As noted in this review, literature exploring the associations between maternal eating,
child feeding practices, child eating behaviours and overweight is sparse. The majority of
supporting evidence comes from laboratory or cross-sectional research in primary schoolaged children, which prohibits assumptions of the direction of this relationship to be made.
Furthermore, research has primarily focused on relationships between child feeding and child
weight. Little is known about eating behaviours of young children, but given this is a time
when eating patterns are developing, it is likely to be an important aspect to consider in the
familial transmission of obesity. Moreover, some data supports an association between
maternal eating, child feeding and child eating but the extent of this association needs to be
CHILD OVEREATING BEHAVIOURS
40
clarified. Overall, there are very few longitudinal studies that cast light on prospective
relationships between maternal eating and child feeding practices as predictors of child eating
behaviours and weight at a formative stage of development. Furthermore, no studies of which
the author is aware has examined prospective relationships between instrumental and
emotional feeding, child eating and BMI outcomes over a time period of greater than one
year in preschool-aged children. This gap in the literature is important to fill because
understanding these prospective relationships over an extended time would increase the
knowledge base of more robust and potentially influential relationships than previously
identified.
Another gap in the literature relates to our understanding of mediating relationships
amongst maternal eating, child feeding, child eating, and child BMI. It could be that eating
behaviours mediate the relationship between child feeding and weight status. Alternatively, it
could be that some eating behaviours are more apparent when children are older and have
greater autonomy in eating (Viana, Sinde & Saxton, 2008). Unfortunately few studies have
explored interrelationships between child feeding, child eating and child weight.
More research is required to clarify the gaps identified above. First, to explore
associations between maternal eating, child feeding, child eating and weight in a preschoolaged sample (M = 5.29 years) to enable comparisons with existing literature in older age
groups. Second, this will be to prospectively explore relationships between maternal eating,
child feeding, child eating, and child BMI over a two year period in a preschool-aged sample
and begin to disentangle the direction of these relationships. It could be that parents use
particular feeding strategies in response to eating behaviours or overweight, or conversely,
eating behaviours and weight may influence the use of different feeding strategies. If child
feeding or child eating behaviours can be identified in early childhood as potentially
CHILD OVEREATING BEHAVIOURS
41
modifiable risk factors, then this could assist to inform the understanding and development of
appropriate early intervention and prevention strategies.
To explore these issues further, the present research extended upon existing
longitudinal research, titled the Child and Family Health Study. Data was collected across
three time points. At Time 1 participants included mothers and their children aged 2 to 4
years old. The current author assisted the research team in data collection at Time 2, analysed
data from Time 1, and solely collected and analysed data at Time 3. For the present research
only Time 1 (children aged 2 to 4 years) and Time 3 (children aged 4 to 6 years) data were
utilised.
In particular, the current research aimed to explore two sets of child feeding and child
eating pathways, including: 1) maternal eating styles and child feeding practices as predictors
of child eating behaviours, and that the relationship between maternal eating and child eating
behaviours is mediated by child feeding practices; and 2) child feeding practices and child
eating behaviours as predictors of child BMI, and that the relationship between child feeding
and child BMI is mediated by child eating behaviours. This research is unique in that very
few studies have examined these constructs together, especially using both cross-sectional
and longitudinal research designs in a sample of preschool and primary school-aged children.
Chapter 5 describes the general method that was used in this research for both the
cross-sectional analyses in Study 1, mediation analyses in Study 2, and longitudinal analyses
in Study 3. Chapter 6 presents information related to the scale properties of child feeding and
eating measures.
Chapter 7 presents a description of analyses examining the cross-sectional findings of
Time 3 data only. The aim of this study was to explore the relationships between maternal
eating (emotional eating and external eating), child feeding practices (instrumental feeding,
emotional feeding, restriction and pressure to eat), child eating behaviours (food
CHILD OVEREATING BEHAVIOURS
42
responsiveness, emotional overeating, external eating, satiety responsiveness, slowness in
eating, and food fussiness) and child BMI. Additionally, regression analyses explored crosssectional predictors of child eating and weight. The specific hypotheses that will be tested can
be found in Chapter 7 (p.76).
Chapter 8 presents the mediation models examined. This included: 1) child feeding
practices as a mediator between maternal eating and child eating, and 2) child eating
behaviours as a mediator between child feeding and child BMI. A summary of hypotheses to
be tested can be found in Chapter 8 (p.118).
Chapter 9 presents longitudinal findings of Time 1 predictors of Time 3 outcomes.
Regression analyses explored prospective predictors (maternal eating and child feeding
practices) of child eating behaviours and child BMI assessed two years previously.
Additionally prospective predictors of child feeding practices assessed two years previously
will also be examined. The specific hypotheses to be tested can be found in Chapter 9
(p.138).
Chapter 10 presents a general discussion that provides a summary of findings, a
discussion of the theoretical and clinical implications of the findings, as well as a discussion
of the limitations of the study and concludes with directions for future research.
CHILD OVEREATING BEHAVIOURS
43
CHAPTER 5: General Method
Child and Family Health Study
This study is part of a larger longitudinal study, titled the Child and Family Health
Study. Data was collected across three time points, each one year apart. A total of 184
mothers and their children aged 2 to 4 years old, ranging from 21 to 48 months (M = 34.90
months, SD = 5.18 months), were recruited at Time 1. Of the child sample, 87 were male and
97 were female. A total of 158 mother-child dyads completed the same questionnaire one
year later at Time 2. This included 78 male children and 80 female children. At Time 3 the
sample consisted of 138 participants. Children were now aged 4 to 6 years (M = 5.30 years,
SD = 0.81); 73 (53%) were male, and 64 (47%) were female. Study 1 will present crosssectional findings from Time 3 data only, Study 2 will present findings of meditation
analyses of Time 3 data only, and Study 3 will present longitudinal findings of Time 1
predictors of Time 3.
Participants
Prior to the commencement of this study a power calculation was conducted to
determine an appropriate sample size. Multiple regression procedures were to be used and
there was the possibility of having up to ten independent variables entered into an analysis.
Consequently, the sample size required to identify a medium effect size (f2=.15), with α = .05
and power of .80 when ten independent variables were considered in the analysis was
determined from Cohen’s (1992) tables. For such an analysis, Cohen proposed that a
minimum sample of 107 participants were required. However, a larger sample than this was
collected to allow for attrition over time.
Table 2 presents the sample demographics at Time 3. The majority of the sample was
born in Australia (70%), married/partnered (86%), tertiary educated (60%), and were
CHILD OVEREATING BEHAVIOURS
44
employed part-time (46%). A broad range of socio-economic groups were represented within
the sample. On average the household income ranged between $60,000 and $100,000.
Table 2
Time 3 Demographic Information for Marital Status, Mother’s Country of Birth, Educational
Level, Employment Status, and Annual Household Income
Demographics
Percentage
Demographics
Percentage
(N =138)
(N = 138)
Mother’s Employment
Marital status
Married/partnered
86.1
Full time
8.7
Separated/divorced
7.3
Part time or casual
44.2
Single
6.6
Home duties
36.2
Unemployment
2.2
Other
3.6
Mother’s Place of Birth
Australia
92.0
United Kingdom
2.2
Europe
1.4
Asia
1.4
> $20,000
9.4
New Zealand
.7
$21-40,000
10.1
Not specified
1.4
$41-60,000
12.3
$61-80,000
18.1
$81-100,000
18.8
Mother’s Education
Annual Household Income
Tertiary
59.9
$101-120,000
10.1
VCE or equivalent
10.9
$121-140,000
5.8
Trade/apprentice/cert
18.8
>$141,000
13.0
Some high school
10.9
Assessment Instruments
Each participant completed the same self-report questionnaires at each time point. The
package included a letter of invitation (i.e., information sheet) (see Appendix A1), a consent
CHILD OVEREATING BEHAVIOURS
45
form (see Appendix A2), and measures to assess demographic characteristics, maternal eating
style, child feeding practices, and child eating behaviours.
Demographic information.
Demographic data collected included child and maternal age, child and maternal
country of birth and ethnicity, maternal marital status, maternal and paternal education levels,
maternal and paternal employment status, the number of children residing in the household,
and the household income (see Appendix B1).
Anthropometric data.
At each interval child and maternal weight and height was reported by mothers.
Maternal Body Mass Index (BMI) was then calculated (weight [kilograms] / height
[meters]₂). BMI is the height-to-weight ratio used most frequently to calculate body weight
status. Self-reported height and weight measurement are highly correlated with actual
measurements (McAdams, Van Dam & Hu, 2006; Stunkard & Albaum, 1981) but systematic
review indicates that where discrepancies occur there is the tendency for over-estimation of
height and under-estimation of weight, resulting in an under-estimate of BMI (Connor
Gorber, Tremblay, Moher & Gorber, 2007). Therefore, some caution should be taken when
interpreting the self-report data presented. The recommended international BMI cut-off
points for weight classifications were established by an expert committee from the World
Health Organisation (1996). Based on WHO criteria, BMI was classified into four categories,
including underweight (≤18.50), normal (18.50 ≥ < 25), overweight (25≥ < 30), and obese
(≥30).
To measure child weight status, height and weight data as reported by mothers was
used. As BMI for children varies with age and gender, the United States Centre for Disease
Control and Prevention (CDC, 2002) developed growth charts using age-specific and sexspecific BMI percentiles and BMI z-scores (BMIz) for children aged between 2 to 20 years
CHILD OVEREATING BEHAVIOURS
46
old. A z-score reflects the median value, where a z-score of 0 is equivalent to the 50th centile
value, a z-score +1.00 is equivalent to the 84th centile, a z-score of +2.00 is equivalent to the
98th centile, and a z-score of +2.85 is equivalent to the 99th centile (Lobstein, Baur, & Uauy,
2004; National Health & Medical Research Council [NHMRC], 2003). To calculate BMI-forage z-score in children the EpiInfo nutrition program, titled NutStat, was utilised (CDC,
2000). Height and weight values, the child’s date of birth and date of data collection were
entered into the Nutstat program and exported to Microsoft Access.
Mei, Grummer-Strawn, Pietrobelli, Goulding, Goran, and Dietz (2002) compared the
use of the CDC’s BMI-for-age cut-offs in identifying underweight with dual energy x-ray
absorptiometry measurements of body fat (DXA) and skinfold thickness, which are
considered gold standards. Strong correlations were found between BMI-for-age and DXA
percentage of body fat in girls (.78) and boys (.80) aged 3 to 5 years (Mei et al., 2002). These
findings support the use of BMI-for-age as a suitable measure of assessing height and weight
in children.
To compare our sample with other studies and with the proportion of overweight and
obese children in Australia, the International Obesity Taskforce (IOTF) criteria were used to
group BMI scores into four categories of underweight (thinness grade 2) (Cole Flegal,
Nicholls, & Jackson, 2007), healthy weight, overweight and obese (Cole, Bellizzi, Flegal, &
Dietz, 2000). The IOTF classifications are widely used internationally. The age and sex
specific cut-offs points for child overweight and obesity are based on adult cut-offs 25kg/m2
and 30kg/m2 at age 18 years respectively (Cole et al., 2000).
CHILD OVEREATING BEHAVIOURS
47
Maternal Eating Behaviours
The Dutch Eating Behaviour Questionnaire (DEBQ).
To assess maternal eating behaviours the Dutch Eating Behaviour Questionnaire
(DEBQ; van Strien, Frijters, Bergers, & Defares, 1986) was utilised (see Appendix B2). The
DEBQ is comprised of three subscales, emotional eating, external eating and restrained
eating. The emotional eating subscale is comprised of 13-items to assess eating in response to
negative emotions, such as, “Do you have the desire to eat when you are irritated?” The
external eating subscale contains 10-items to measure eating in response to the presence of
food despite feelings of satiety, such as, “If food tastes good to you, do you eat more than
usual?” Lastly, restrained eating is a 10-item subscale that assesses the extent to which food
intake is controlled in an attempt to lose or maintain weight, for example, “Do you
deliberately eat foods that are slimming?” All items are rated on a 5-point Likert scale
ranging from never (1) to very often (5). For some items an additional option of “not
relevant” was included because the scale’s developers found that some participants reported
that they did not experience particular emotions, never overate, or were always able to
maintain their weight, thus deeming some questions irrelevant (van Strien, Frijters, Bergers,
& Defares, 1986). In this study, “not relevant” was scored as never (1).
The DEBQ has been shown to have satisfactory scale properties with good internal
consistency and factorial validity (van Strien, Frijters, Bergers, & Defares, 1986). In a large
sample of 653 women and 517 men, van Strien and colleagues reported Cronbach’s alpha
values of .95 for restrained eating, .94 for emotional eating, and .80 for external eating. The
DEBQ has been validated among a number of cross-cultural samples such as English
(Wardle, 1987), French (Lluch, Kahn, Stricken-Krongrad, Ziegler, Drouin, &Mejean, 1996),
and Turkish (Bozan, Bas, & Asci, 2011). Moreover, it has shown to have robust factor
structures (e.g., Wardle, 1987).
CHILD OVEREATING BEHAVIOURS
48
Child Feeding Practices
Instrumental and Emotional Feeding Practices
At Time 1 items from three different child feeding scales were used to assess
instrumental and emotional feeding, namely: The Parental Feeding Style Questionnaire
(PFSQ; Wardle, et al., 2002), The Child Feeding Questionnaire (CFQ; Birch et al., 2001), and
The Preschooler Feeding Questionnaire (PFQ; Baughcum, et al., 2001) (see Appendix B3).
Subscales and items were selected based on the theoretical underpinnings of each child
feeding practice.
As these scales had not been used widely with younger children and some
inconsistencies in measurement had previously been observed, the 19 items from the three
scales were subjected to a factor analysis (see Table 3, page 62 for a summary of items
included in the Principal Component analysis). Three factors were identified. This included
two instrumental feeding subscales, as well as an emotional feeding subscale. To maintain
consistency with the original factor analysis completed at Time 1, the same emotional and
instrumental feeding items were utilised at Time 3. The 19 items were examined in a
confirmatory factor analysis to ensure internal reliability before proceeding (see Examination
of Scale Properties for a full summary of these analyses; Chapter 6). Below is a summary of
the PFSQ, CFQ, and PFQ subscales and items included.
The Parental Feeding Style Questionnaire (PFSQ).
The PFSQ (Wardle et al., 2002) is a 27-item questionnaire that is comprised of four
subscales designed to measure parental feeding styles. The two subscales of interest were the
instrumental feeding and emotional feeding subscales. The instrumental feeding subscale
includes four items that assess when food is given as a reward for good behaviour or when
dessert is given for eating specific behaviour. For example, “In order to get my child to
behave him/herself I promise him/her something to eat”, and “I use dessert as a bribe to get
CHILD OVEREATING BEHAVIOURS
49
my child to eat his/her main course”. The PFSQ is a self-report questionnaire rated on a 5point Likert scale, ranging from never (1) to always (5), and assesses the frequency for which
these parental feeding styles are used. The emotional feeding subscale included five items
that assessed feeding in response to a child’s emotional distress, such as upset, hurt, bored,
angry or worried. For example, “I give my child something to eat to make him/her feel better
when s/he has been hurt”.
The PFSQ has been shown to have satisfactory psychometric properties, with
Cronbach’s alpha values of .67 and .83 obtained respectively for the instrumental feeding
and emotional subscales in a sample of 214 families (with 428 twin children aged 4-to-7
years) (Wardle et al., 2002). Two week test-retest reliability was .82 for the instrumental
feeding subscale and .76 for the emotional feeding subscale. A more recent study examined
the properties of PSFQ in a sample of 6 to 7 year olds in relation to dietary intake behaviours
(Sleddens, Kremers, De Vries, & Thijs, 2010). Internal consistency, using the original items
developed by Wardle and colleagues, was found to be .67 and .75 respectively, for the
instrumental feeding and emotional feeding scales. These findings represent similar
psychometric properties to those found in the original scale and therefore suggests adequate
reliability of the PFSQ subscales.
However, with further examination of the constructs of the PFSQ it appears that the
instrumental feeding subscale could be better represented as two feeding styles. That is, when
food is given as a reward for good behaviour and when food is given as a reward for eating
specific behaviour. This will be discussed further in the results and discussion sections.
The Child Feeding Questionnaire (CFQ).
The CFQ is comprised of seven subscales that were designed to assess parental
beliefs, concerns, and feeding practices in relation to their child’s obesity proneness (Birch et
al., 2001). Two items from the restriction subscale were included to assess instrumental
CHILD OVEREATING BEHAVIOURS
50
feeding (Birch et al., 2001). These items were, “I offer sweets (i.e., lollies, ice cream, cake,
pastries) to my child as a reward for good behaviour”, and “I offer my child his/her favourite
foods in exchange for good behaviour”, which were rated by maternal self-report, with both
items rated on a 5-point Likert scale ranging from disagree (1) to agree (5) (Birch et al.,
2001).
These items were selected because they appeared to be more related to instrumental
feeding practice than restrictive feeding practices. The stability of the restrictive subscale has
been examined in several studies (e.g., Anderson, Hughes, Fisher, Nicklas 2005; Corsini,
Danthiir, Kettler, Wilson, 2008; Kaur et al., 2006). Problems with the factorial integrity of the
restriction subscale were first highlighted in the initial confirmatory factor analysis (CFA)
conducted by Birch et al. (2001). The restriction subscale was found to cross-load with
another subscale in one study and not load significantly in another. In a study by Corsini and
colleagues (2008), they examined the psychometric properties of the CFQ using a sample of
203 children aged 4 to 5 years-old. An exploratory factor analysis revealed an eighth factor
that comprised of two items (Cronbach’s alpha .83) from the restriction subscale that were
related to the use of food as a reward for behaviour. These findings supported consideration
of these two items as assessing instrumental feeding.
The Preschooler Feeding Questionnaire (PFQ).
Two subscales of the PFS were also utilised to assess instrumental feeding and
emotional feeding (Baughcum et al., 2001). To assess instrumental feeding 4 items from the
Pushing the Child to Eat subscale were selected, for example “Did you offer him/her a
dessert after a meal to get him/her to eat foods that were food for him/her” (Baughcum et al.,
2001). Additionally, 4 items from the Using Food to Calm the Child subscale were included
to assess emotional feeding, such as “Did you give him/her something to eat or drink if s/he
was upset even if you thought s/he was not hungry?”, All items were rated on 5-point likert
CHILD OVEREATING BEHAVIOURS
51
scales ranging from never (0) to always (4). One item, however, from the Using Food to
Calm the Child subscale was originally recorded using a different scale range. Item PFQ_E4
“Offering my child something to eat is one if the best ways to stop temper tantrums” was
originally worded as disagree a lot (0), disagree a little (1), no strong feelings (2), agree a
little (3), and agree a lot (4) (Baughcum et al, 2001). This item was recorded as never to
always in our questionnaire pack to maintain consistency across the subscales. Furthermore,
in order to remain consistent with the scale ranges in the former two questionnaires (PSFQ
and CFQ) all items were recoded and scored as 1-to-5.
Restrictive Feeding Practices
Child Feeding Questionnaire (CFQ).
Two subscales of the Child Feeding Questionnaire (CFQ; Birch et al., 2001) were
included; namely, the restriction and pressure to eat subscales to assess control feeding
practices (see Appendix B3). The restriction subscale is an 8-item Likert scale; however, as
previously discussed, the restriction subscale appears to measure two distinct factors,
therefore two items from the original instrument were excluded (items RST3A and RST3B)
(Birch et al., 2001). The feeding style restriction assesses the level with which parents’
restrict the amount and types of food available to their child, for example, “I have to be sure
that my child does not eat too many high-fat foods”. pressure to eat enforces the opposite
feeding strategy of pressuring a child to eat more food, such as “If I did not guide or regulate
my child’s eating, s/he would eat much less than s/he should”. Both of these subscales are
recorded on a 5-point Likert scale ranging from disagree (1) to agree (5). Birch and
colleagues (2001) reported Cronbach alpha values of .73 for the Restriction subscale (for 8items), and .70 for the Pressure to Eat subscale.
The CFQ is a widely used instrument and apart from the stability of the restriction
subscale, it has shown to have factorial integrity and adequate reliability (Anderson et al.,
CHILD OVEREATING BEHAVIOURS
52
2005; Corsini et al., 2008). Anderson et al. (2005) examined the scale properties of the CFQ
in a sample of 130 children (aged 3 to 5 years old) and found that the pressure to eat subscale
loaded as expected but similarly found items on the restriction subscale to be problematic. In
particular, the two items related to using food as a reward for good behaviour created issues.
Furthermore, in a study conducted by Corsini and Colleagues (2008) using an Australian
sample of 203 children (aged 4 to 5 years old), it was also found that the pressure to eat
subscales replicated the original model by Birch et al (2001), but the restriction subscale was
spilt into two factors. Corsini et al. (2008) reported Cronbach alpha values of .83 for
restriction subscale (excluding the two problematic items), and .80 for the pressure to eat
subscale.
Child Eating Behaviours
The Children’s Eating Behaviour Questionnaire (CEBQ, Wardle et al., 2001) and the
external eating subscale of the Dutch Eating Behaviours Questionnaire – Parent Version
(DEBQ- P; Braet & Van Strien, 1997) were utilised to assess child eating behaviours (see
Appendix B4).
The Children’s Eating Behaviour Questionnaire (CEBQ).
The CEBQ, developed by Wardle et al. (2001), is a 35-item questionnaire designed to
measure eating styles in children aged 2 to 7 years old. Five subscales were selected for this
research, two assessing food approach eating behaviours (emotional overeating and food
responsiveness) and three assessing food avoidant eating behaviours (satiety responsiveness,
slowness in eating, and food fussiness) (Wardle et al., 2001).
The emotional overeating (EO) subscale comprised 4-items to measure increased
eating in response to negative emotions, such as, “My child eats when worried”. The food
responsiveness (FR) subscale contained 5-items to assess eating in response to environmental
CHILD OVEREATING BEHAVIOURS
53
food cues and a general appetite for food, for example, “Even if my child is full up s/he finds
room to eat his/her favourite food” (Sleddens, Kremer, & Thijs, 2008; Wardle et al., 2001).
For the food avoidant subscales, the satiety responsiveness (SR) subscale comprised
5-items to measure the child’s ability to regulate food intake based on perceived fullness, for
example, “My child cannot eat a meal if s/he has had a snack just before”. The 4-item
slowness in eating (SE) subscale is characterised by the speed of eating due to a lack of
interest in food, for example “My child takes more than 30 minutes to finish a meal”. The last
food avoidant eating behaviour is the food fussiness (FF) subscale which is comprised of 6items to measure the rejection of familiar and new foods, such as, “My child refuses new
foods at first” (Sleddens, Kremer, & Thijs, 2008; Wardle et al., 2001). Wardle et al. (2001)
reported good internal consistency of the CEBQ subscales (Cronbach’s alpha ranging from
.74 to .91), high internal validity, and adequate test-retest reliability (correlation coefficients
ranged from .52 to .87).
A number of studies have examined the psychometric properties of the CEBQ and
overall the factor structure has been found to correspond well with the original factor
structure identified by Wardle and Colleagues (e.g., Carnell & Wardle, 2007; Sleddens,
Kremers, Thijs, 2008; Viana, Sinde, & Saxon, 2008). For example, in a Dutch sample (N =
135) of children aged 6 to 7 years old, principal components analysis found a similar sevenfactor solution, which accounted for 62.8% of the variance (Sleddens, Kremers, & Thijs,
2008). Food responsiveness and emotional overeating loaded onto the same factor; however
the researchers maintained Wardle’s original solution in order to allow comparisons with the
original subscales. The internal consistency of the subscales ranged from .75 to .91. These
findings lend support that the CEBQ is a psychometrically sound instrument (Sleddens,
Kremers, Thijs, 2008). The CEBQ scale properties were examined in this study, and can be
found in the results section.
CHILD OVEREATING BEHAVIOURS
54
The Dutch Eating Behaviour Questionnaire – Parent Version (DEBQ-P).
The DEBQ-P, developed by Braet and van Strien (1997), is comprised of three
subscales. Of particular interest in this research was the 10-item external eating subscale,
which is a parent assessment of their child’s food consumption in response to the sight or
smell of food (Braet & van Strien). For example, “If food smells and looks good, does your
child eat more than usual?”. Items are rated on a 5-point Likert scale ranging from never (1)
to always (5).
The external eating subscale has been shown to have factorial validity and adequate
reliability (e.g., Braet & van Strien, 1997; Caccialanza et al., 2004). In a study examining the
differences between obese and non-obese children (aged 9 to 12 years old) on a range of
nutritional parameters and psychological measures, it was found that external eating was
associated with higher caloric intake (i.e., fats, sugar, and energy) in obese children (Braet &
van Strien, 1997), supporting the construct validity of the scale. Internal consistency for the
individual subscales was not reported by Braet and van Strien (1997); however, all
Cronbach’s alpha values ranged from .79 to .86. Furthermore in a study by Caccialanza et al.
(2004) of 11-to-14 year-olds Italian children, Cronbach’s alpha for the external eating
subscale was .81.
It is noteworthy that the original scale was developed for parental report of their
children aged 9 to 12 years old (Braet & van Strien, 1997). An adapted version of the DEBQ
has since been developed with modified language for self-report by children aged from 7years old (van Strien & Oosterveld, 2008). To our knowledge, the scale properties of DEBQP have not been assessed in a younger sample. Consequently, we aimed to examine the scale
properties of the external eating subscale of DEBQ-P in our sample of children aged 4 to 6
years old.
CHILD OVEREATING BEHAVIOURS
55
Procedure
Ethics approval for the study was obtained from the La Trobe University Human
Ethics Committee (Project Number: UHEC 07-064). At Time 1 of the Child and Family
Health Study participants were recruited through advertisements published in Melbourne
metropolitan community newspaper’s (e.g., Leader) and the La Trobe University newsletter.
Furthermore, playgroup coordinators were contacted via Playgroups Victoria
(www.playgroup.org.au) and invited to distribute a questionnaire package to interested
mothers within their playgroups. Participants were eligible to take part in this study if their
child was aged between 2 and 4 years old, and were able to read and understand English.
Mothers who participated in the study received a $10 Coles/Myer gift voucher for taking part
on each occasion. As a further incentive to return the questionnaire at Time 2 and Time 3,
each participant who returned their questionnaire went into a draw and had a chance to win
one $100 voucher or one of five $25 vouchers. Prior to sending questionnaire packs for Time
2 and Time 3, all participants received a courtesy call from a researcher to invite them to
participate in the research. Interested participants received a questionnaire package
containing the questionnaire, an information sheet, two consent forms (one for the participant
to keep), and a reply paid envelope. Upon receiving the returned questionnaire all participants
were sent a thank you letter with a $10 Coles/Myer gift voucher for their participation in the
study (see Appendix C1). It was aimed to follow-up with participants 12 months after
completing the previous questionnaire. Therefore, for Time 3, the recruitment process took
place over a five month period in order to correspond with participants return date in the
previous year.
Data analysis
The first study reported in this thesis is a cross-sectional design, whilst the second
study explored mediation models, and the third study is a longitudinal design. PASW
CHILD OVEREATING BEHAVIOURS
56
statistical software (Version 18) was used to analyse the data. Initially, at each time point,
data were screened and scale integrity was investigated using descriptive statistics to ensure
the assumptions for regression analyses of normality, linearity, and homoscedasticity were
met. The first step of analysis was to explore the factor structure of the measures of child
feeding and child eating for use in this research. Findings from the exploratory factor analysis
using varimax rotations can be found in Chapter 6.
In Study 1, the predictor variables included maternal BMI, maternal eating styles
(emotional, external, restrained), and child feeding practices (emotional, instrumental,
restriction, and pressure to eat). The outcome variables were child eating behaviours
(emotional overeating, food responsiveness, external eating, satiety responsiveness, slowness
in eating, and food fussiness), and child BMI z-score. The specific hypotheses that will be
tested can be found in Chapter 7 (p. 76). Independent samples t-tests were used to determine
if there were significant differences between gender or child weight categories for child
feeding practices and child eating behaviours, and to determine if there were any significant
differences between maternal weight categories for maternal eating styles and child practices.
Weight categories were defined as overweight (including overweight and obese categories)
and non-overweight (including normal weight and underweight categories)
To examine relationships between dependent variables and independent variables (as
outlined in hypotheses 1, 2 and 3) initially, Pearson’s product moment correlation analyses
were performed. A series of hierarchical regression analyses were then performed to examine
the variance explained by the proposed independent variables (maternal eating and child
feeding practices) on child eating behaviours and child weight status.
In Study 2, hierarchical regression analysis using a mediation model examined if child
feeding practices mediated the relationship between maternal eating and child eating.
Furthermore, child eating behaviours were also examined as mediators between child feeding
CHILD OVEREATING BEHAVIOURS
57
practices and child BMI. A summary of hypotheses to be tested can be found on Chapter 8
(p. 118).
Study 3 was a longitudinal design. Please refer to Chapter 9 (p. 138) for a summary of
the specific hypotheses to be tested. A step taken before the hypotheses were examined, was
to explore the stability of all variables across time using Pearson’s product moment
correlations and paired samples t-tests. Data from the same variable will be correlated at
different time points (e.g., Time 1 emotional feeding will be correlated with Time 3
emotional feeding) and then examined to see if there is a significant difference between the
subscale scores across time using paired samples t-tests. For hypotheses 1 and 2, the key
dependent variables were measures of child overeating behaviours (emotional overeating,
food responsiveness and external eating) and child BMI z-scores at Time 3. The key
independent variables were maternal eating styles (emotional and external eating) and child
feeding practices (emotional feeding, instrumental feeding-behaviour, instrumental feedingeating and restriction) at Time 1. For hypothesis 3, the dependent variables were Time 3 child
feeding practices (emotional feeding, instrumental feeding-behaviour, instrumental feedingeating and restriction) and the independent variable was Time 1 child BMI z-score.
To examine relationships outlined in hypotheses 1 and 2, cross-lag correlations were
used to identify bivariate associations between Time 1 maternal eating and child feeding
practices, and Time 3 child eating behaviours and child weight status. Furthermore, to
examine the predictive contribution of Time 1 maternal eating styles and child feeding
practices on Time 3 child eating variables and child BMI, a series of multiple regression
models were utilised. Each model controlled for Time 1 child age and gender, maternal BMI,
and the corresponding Time 1 variable. Lastly, to test hypothesis 3, which explored Time 1
BMI as a predictor of Time 3 child feeding practices (emotional feeding, instrumental
feeding-behaviour, instrumental feeding-eating and restriction), multiple regression analysis
CHILD OVEREATING BEHAVIOURS
were utilised. Child age, gender and Time 1 BMI variables were controlled for in step 1 of
the model.
58
CHILD OVEREATING BEHAVIOURS
59
CHAPTER 6: Examination of Scale Properties for Child Feeding and Child Eating
Measures
Instrumental and Emotional Feeding
The scale properties of the child feeding measures were examined to ensure
appropriateness for young children at Time 1 and again at Time 3. Time 1 analysis was
conducted by Brozovic (2009) from the Child and Family Health Study but will be described
briefly here. The 19 items measuring instrumental and emotional feeding, as described in the
method section, were selected from the Parental FSQ (Wardle et al., 2002), the CFQ (Birch et
al., 2001), and the PFQ (Baughcum et al., 2001).
Principal components analysis (PCA) at Time 1 showed that a three factor structure
emerged. Results revealed that two items loaded ambiguously, (item PFQ_P2, ‘Punish or
remove privileges to get him/her to eat more’ and item PFQ_C4, ‘Offering something to eat
is the best way of stopping temper tantrums’) and following inspection of the item properties
both items were removed and the analysis was repeated (see Appendix D1 for the final 17item PCA from Time 1). Overall, the final three factor solution at Time 1 accounted for
57.4% of the total variance, with 38.4%, 11.1% and 7.9% found respectively for each of the
three factors. Results at Time 1 revealed that instrumental feeding would be better
represented as two feeding styles. Whereas factor one appeared to reflect a feeding style in
which food is employed as a strategy to shape and modify behaviour, factor two appeared to
represent a feeding style where food is utilised to shape eating behaviour only. The third
factor included emotional feeding items where food is aimed at alleviating emotional
discomfort. Factor one was named instrumental feeding-behaviour, factor two was named
instrumental feeding-eating, and factor three was named emotional feeding.
To enable comparison with Time 1 data, a principal components analysis (PCA) with
varimax rotations was performed on Time 3 data using the 17 instrumental and emotional
CHILD OVEREATING BEHAVIOURS
60
feeding items used at Time 1 (see Table 3). Time 3 included 138 mother-child dyads, with
children ranging from age 4 to 6 years. Tabachnick and Fidell (2007) recommend that a
minimum of five cases per item should be analysed in a factor analysis, and the sample of
138 met the minimum requirement. The factorability of the correlational matrix was
supported as many of the coefficients loaded above .3. The Kaiser-Meyer-Oklin (KMO)
value was .86, which was above the recommended value of .6. Bartlett’s Test of Sphericity
was significant, and all of the communalities loaded above .3, thus confirming that a common
variance was shared between items.
The PCA of Time 3 data also revealed a three factor structure. The final solution
accounted for 61.23% of the variance, with factor one explaining 42.21%, factor two
accounting for 12.43%, and factor three accounting for 6.59%. Inspection of the scree plot
revealed a large break between factor one and factor two, and a smaller break between factor
two and factor three. This finding replicated Time 1, which demonstrated that instrumental
feeding was spilt across two factors. Factor one represented feeding in relation to feeding in
an effort to shape and modify behaviour (i.e., offering food treats for good behaviour), while
factor two was related to feeding in order to shape eating behaviours only (i.e., offering
dessert for eating a main meal or eating healthy food). Therefore, the same factor labels
proposed at Time 1 were retained; that is, instrumental feeding-behaviour, instrumental
feeding-eating and emotional feeding. The rotated solution of the three factors, including the
pattern matrix and communalities, are presented in Table 3.
At Time 3, item PFQ_P3 (“Used food that s/he liked to get him/her to eat healthy
food”) and item PFQ_C1 (“When fussy, giving something to eat or drink is the first thing”)
both had unexpected loadings. As can be seen in Table 3, both items had low communality
values, .32 and .41 respectively, suggesting that these items did not fit well with the other
items. For example, item PFQ_C1 relates to the child being “fussy” and managing this
CHILD OVEREATING BEHAVIOURS
61
behaviour through offering something else (other food or drink items). While the underlying
notion is to calm the child, the wording of this item is unclear and it could be interpreted that
offering other food or drink items in order for the child to eat the first food item may be a
strategy used to shape eating behaviour. Nevertheless these items were retained as in the
original subscale structure (instrumental feeding and emotional feeding respectively) in order
to be consistent and compare results found at Time 1 in Study 3.
Finally, it is noteworthy that two emotional feeding items loaded on factor one
(instrumental feeding-behaviour) in the final 17-item solution at Time 1 and at Time 3. These
items were item PFSQ_E1 (“Give something to eat to make him/her feel better when upset”)
and item PFSQ_E2 (“Give child something to eat to make him/her feel better when hurt”). At
both Time 1 and at Time 3 results revealed high communality values (above .60), which
confirms that these items share a common variance with the other items on factor one. These
items appear to be related to a type of nurturing feeding style to reduce negative emotions;
however it could be interpreted that this strategy aims to shape behaviour related to the child
feeling hurt or upset, which may explain the high communality values for these items loading
in factor one (instrumental feeding-behaviour). As the items were retained at Time 1 on the
instrumental feeding-behaviour scale, the two emotional feeding items were also retained on
the same factor at Time 3, particularly so as to allow for meaningful comparison with results
found at Time 1 in Study 3.
CHILD OVEREATING BEHAVIOURS
62
Table 3
Time 3 Principal Components Analysis with a Forced Three Factor Solution of Emotional and Instrumental Feeding Items (17 items)
Items
Pattern Matrix
Instrumental Instrumental
-behavior
-eating
CFQ_R1
CFQ_R2
PFSQ_E1
PFSQ_E2
PFSQ_I1
PFSQ_I2
PFSQ_I4
PFQ_P3
PFSQ_I3
PFQ_P1
PFQ_P4
PFQ_C1
PFSQ_E3
PFSQ_E4
PFSQ_E5
PFQ_C2
PFQ_C3
Offer sweets as a reward for good behavior
Offer my child favourite food in exchange for good behavior
Give something to eat to make him/her feel better when upset
Give child something to eat to make him/her feel better when hurt
To get him/her to behave, promise something to eat
If misbehaves, withhold favourite food
Reward with something to eat when well behaved
Used foods that s/he liked to get him/her to eat healthy foods
Use dessert as a bribe to get him/her to eat main meal
Offer dessert after meal to get him/her to eat foods that were good
Make him/her finish all their dinner before s/he could have dessert
When fussy, giving something to eat or drink is the first thing
Give something to eat if s/he is feeling bored
Give something to eat to make him/her feel better when worried
Give something to eat to make him/her feel better when angry
Give something to eat if s/he is feeling bored even when not
hungry
Give something to eat if s/he was upset even when not hungry
.82
.85
.55
.57
.68
.70
.69
.42
.31
.24
-.07
.01
.20
.36
.16
-.18
.06
-.02
-.10
-.13
.10
.17
.06
.25
-.02
Communalities
Emotional
Feeding
.66
.76
.77
.50
-.13
-.01
-.05
.14
.03
-.01
.44
.44
.17
-.19
.19
.00
-.11
-.07
.06
.33
.70
.60
.64
.86
.74
.71
.65
.67
.65
.52
.66
.32
.66
.75
.57
.41
.62
.66
.51
.67
.15
.77
.62
Note: Major loadings are shown in bold. Item coding: Child Feeding Questionnaire – restriction scale (CFQ_R); Parental Feeding Style Questionnaire – Instrumental Feeding (PFSQ_I) and
Emotional Feeding (PFSQ_E); Preschooler Feeding Questionnaire – Pushing the Child to Eat (PFQ_P) and Using Food to Calm (PFQ_C)
CHILD OVEREATING BEHAVIOURS
63
Table 4 presents correlations between subscales for instrumental feeding-behaviour,
instrumental feeding-eating, and emotional feeding. The high correlation observed between
instrumental feeding-behaviour and emotional feeding (r = .67**) may suggest some
overlapping variability between these constructs. This will be discussed further in Chapter 7.
Table 4
Intercorrelations between Instrumental Feeding and Emotional Feeding at Time 3 (N = 138)
Child Feeding Practices
Instrumental
Instrumental
feeding-behaviour
feeding-eating
Instrumental feeding-behaviour
-
Instrumental feeding-eating
.56**
-
Emotional feeding
.67**
.36**
*p<.05; **p<.01
The descriptive statistics for the final item factors are presented in Table 5. As can be
seen, internal consistency for each of the scales was satisfactory and had Cronbach’s alpha
that ranged between .74 and .89.
Table 5
Descriptive Statistics for the Three Factor Structures at Time 3 (N = 138)
Child Feeding Practices
No. of
Item range
Mean (SD)
items
Cronbach’s
Alpha
Instrumental Feeding-behaviour
7
1-5
2.23 (.79)
.89
Instrumental Feeding-eating
4
1-5
2.41 (.77)
.74
Emotional Feeding
6
1-5
1.59 (.52)
.81
CHILD OVEREATING BEHAVIOURS
64
Child Eating Behaviour Questionnaire (CEBQ)
To clarify the scale properties of the CEBQ (Wardle et al., 2001) in the Time 3
sample, as discussed in the Measures section of Chapter 5, an exploratory factor analysis was
performed on the 35-items. All items were included to compare the findings with the original
solution by Wardle and colleagues (2001). The Kaiser-Meyer-Oklin (KMO) value was .81,
which was above the recommended value of .6, Barlett’s Test of Sphericity was significant,
and all of the communality values loaded above .6 (except two items, which loaded above .3).
Eight factors with eigenvalues above one were revealed (see Table 6). The total
variance for the eight factor solution was 69.41%. Although the factors extracted were similar
to the original factors found by Wardle and colleagues (2001), a number of discrepancies
were found. In particular, factor seven ambiguously included three items from three different
subscales. The relationship between these items was not clear. The slowness in eating item
(“My child eats more slowly during the course of a meal”) had a primary loading of -.56 and
appeared to cross-load on factor one (enjoyment of food) and factor four (desire to drink),
albeit low loadings, and the food responsiveness item (“Even if my child is full up s/he finds
room to eat their favourite food”) revealed a primary loading of -.74.
Additionally, the food responsiveness subscale loaded ambiguously across three
factors. Two items loaded on factor one with the enjoyment of food subscale, two items
loaded on factor two with the emotional overeating subscale, and one item loaded on factor
seven. A similar result was found by Sleddens, Kremer and Thijs (2008) who examined the
psychometric properties of the CEBQ in a Dutch sample of 6 to 7 year olds. The food
responsiveness and emotional overeating subscales loaded onto the same factor; however
given a similar factor structure emerged, the authors maintained Wardle’s eight factor
solution to allow comparison with the original scale.
CHILD OVEREATING BEHAVIOURS
65
Table 6
Time 3 Principal Component Analysis of the Child Eating Behaviour Questionnaire
Items
EF
EF
EF
EF
FR
FR
SR
EO
EO
EO
FR
FR
EO
SE
SE
SE
DD
DD
DD
SR
SR
SR
EU
EU
EU
EU
FR
SE
SR
FF
FF
FF
FF
FF
FF
My child is interested in food
My child enjoys eating
My child looks forward to meal times
My child loves food
My child is always asking for food
Given the choice, my child would eat most of the
time
My child has a big appetite*
My child eats more when anxious
My child eats more when annoyed
My child eats more when worried
If given the chance, my child would always have
food in his/her mouth
If allowed to, my child would eat too much
My child eats more when s/he has nothing else to
do
My child eats slowly
My child takes more than 30 minutes to finish a
meal
My child finishes his/her meal quickly
If given the chance, my child would always be
having a drink
If given the chance, my child would drinks
continuously during the day
My child is always asking for a drink
My child gets full before their meal is finished
My child leaves food on their plate at the end of a
meal
My child gets full up easily
My child eats less when tired
My child eats more when s/he is happy
My child eats less when upset
My child eats less when angry
Even if my child is full up s/he finds room to eat
their favourite food
My child eats more and more slowly during the
course of a meal.
My child cannot eat a meal if s/he has just had a
snack
My child is interested in tasting food s/he hasn’t
tasted before*
My child refuses new foods at first
My child enjoys tasting new foods
My child decides that s/he doesn’t like food, even
without tasting it
My child enjoys a wide variety of food*
My child is difficult to please with meals
Pattern Matrix
F1
F2
F3
EF
EO
SE
-.74
-.73
-.68
-.68
-.65
-.55
F4
DD
F5
SR
F6
EU
F7
FR
F8
FF
.47
.91
.85
.82
.59
-.44
.50
.44
.85
.78
.77
.87
.87
.77
.86
.73
.61
-.70
-.63
-.62
-.58
.43
.33
-.74
.34
.34
-.56
-.33
-.36
.89
.86
.85
.77
.76
.68
*Reversed scored items. Note: Factor loadings < .3 are suppressed. Item coding: EF – Enjoyment of Food; FR – Food
Responsiveness; EO – Emotional Overeating; SE – Slowness is Eating; DD – Desire to Drink; SR – Satiety Responsiveness;
EU – Emotional Undereating; FF – Food Fussiness.
CHILD OVEREATING BEHAVIOURS
66
Finally, for the satiety responsiveness subscale, three items loaded onto factor five,
one item loaded onto factor one (enjoyment of food) and one item loaded onto factor seven
(food responsiveness). Both items had low communality values of .49 and .37 respectively,
which may suggest that these items did not share a common variance with the other items on
that particular factor. However, given the overall factor structure loaded similarly to the
original solution found by Wardle and colleagues (2001), it was decided to maintain the
published subscales for statistical analysis.
Descriptive statistics for the eight CEBQ subscales at Time 3 are shown in Table 7. It
is noteworthy that the enjoyment of food, desire to drink, and the emotional undereating
subscales were not the focus of this research and were therefore excluded from subsequent
analyses. Internal consistency was satisfactory as indicated by Cronbach’s alpha ranging from
.69 to .91, and was comparable to results reported by Wardle et al (Cronbach’s alpha ranged
from .74 to .91) and Sleddens et al (Cronbach’s alpha ranged from .75 to .91). Finally, a
summary of correlations between the subscales for child eating behaviours are presented in
Appendix D2.
Table 7
Descriptive Statistics for the Original CEBQ Eight Factor Solution by Wardle et al (2001)
Child Feeding Practices
No. of
Item range
Mean (SD)
items
Cronbach’s
Alpha
Emotional Overeating
4
1-5
1.91 (.62)
.79
Food Responsiveness
5
1-5
2.49 (.66)
.76
Enjoyment of Food
4
1-5
3.83 (.67)
.88
Desire to Drink
3
1-5
2.56 (.94)
.86
Satiety Responsiveness
5
1-5
2.47 (.44)
.69
Slowness in Eating
4
1-5
2.91 (.52)
.71
Emotional Undereating
4
1-5
2.85 (.76)
.73
Food Fussiness
6
1-5
2.87 (.76)
.91
CHILD OVEREATING BEHAVIOURS
67
Dutch Eating Behaviour Questionnaire – Parent Version (DEBQ-P)
As discussed in the Measures section in Chapter 5, the DEBQ-P (Braet & van Strien,
1997) was developed for children aged 9 to 12 years old. This study aimed to examine the
scale properties of the external eating subscale in a young sample of children aged 4 to 6
years old. Exploratory factor analysis was performed on the 10-item external scale. The
Kaiser-Meyer-Oklin (KMO) value was .73, which was above the recommended value of .6,
Barlett’s Test of Sphericity was significant, and all of the communality values loaded above
.3. Exploratory factor analysis revealed three factors with eigenvalues above one (see Table
8). The total variance was 61.94%, with factor one accounting for 38.43%, factor two
accounting for 12.39%, and factor three accounting for 11.13%. Inspection of the scree plot
revealed a large break between factor one and factor two, and a smaller break between factor
two and factor three.
The external eating subscale loaded onto three factors when examined in a sample of
4 to 6 year olds. Factor one appeared to be an external eating style related to the sight or
smell of palatable foods, factor two appeared to be related to eating more than usual when
food tastes or smells good, and finally, factor three appeared to be related to the social aspect
of eating (i.e., eating more or having a desire to eat when in the presence of others).
With further inspection of the three factor solution, a small difference was found
between the mean scores (Factor 1, M = 3.23, SD = .61; Factor 2, M = 3.11, SD = .63; Factor
3, M = 2.78, SD = .64) and significant positive correlations were found between each of the
three subscales that emerged, indicating that each of the subscales were related. Furthermore,
when a forced one factor solution was performed, all items had primary loadings above .50
and communalities values above .30, indicating a common variance with the other items. The
total variance of the one factor solution was 38.43%.
CHILD OVEREATING BEHAVIOURS
68
Consequently, despite finding a three factor solution for the external eating subscale
when examined in this sample of 4 to 6 year-olds, a decision was made to retain the items as
one factor. Being able to separate prompts for external eating might be insightful in some
environments; however for the purpose of this research an overall measure of external eating
was suitable and would facilitate comparisons of child eating behaviours with other studies,
and with the maternal DEBQ external eating subscale, which is also captured as one scale.
Internal consistency using Cronbach’s alpha revealed a satisfactory coefficient value of .82
for the 10-item external eating subscale.
CHILD OVEREATING BEHAVIOURS
69
Table 8
Principal Components Analysis of the External Eating subscale of the Dutch Eating Behaviour Questionnaire – Parent Version (DEBQ – P)
Item
Item
Pattern Matrix
Communalities
No.
F1
F2
F3
5
If your child walks past the baker, does s/he have the desire to buy something delicious?
.80
-.41
-.08
.73
4
If your child has something delicious to eat, does s/he eat it straight away?
.78
.15
.22
.72
8
If your child walks past the snack bar or cafe, does s/he have the desire to buy something
.70
-.16
-.29
.49
delicious?
3
If your child sees or smells something delicious, does s/he have the desire to eat it?
.63
.20
.07
.64
7
Can your child resist eating delicious foods?*
.59
.04
-.06
.64
1
If food tastes good to your child, does s/he eat more than usual?
.11
.83
.09
.66
2
If food smells good, does your child eat more than usual?
.06
.77
-.19
.40
9
Does your child eat more than usual when s/he sees others eating?
.06
-.06
-.84
.63
6
If your child sees others eating, does s/he also have the desire to eat?
.38
.06
-.60
.73
10
When a meal is being prepared, is your child inclined to eat something?
-.12
.41
-.59
.55
Note: Major loadings are shown in bold. *reversed scored item
CHILD OVEREATING BEHAVIOURS
70
Discussion
The aim of this chapter was to explore the integrity of subscales that measured
instrumental and emotional feeding, and child eating behaviours, to ensure their
appropriateness for young children before investigating the hypotheses of this study.
In order to explore instrumental and emotional feeding, a number of items were
selected across a range of frequently used measures. It was proposed that instrumental
feeding would encompass two distinct feeding styles, and a separate factor would encompass
items related to emotional feeding. Data extraction in this study supported this hypothesis.
Instrumental feeding included a feeding component that used food rewards for good
behaviour and another that used food rewards for eating specific behaviour. A third factor
included items related to emotional feeding and using food to comfort a child.
Instrumental feeding was comprised of 11 items taken from the Pushing the Child to
Eat More subscale of the Parental Feeding Questionnaire (PFQ; Baughcum et al, 2001), and
the Instrumental Feeding subscale of the Parental Feeding Style Questionnaire (PFSQ;
Wardle et al., 2002). Consistent with an earlier analysis of this sample at a younger age
(Brozovic, 2009), two instrumental feeding practices were identified. The first type appeared
to be related to feeding aimed to shape behaviour that included using food to reward good
behaviour and withholding food as punishment for unwanted behaviour. The second type
appeared to be related to rewarding-specific eating behaviours.
Whilst the common link of this feeding practice is to use food as a reward, it also
highlighted that the underlying motivation for using rewards varies. In particular,
instrumental feeding-behaviour appeared to be aimed at modifying behaviour in any context
regardless of appetite or satiety. On the other hand, the motivation for instrumental feedingeating appeared to be aimed at promoting food intake when parents are concerned the child is
not eating enough either due to food fussiness or a general disinterest in food. Arguably, the
CHILD OVEREATING BEHAVIOURS
71
context for this feeding style is focused primarily at mealtimes. Therefore, given the varying
contexts for using each of these feeding strategies it seems likely that instrumental feedingbehaviour may be associated with child overeating behaviours (food approach) and
instrumental feeding-eating may be associated with undereating behaviours (food avoidant).
Instrumental feeding was retained as two separate constructs to test the hypotheses of this
study.
For emotional feeding, six items from two scales, including the Emotional Feeding
subscale from the Parental Feeding Style Questionnaire (PFSQ; Wardle et al., 2002), and the
Using Food to Calm subscale from the Parental Feeding Questionnaire (PFQ; Baughcum et
al, 2001) were included in the final model. The finding that items from each of these scales
loaded onto the same factor and had robust communality values, indicated that the scales
were measuring the same construct in that food is used to influence mood. The items were
combined and used as one measure labeled emotional feeding to test the hypotheses of this
study.
Comparable to other studies (Sleddens, Kremer & Thijs, 2008; Viana, Sinde & Saxon,
2008) that have examined the integrity of the Child Eating Behaviour Questionnaire (CEBQ),
the findings did not exactly replicate the original factor structure developed by Wardle and
colleagues (2001). However, the final solution was shown to have good psychometric
properties (i.e., internal reliability; correlations between subscales) such that it corresponded
closely with the original eight factors proposed. Notably, in the current sample of 4 to 6 year
old children, items from the food responsiveness (FR) and satiety responsiveness (SR) scales
had loadings with other subscales.
The finding that the food responsiveness subscale was problematic is consistent with
that found by Sleddens, Kremer and Thijs (2008), and Viana and colleagues (2008), in which
it has cross loadings with emotional overeating and slowness in eating items. Furthermore,
CHILD OVEREATING BEHAVIOURS
72
the finding that items from the satiety responsiveness subscale loaded ambiguously and had
loadings with other subscales is contrary to previous studies that have examined the scale
properties of the CEBQ (Sleddens, Kremer & Thijs, 2008; Viana et al., 2008; Wardle et al.,
2001). The wording of satiety responsiveness items, for example, “My child has a big
appetite” (reversed scored item), may account for these items loading onto the food approach
scales. This item could also be interpreted as a child’s interest and desire to eat food rather
than capturing a lack of appetite and the ability of a child to reduce food intake after eating to
regulate energy intake, as the construct proposes. Overall, given that the final solution
corresponded well with the original factor structure proposed by Wardle and colleagues, the
original eight factors were utilised to test the hypotheses in this study.
Finally, contrary to previous findings from studies that have examined the scale
properties of the DEBQ-P in an older aged sample (e.g., Caccialanza, Nicholls, Cena,
Maccarini, Rezzani, Antoniolo, et al., 2004), the external eating subscale loaded onto three
factors in the current 4 to 6 year old sample. The three scales related to eating in response to
palatable foods, eating more than usual, and eating more when around others, but as
described above, were retained as one factor for the purpose of this research.
CHILD OVEREATING BEHAVIOURS
73
CHAPTER 7: Study One - An Examination of Cross-Sectional Relationships between
Child Feeding Practices and Eating Behaviours in Young Children
Introduction
The prevalence of childhood obesity has risen at such an alarming rate that it has
become one of the foremost contemporary problems. It is estimated that 25% of Australian
children are overweight or obese (Department of Health and Aging [DoHA]). Additionally,
research now indicates that aspects of eating behaviours are established by the age of 4 years
and remain stable across childhood (Ashcroft et al., 2008). Therefore, it is critical to develop
a greater understanding of the factors associated with overeating behaviours that are likely to
increase overweight and obesity from a younger age.
As previously described in Chapter 1, it is important to explore environmental risk
factors and one area of interest is child feeding factors. Evidence suggests that particular
feeding practices may lead to the development of unhealthy eating behaviours among
children (Rhee, 2008). Common feeding practices used by parents include using food as a
reward for good behaviour or promising dessert if the child eats their vegetables
(instrumental feeding), using food to reduce emotional distress (emotional feeding), limiting
access to desired foods (restriction), and encouraging the child to eat all the food on their
plate (pressure to eat) (Wardle, et al., 2002; Moore, Tapper, & Murphy, 2007). It has been
proposed that many of these feeding practices interfere with the child’s self-regulatory
ability, such that the child may associate eating with cues other than hunger (Wardle et al,
2002).
A small number of cross-sectional studies have examined instrumental and emotional
feeding practices and yielded inconsistent results. While an association has been found with a
mother’s own eating styles (Wardle et al., 2002), inconsistencies have emerged in respect to
child eating behaviours (Carnell & Wardle, 2008a) and no studies have found a relationship
CHILD OVEREATING BEHAVIOURS
74
with child BMI (Baughcum et al., 2001; Carnell & Wardle, 2007). A number of different
measures have been devised to measure these feeding styles. Instrumental feeding has been
assessed as offering food rewards for good behaviour in some studies (Wardle et al., 2002),
and offering dessert for eating healthy foods in other studies (e.g., Baughcum et al., 2001).
Results from the factor analysis reported in Chapter 6 identified that instrumental feeding can
be conceptualised as two distinct types of feeding. Therefore, these feeding practices were
labeled instrumental feeding-behaviour and instrumental feeding-eating, and will be referred
to as separate constructs from herein.
Restriction and pressure to eat are the most commonly examined child feeding
practices in the research literature. These feeding practices are directive feeding styles aimed
at either limiting access to food (restriction) or encouraging the child to eat more (pressure to
eat) (Birch et al., 2001). Restriction has typically supported a positive association with child
weight status (Birch et al., 2001; Francis, Hoffer & Birch 2001; Webber, Hill, Cooke,
Carnell, & Wardle, 2010), and pressure to eat has typically supported an inverse association
with child weight status (Birch et al., 2001; Carnell & Wardle, 2007; Powers et al., 2006;
Spruit-Metz et al., 2002; Webber, Hill et al., 2010). However in some studies no associations
have been found in relation to either feeding practice or child weight status (e.g., Kroller &
Warschburger, 2008).
In terms of child eating behaviours, recent literature refers to food approach and food
avoidant eating behaviours. This includes, eating in response to external cues, negative
emotions, and a general appetite for food (food approach eating); or the ability to recognise
when full, a lack of interest in food, and rejecting new foods (food avoidant eating) (Wardle
et al., 2001).
Research has found that food approach eating styles have been positively associated
with BMI (Janke & Warschburger, 2008; Viana et al., 2008; Webber et al., 2008) and food
CHILD OVEREATING BEHAVIOURS
75
avoidant eating styles have been inversely associated with child BMI (Sleddens, Kremer, &
Thijs, 2008). Additionally, while only a few studies have examined the association between
child feeding practices and child eating behaviours, instrumental feeding (behaviour) and
emotional feeding appear to be associated with a tendency to overeat (i.e., emotional
overeating and food responsiveness) and with eating in response to environmental cues (i.e.,
external eating). Restriction, on the other hand, has been associated with eating in the
absence of hunger (external eating) (Fisher & Birch, 2000, 2002); and pressure to eat has
been associated with picky eating (food fussiness) and eating slower during the course of a
meal (slowness in eating) (Farrow, Galloway, Fraser, 2009). Typically, many of these studies
have examined child feeding practices and child eating behaviours in children aged 7 years
old and above. However, given that recent research indicates that eating behaviours may in
fact be established by the age of 4 years, it is imperative to explore these relationships in
young children.
Another factor to consider in the development of child eating behaviours is the role of
maternal eating styles. Whilst it is not entirely clear what influences a mother’s food choices,
findings are suggestive of a familial transmission of obesity whereby mothers and children
show similarities in overeating behaviours (Brozovic, 2009; Jahnke & Warschburger, 2008).
Emotional and external eating behaviours have been causally linked to obesity (van Strien,
Frijters, Bergers & Defares, 1986) and it has been argued that these behaviours have
potentially commenced through early learning experiences about food. Alternatively, it could
be that child feeding practices are a mechanism that mediates the relationship between
maternal eating and child eating. This relationship requires further clarification however.
CHILD OVEREATING BEHAVIOURS
76
Aims and Hypotheses
The overall aim of Study 1 was to investigate cross-sectional relationships between
maternal eating styles, child feeding practices, child eating behaviours and child BMI in
young children. Two pathways examined were: 1) maternal eating and child feeding practices
as predictors of child eating behaviours; and 2) child feeding practices and child eating
behaviours as predictors of child BMI.
A secondary aim of the present study was also to explore whether child feeding
practices and child eating behaviours were significantly different between boys and girls or
between children of a different weight status. In addition, an aim was to explore if there were
any significant differences in maternal eating styles and child feeding practices between
mothers in different weight categories.
Moreover, based on previous research as indicated in the introduction the following
hypotheses for Time 3 were proposed:
Hypotheses 1: Associations with child feeding practices.
(1) It was hypothesised that maternal emotional eating and external eating would be
positively associated with instrumental feeding-behaviour, instrumental feeding-eating,
emotional feeding and restriction; and (2) that maternal restrained eating would be positively
associated with restriction and negatively associated with pressure to eat feeding practices.
Hypotheses 2: Associations with child eating behaviours.
(1) It was hypothesised that maternal emotional eating, external eating, and restrained
eating, as well as instrumental feeding-behaviour, instrumental-eating, emotional feeding,
and restriction will be positively associated with food approach child eating behaviours
(emotional overeating, food responsiveness, and child external eating); and (2) that maternal
emotional and external eating, as well as instrumental feeding-behaviour, instrumental
CHILD OVEREATING BEHAVIOURS
77
feeding-eating and pressure to eat would be positively associated with food avoidant child
eating behaviours (satiety responsiveness, slowness in eating and food fussiness).
Hypotheses 3: Associations with child BMI.
(1) It was hypothesised that instrumental feeding-behaviour, emotional feeding, and
restriction feeding practices, and food approach child eating behaviours would be positively
associated with child BMI; and (2) that instrumental feeding-eating and pressure to eat, and
food avoidant eating styles would be negatively associated with child BMI.
CHILD OVEREATING BEHAVIOURS
78
Method
Participants
Time 3 participants were 138 mother-child dyads, including 73 male (53%) and 64
(47%) female children. Mothers were aged 24 to 50 years old (M = 37.61 years, SD = 4.95
years) and children were aged 4 to 6 years old (M = 5.30 years, SD = 0.81 years).
Measures
Participants received a questionnaire package, which included an information sheet, a
consent form, and measures to assess demographic characteristics, maternal eating style,
child feeding practices, and child eating behaviours. A full summary of all measures can be
found in the General Method Section in Chapter 5.
In brief, demographic information was collected for child and maternal age, child and
maternal country of birth and ethnicity, maternal marital status, maternal and paternal
education level, maternal and paternal employment status, the number of children residing in
the household, and the household income. Furthermore, child and maternal height and weight
information was collected to calculate BMI for women, and BMI z-scores for children (CDC,
2000).
To assess maternal eating, the emotional eating, external eating and restrained eating
subscales from the Dutch Eating Behaviour Questionnaire (DEBQ; van Strien, Frijters,
Bergers, & Defares, 1986) was utilised. Cronbach alpha values of .96, .83, and .89 were
found respectively for the aforementioned subscales.
To assess child feeding practices several measures were included. For instrumental
and emotional feeding, items from The Parental Feeding Style Questionnaire (PFSQ; Wardle
et al., 2002), the Child Feeding Questionnaire (CFQ; Birch et al., 2001), and the Preschooler
Feeding Questionnaire (PFQ; Baughcum et al., 2001) were included. As presented in Chapter
6, a confirmatory factor analysis was conducted and three constructs emerged. These
CHILD OVEREATING BEHAVIOURS
79
subscales were labelled instrumental feeding-behaviour, instrumental feeding-eating, and
emotional feeding. A full summary of this analysis can be found in Chapter 6. Each of these
subscales were shown to have satisfactory psychometric properties, with Cronbach’s alpha
values of .89 for instrumental feeding-behaviour, .74 for instrumental feeding-eating, and .81
for emotional feeding. To assess restriction and pressure to eat the Child Feeding
Questionnaire (CFQ; Birch et al., 2001) was utilised. Cronbach alpha’s values of .85 and .82
were obtained respectively for these subscales.
To assess child eating behaviours the Children’s Eating Behaviour Questionnaire
(CEBQ, Wardle et al., 2001) and the external eating subscale of the Dutch Eating Behaviour
Questionnaire – Parent Version (DEBQ- P; Braet & Van Strien, 1997) were utilised. Factor
analysis of these items demonstrated acceptable levels of reliability, with Cronbach’s alpha
ranging from .69 to .91. A detailed list of Cronbach alpha’s for each subscale can be found in
Chapter 6.
Procedures
Ethics approval was obtained by the La Trobe University Human Ethics Committee
(Project Number: UHEC 07-064) to perform this research. A full summary of the procedure
can be found in the General Method section in Chapter 5.
Data Analysis
A detailed summary of the data analysis procedures can be found in the General
Method section in Chapter 5. In brief, all data were screened to ensure all assumptions of
normality, linearity, and homoscedasticity were met. The dependent variables were measures
of child eating behaviours and child BMI, and the independent variables were measures of
maternal eating styles and child feeding practices.
Descriptive information relating to child and maternal BMI is reported. Independent
samples t-test were used to explore if there were significant differences between gender or
CHILD OVEREATING BEHAVIOURS
80
child weight status on child feeding and child eating behaviour variables. Furthermore,
independent samples t-tests were used to determine if there were any significant differences
between maternal weight categories in maternal eating and child feeding practices. Pearson’s
product moment correlations were used to explore associations between maternal eating,
child feeding, child eating, and child BMI. Multivariate relationships were explored using
hierarchical regression analyses to examine the unique variance accounted for by the
proposed cross-sectional predictor variables of child eating and child BMI.
CHILD OVEREATING BEHAVIOURS
81
Results
Data Preparation
Data screening.
Inspection of data revealed several missing items across all measures. According to
the recommendations of Tabachnick and Fidell (2007), missing items were replaced with the
mean value for the remaining items of the specific subscale. In the instance where greater
than 25% of the items on a scale were missing, the participant was excluded from analysis
involving those measures. Data were then screened for outliers. Using criteria specified by
Tabachnick and Fidell, who suggest a value three standard deviations above or below the
mean to be considered an outlier, a small number of outliers were identified. Where possible
the item was replaced with the next most extreme value for that item. In the instance where a
subscale significantly departed from normality, a transformation was performed
corresponding to the skewness of the subscale.
Of the anthropometric data, there were missing BMI data from four mothers (n = 134)
and 12 children (n = 126). For child BMI, two participants were deleted due to invalid data.
For maternal BMI, one extreme outlier was moved to the next most extreme value.
Participants with missing maternal and child BMI data were excluded from analysis
involving those measures.
Assumptions of parametric tests.
All data were screened for normality, linearity, and homoscedasticity. Normality was
assessed using skewness and kurtosis where > 3.30 indicated skewed data. Exploration of all
scales revealed two significant departures from normality, which were maternal BMI and
emotional feeding.
For maternal BMI there were six BMI values that were considered outliers (BMI >
37.6). Maternal BMI ranged from 17.72 to 40.77. These participants were retained; however
CHILD OVEREATING BEHAVIOURS
82
the BMI values were changed to the next highest score in the distribution. After addressing
the outliers, the distribution was still skewed. A logarithm transformation was performed and
improved the distribution.
The emotional feeding subscale was positively skewed. A square root transformation
improved the distribution of scores. The new transformed variable was included in
subsequent analyses.
Participant Characteristics
Table 9 outlines the mean and standard deviation values for child and maternal BMI,
maternal eating styles, child feeding practices, and child eating behaviours. The mean child
BMI z-scores were marginally higher than the standardised Centre for Disease Control and
Prevention (CDC, 2002) population, as shown by the mean value being greater than zero and
the percentile value greater than 50. For maternal eating styles, the mean for each of the
subscales were centred around the middle range of the scores, with the external eating mean
being slightly higher than the means for restrained eating and emotional eating. In respect to
child feeding practices, mean scores showed that most mothers reported higher levels of
pressure to eat and lower levels of emotional feeding. In terms of child eating behaviour
shown in Table 9, mean scores showed that the majority of subscales were generally
distributed in the middle range of the scale, with external eating shown to be most common
(M = 3.07) and emotional overeating the least common (M = 1.91) eating behaviour among
children in this sample.
CHILD OVEREATING BEHAVIOURS
83
Table 9
Means and Standard Deviations for all Measures at Time 3
Measure
No. of
items
Child Age (years)
Child BMI (n = 127)
Z-score
Percentile
Maternal BMI (n = 134)
Range
Mean
SD
3.83 – 7.00
12.40 – 27.00
-3.69 – 3.73
17.75 - 40.77
5.29
16.07
.21
56.45
25.48
.85
2.23
1.30
31.39
5.14
Maternal Eating Behaviour
Emotional Eating
External Eating
Restrained Eating
13
10
10
1-5
1-5
1-5
2.45
2.86
2.73
.95
.52
.72
Child Feeding Practices
Instrumental Feeding-behaviour
Instrumental Feeding-eating
Emotional Feeding*
Restriction
Pressure to Eat
7
4
6
6
4
1-5
1-5
1-5
1-5
1-5
2.24
2.41
1.59
2.67
2.73
.79
.77
.52
.53
1.03
4
5
10
1-5
1-5
1-5
1.91
2.49
3.07
.62
.66
.49
5
4
6
1-5
1-5
1-5
2.47
2.19
2.87
.44
.52
.76
Child Eating Behaviours
Food Approach
Emotional Overeating
Food Responsiveness
External Eating
Food Avoidance
Satiety Responsiveness
Slowness in Eating
Food Fussiness
*Untransformed mean scores
CHILD OVEREATING BEHAVIOURS
84
Child BMI.
To enable comparison with other studies, the actual BMI scores for children were
categorised using the age and gender-specific cut-off points as defined by the IOTF
thresholds (Cole et al., 2000; Cole et al., 2007). Figure 5 shows the proportion of boys and
girls in each weight category. The current study’s found that 14.28% (4.76% boys and 9.52%
girls) were overweight and 5.55% (3.17% boys and 2.38% girls) were obese. The proportion
of overweight in obesity is slightly lower compared to results found in the 2007 Australian
National Children’s Nutrition and Physical Activity Survey (DoHA). This study used the
IOTF cut-offs to examine children aged 2 to 16 years old. Overall, 5% were underweight,
72% were in the healthy weight range, 17% were overweight and 6% were obese (DoHA).
45
38.89
40
34.92
35
Percentage %
30
25
Boys (n= 57)
20
Girls (n = 69)
15
9.52
10
5
2.38
3.97
4.76
3.17 2.38
0
Underweight Healthy Weight
Overweight
Obese
Figure 5. Proportion (%) of Children Classified as Underweight, Healthy Weight,
Overweight, and Obese using the IOFT Age and Gender-Specific Cut-offs (Cole et al., 2000;
Cole et al., 2007) (n = 126).
CHILD OVEREATING BEHAVIOURS
85
Maternal BMI.
The mean BMI for mothers was 25.43 kg/m2 (SD = 5.14). Figure 6 shows the
proportion of mothers in each weight category. BMI was calculated according to WHO
(1996) criteria for underweight, normal weight, overweight, and obese. For this sample,
47.76% of mothers were overweight or obese, which is lower than the national
overweight/obese proportions. The Australian Bureau of Statistics reported that in 2007-08,
55% of Australian women were overweight and obese (ABS, 2010).
60
49.25
50
Percentages
40
32.09
30
20
15.67
10
2.98
0
Underweight
Normal
Overweight
Obese
Figure 6. Proportion (%) of Mothers Classified as Underweight (BMI <18.5kg/m2), Normal
Weight (BMI ≥18.5 to <25 kg/m2), Overweight (BMI ≥ 25 to < 30kg/m2), and Obese (BMI ≥
30 kg/m2) according to WHO Weight Categories (n = 134).
CHILD OVEREATING BEHAVIOURS
86
Differences between Gender and Weight Groups
Gender differences in children.
To determine if any gender differences were found between male and female children
independent samples t-test were performed on all measures (child feeding practices and child
eating behaviours). A significant gender difference was found for instrumental feedingbehaviour. Mothers tended to use rewards for good behavior more often in male children (M
= 2.39, SD = 0.81) than female children (M = 2.11, SD = 0.74); t (136) = 2.08, p = .04 (twotailed). Similarly, the magnitude of difference in the means scores was very small (η2 = .03).
That is, gender accounted for 3.07% of the variance in instrumental feeding-behaviour.
Therefore, the boys and girls data were combined in subsequent regression analyses but
gender was controlled for at step 1 in the hierarchical regression analyses.
Overweight and non-overweight children.
Independent samples t-test were performed to examine differences between
overweight and non-overweight child eating behaviours. One significant difference was
found in Slowness in Eating. Mean scores revealed that non-overweight weight children,
according to the CDC growth charts for age-and-gender, scored significantly higher (M =
2.23, SD = 0.05) than overweight and obese children (M = 2.02, SD = 0.49); t (125) = 1.98, p
= .05. That is, children of lower weight were more likely to take longer to finish a meal
compared to overweight and obese children. The magnitude of difference in means was very
small (η2 = .03). Therefore, weight status was grouped as one variable for subsequent
regression analyses.
Overweight and non-overweight mothers.
No differences were found for child feeding practices between overweight and nonoverweight weight mothers. However, significant differences were found for all maternal
eating behaviours. Consistent with previous research, means for maternal emotional eating
CHILD OVEREATING BEHAVIOURS
87
was significantly higher in overweight and obese mothers (M = 2.78, SD = 0.98) than for
non-overweight mothers (M = 2.09, M = 0.85); t (131) = -4.32, p = .00. This indicated that
overweight and obese mothers were more likely to eat in response to negative emotions than
non-overweight mothers. In this instance the magnitude of difference was large (η2 = .12), and
indicated that 12.45% of the variance in emotional eating was explained by maternal weight.
A significant difference was found for maternal external eating. Similarly the means for
overweight and obese mothers was significantly higher (M = 2.92, SD = 0.46) than nonoverweight mothers (M = 2.76, SD = 0.52); t (131) = -1.93, p = .05. A small magnitude of
difference was found (η2 = .02). This showed that overweight and obese mothers were more
likely to eat in the presence of food despite feelings of satiety. Finally, a significant mean
difference was found for restrained eating. Overweight and obese mothers were more likely
(M = 2.86, SD = 0.65) to restrict access to particular foods than non-overweight mother’s (M
= 2.58, SD = 0.77); t (131) = -2.28, p = .02. Therefore, maternal BMI was controlled for in
the regression analyses including maternal eating measures.
Differences Among the Sample on Demographic Variables
Exploration of relationships between demographic variables (including marital status,
education level, employment and income level) and outcome variables (maternal eating
styles, child feeding practices, and child BMI) were considered. Given the majority (82%) of
the sample reported their ethic background as Australian, the groups were too small to
compare differences on outcome variables. Independent samples t-test revealed no significant
differences for maternal education (split into tertiary educated and other), employment status
(working and not working), or family income (split into 60, 000≤ 141,000+) for outcome
variables. Therefore, these variables were excluded from further analysis.
CHILD OVEREATING BEHAVIOURS
88
Associations between Variables
Associations with child feeding practices.
The association between maternal eating styles and child feeding practices can be
found in Table 10. Inspection of data revealed significant associations between maternal
emotional eating and maternal external eating but contrary to expectations no associations
were found with maternal restrained eating. In particular, maternal emotional eating was
shown to have a moderate positive relationship with instrumental feeding-behaviour and
emotional feeding (r ≥ .18 < .28), and maternal external eating was shown to have a
moderate positive relationship with instrumental feeding-behaviour and emotional feeding (r
≥ .19< .27). Maternal BMI was shown to have significant associations with maternal
emotional eating, external eating, and restrained eating.
Table 10
Pearson’s Product Moment Correlations of Maternal Eating Behaviours and Child Feeding
Practices of Time 3 (N = 138)
Maternal Eating Behaviours
Emotional Eating
External
Restrained
Eating
Eating
.48**
.24**
.32**
Instrumental feeding-behavior
.18*
.19*
-.08
Instrumental feeding-eating
.10
.02
-.07
Emotional Feeding1
.28**
.27**
-.08
Restriction
.21*
.20*
.14
Pressure to Eat
.09
.13
-.03
Maternal BMI
Child Feeding Practices
*<.05; **<.01 (2 tailed); 1Squareroot Transformation
CHILD OVEREATING BEHAVIOURS
89
Associations with child eating behaviours.
Table 11 presents correlations of child eating behaviours with maternal eating styles
and child feeding practices. Inspection of the data revealed several significant positive
relationships. In relation to food approach eating styles, emotional overeating was shown to
have significant moderate associations with maternal emotional eating and external eating (r
≥ .22< .31), as well as instrumental feeding-behaviour and instrumental feeding-eating (r ≥
.20< .37), and a significant strong relationship with emotional feeding (r = .56). Restriction
was also found to be significantly associated with emotional overeating. For food
responsiveness, significant moderate associations were found for maternal external eating, as
well as instrumental feeding-behaviour and emotional feeding (r ≥ .23 < .37). No associations
were found with maternal emotional eating and instrumental feeding-eating. Similarly, for
external eating, significant associations were found with maternal emotional and external
eating, as well as instrumental feeding-behaviour, emotional feeding and restriction (r ≥ .19<
.43). No association was found between maternal restrained eating and child external eating.
In relation to food avoidant eating styles, results indicated that pressure to eat was
significantly associated with satiety responsiveness, slowness in eating, and food fussiness (r
≥ .19< .33). As predicted, instrumental feeding-eating was found to be positively associated
food avoidant eating styles, including slowness in eating and food fussiness.
CHILD OVEREATING BEHAVIOURS
90
Table 11
Pearson’s Product Moment Correlations of Maternal Eating Styles, Child Feeding Practices and Child Eating Behaviours of Time 3 (N =138)
Child Eating Behaviours
Food Approach
Food Avoidant
Emotional
Food
Overeating
Responsiveness Eating
Responsiveness Eating
Fussiness
.01
-.06
.03
.09
.13
.09
Emotional Eating
.31**
.11
.19*
.23**
.22**
.14
External Eating
.22*
.23**
.43**
.25**
.17*
.07
Restrained Eating
-.00
-.03
-.07
.11
.14
.04
Instrumental feeding-behaviour
.37**
.37**
.34**
.03
.08
.12
Instrumental feeding-eating
.20*
.16
.13
-.01
.20*
.17*
.56**
.37**
.34**
.07
.07
.15
Restriction
.18*
.15
.34**
.05
-.02
.06
Pressure to Eat
.11
.02
.14
.19*
.28**
.33**
Maternal BMI
External
Satiety
Slowness in
Food
Maternal Eating Styles
Child Feeding Practices
Emotional
1
*<.05; **<.01 (2 tailed); 1Transformed subscale
CHILD OVEREATING BEHAVIOURS
91
Associations with child BMI.
As can be seen in Table 12, moderate negative correlations were found between
satiety responsiveness, slowness in eating and child BMI-for-age. For satiety responsiveness,
a negative association suggested that children of lower weight status were more sensitive to
internal satiety cues and were more able to regulate their food intake based on perceived
fullness. Similarly, for slowness in eating, a negative association indicated that children of
lower weight tended to eat to more slowly during the course of a meal and may suggests that
they were also able to recognise internal satiety cues to stop eating when full.
Table 12
Pearson Product Moment Correlations between Child BMI and Maternal BMI, Child
Feeding Practices and Child Eating Behaviours (N = 138)
Measures
Child BMI-for-age
z-score
Maternal BMI
.10
Child Feeding Practices
Instrumental Feeding-behaviour
-.11
Instrumental Feeding-eating
-.14
Emotional Feeding1
.01
Restriction
.05
Pressure to Eat
-.05
Child Eating Behaviours
Emotional Overeating
.02
Food Responsiveness
.04
External Eating
.03
Satiety Responsiveness
-.19*
Slowness in eating
-.27**
Food Fussiness
*p<.05; **p<.01 (2 tailed); 1 transformed subscale
.03
CHILD OVEREATING BEHAVIOURS
92
Multivariate Relationships
Assumptions for multivariate analyses.
Following examination of univariate relationships between maternal eating styles,
child feeding practices and child eating behaviours, a number of hierarchical regression
analyses were performed to examine the unique variance accounted for by the proposed
cross-sectional predictor variables.
Assumptions that are required to be met to perform regression analyses were first
examined. The present study consisted of 138 participants, which met the principal
requirement for an adequate case-to-variable ratio (Tabachnick & Fidell, 2007). In addition,
normality, linearity, outliers, and homoscedasticity were assessed during preliminary analysis
of predictor variables to ensure no violations of these assumptions occurred, in order to
perform regression analyses.
Overall, a summary table of the significant multivariate associations between
maternal eating styles, child feeding practices, child eating behaviours and child BMI can be
found in Appendix D3
Hypotheses 1: Predictors of child feeding practices.
To examine which maternal eating behaviours were the best predictors of child
feeding practices, a series of hierarchical regression analyses were performed. Based on
previous research the primary hypothesis predicted that (1) maternal emotional eating and
external eating styles would predict emotional and instrumental feeding-behaviour,
instrumental feeding-eating and restriction; and the secondary hypothesis predicted that (2)
maternal restrained eating would predict restriction and pressure to eat feeding practices.
Notably, no significant univariate associations were found between maternal restrained eating
and any child feeding practice, or between instrumental feeding-eating and any maternal
CHILD OVEREATING BEHAVIOURS
93
eating style. Thus, no further multivariate analyses were explored for these variables. To
explore each model a two-step hierarchical regression analysis was performed. In step 1,
three control variables including child age, child BMI, and maternal BMI, were entered. In
step 2, maternal emotional eating and external eating were entered into the model.
Summary statistics for the hierarchical regression for instrumental feeding-behaviour
are shown in Table 13. Gender was also included at Step 1 in this model due to significant
gender difference found for instrumental feeding-behaviour. Step 1 explained 5.8% of the
variance in instrumental feeding-behaviour and was not significant, F(4,117) = 1.81, p = .13.
At step 2, after the inclusion of maternal eating variables, the total variance explained by the
model was 12.1%, R squared change = .06, F(6,115) = 2.64, p = .02. In the final model two
significant unique predictors of instrumental feeding-behaviour were revealed. Maternal
emotional eating showed a higher beta value (β = .23. p = .05) than maternal BMI (β = -.20, p
= .05). At step 2, child gender was approaching significance (β = -.17. p = .06).
CHILD OVEREATING BEHAVIOURS
94
Table 13
Summary of Hierarchical Regression Analysis for Maternal Eating Style as Predictors of
Instrumental Feeding-behaviour (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.06
Child Age
.39
.59
.06
Child Gender
-2.24
1.0
-.20*
Child BMI
-.56
.39
-.13
Maternal BMI1
-5.42
6.07
-.08
Step 2
.06*
Child Age
.35
.58
.05
Child Gender
-1.90
.98
-.17
Child BMI
-.54
.38
-.13
-14.23
6.77
-.21*
Maternal Emotional Eating
.10
.05
.23*
Maternal External Eating
.10
.11
.09
Maternal BMI1
*p<.05; **p<.01; 1Logarithm Transformation
The second model investigated which maternal eating styles were the best predictors
of emotional feeding. Summary statistics for the hierarchical regression for emotional feeding
are shown in Table 14. Step 1 explained 0.2% of the variance in emotional feeding, F(3,118)
= .06, p = .98. This step was not significant. After the inclusion of maternal eating variables
at Step 2 the total variance explained by the whole model was 12.7%, R squared change =
.13, F(5,115) = 3.37, p = .01. In the final model, maternal emotional eating was shown to be a
significant unique predictor of emotional feeding (β = .26, p = .02).
CHILD OVEREATING BEHAVIOURS
95
Table 14
Summary of Hierarchical Regression Analysis for Maternal Eating Style as predictors of
Emotional Feeding (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.00
Child Age
Child BMI
1
Maternal BMI
.02
.05
.03
.01
.04
.01
-.01
.55
-.01
Step 2
.13**
Child Age
.02
.05
.03
Child BMI
.01
.03
.02
Maternal BMI1
-.02
.01
-.20
Maternal Emotional Eating
.01
.01
.28*
Maternal External Eating
.02
.01
.17
*p<.05; **p<.01; 1Logarithm Transformation
The third model investigated maternal eating styles predicting restriction. Summary
statistics for the hierarchical regression model for restriction are shown in Table 15. Step 1
explained 1% of the variance in restriction, and was found to be non-significant F(3, 118) =
.38, p = .77. After the inclusion of maternal eating variables at Step 2, the total variance was
6.8%. However the model as a whole was found to not be significant, F(6, 115) = 1.68, p =
.14.
CHILD OVEREATING BEHAVIOURS
96
Table 15
Summary of Hierarchical Regression Analysis for Maternal Eating Style as Predictors of
Restriction (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.01
Child Age
Child BMI
1
Maternal BMI
.25
.35
.06
.01
.23
.04
1.97
3.56
.05
Step 2
.06*
Child Age
.26
.34
.07
Child BMI
.12
.22
.05
-2.52
4.01
-.07
Maternal Emotional Eating
.04
.03
.16
Maternal External Eating
.08
.07
.14
Maternal BMI1
*p<.05; **p<.01; 1Logarithm Transformation
Hypotheses 2: Predictors of child eating behaviours.
The following models investigated which child feeding practices and maternal eating
styles were the best predictors of child eating behaviours. The primary hypothesis predicted
that maternal emotional eating, external eating, and restrained eating, as well as emotional
feeding, instrumental feeding (behaviours), instrumental feeding (eating), and restriction
would predict child emotional overeating, food responsiveness, and external eating. As no
significant univariate associations were found with maternal restrained eating, no further
analyses were explored with this variable. For each model a two-step hierarchical regression
analysis was performed. In Step 1, child age was entered into the model as a control variable.
In Step 2, the hypothesised child feeding practices and maternal eating styles noted above
were entered into the model.
CHILD OVEREATING BEHAVIOURS
97
The first model examined child emotional overeating. Summary statistics for the
hierarchical regression for emotional overeating are shown in Table 16. Step 1 accounted for
0.4% of the variance in child emotional overeating, and was found to not be significant,
F(1,135) = .54, p = .46. With the inclusion of child feeding practices as well as maternal
eating behaviours at Step 2, the total variance explained by the model as a whole was 34%, R
squared change = .34, F(7,129) = 9.51, p < .001. In the final model emotional feeding was the
only significant unique predictor of child emotional overeating (β = .50, p < .001).
Table 16
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Maternal
Eating Style as Predictors of Child Emotional Overeating (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.00
Child Age
.18
.25
.06
Step 2
.34**
Child Age
.09
.21
.03
Instrumental Feeding-behaviour
.00
.05
.01
Instrumental Feeding-eating
-.00
.07
-.00
Emotional Feeding1
2.53
.50
.50**
Restriction
.06
.06
.08
Maternal Emotional Eating
.03
.02
.15
Maternal External Eating
-.00
.04
-.01
*p<.05; **p<.01; 1Square root Transformation
The second model examined food responsiveness. Summary statistics for the
hierarchical regression for food responsiveness are shown in Table 17. Step 1 accounted for
0.3% of the variance in child food responsiveness, and was found to not be significant,
F(1,135) = .44, p = .51. In Step 2, after the inclusion of child feeding practices and maternal
CHILD OVEREATING BEHAVIOURS
98
eating variables the total model accounted for 19.7% of the variance in food responsiveness,
R squared change = .19, F(7,129) = 4.52, p < .001. As can be seen in Table 17, instrumental
feeding-behaviour was the only significant unique predictor of food responsiveness (β = .24,
p = .05). Emotional feeding was approaching significance (β = .20, p = .07).
Table 17
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Maternal
Eating Style as Predictors of Child Food Responsiveness (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.00
Child Age
.22
.33
.06
Step 2
.19**
Child Age
.23
.31
.06
Instrumental Feeding-behaviour
.14
.07
.24*
Instrumental Feeding-eating
-.05
.10
-.05
Emotional Feeding1
1.33
.73
.20
Restriction
.09
.09
.09
Maternal Emotional Eating
-.02
.02
-.07
Maternal External Eating
.10
.06
.16
*p<.05; **p<.01; 1Square root Transformation
The third model examined child external eating. Summary statistics for the
hierarchical regression for external eating are shown in Table 18. Step 1 accounted for .9% of
the variance in child external eating, and was found to not be significant, F(1,135) = 1.17, p
= .28. After the entry of child feeding practices and maternal eating variables at Step 2, the
total variance explained 34.1% of the model as a whole, R squared change = 33.2, F(7,129) =
9.53, p < .001. As shown in Table 18, two child feeding practices, instrumental feedingbehaviour and restriction, and maternal external eating were significant unique predictors of
CHILD OVEREATING BEHAVIOURS
99
external eating. Maternal external eating recorded the highest beta value (β = .39, p < .001),
then restriction (β = .26, p < .001) and then instrumental feeding-behaviour (β = .23, p<.05).
Table 18
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Maternal
Eating Style as Predictors of Child External Eating (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.01
Child Age
.54
.50
.09
Step 2
.33**
Child Age
.65
.42
.11
Instrumental Feeding-behaviour
.21
.10
.23*
Instrumental Feeding-eating
-.09
.14
-.05
Emotional Feeding1
.93
.99
.09
Restriction
.39
.12
.25**
Maternal Emotional Eating
-.05
.03
-.13
Maternal External Eating
.37
.08
.39**
*p<.05; **p<.01; 1Square root Transformation
The secondary hypothesis predicted that maternal emotional and external eating, as
well as emotional, instrumental feeding-behaviour, instrumental feeding-eating, and pressure
to eat, would predict food avoidant eating styles including satiety responsiveness, slowness is
eating and food fussiness. Notably, restriction was removed and pressure to eat was included
into the model at step 2. Age was entered at Step 1, and maternal eating and child feeding
variables were entered at step 2.
The first model examined satiety responsiveness. Summary statistics for the
hierarchical regression analysis for child satiety responsiveness is shown in Table 19. Step 1
accounted for 6.4% of the variance in child satiety responsiveness F(1,135) = .06, p = .81.
CHILD OVEREATING BEHAVIOURS
100
With the inclusion of child feeding practices and maternal eating variables at Step 2, the total
variance explained by the model as a whole was 15.3%, R squared change = .09, F(7,129) =
3.33, p = .00. As can be seen in Table 19, child age was shown to be significant at Step 1 and
Step 2. Furthermore, while there were no significant unique predictors of satiety
responsiveness, the overall model was significant and indicates that there is shared variance
among the variables.
Table 19
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Maternal
Eating Style as Predictors of Child Satiety Responsiveness (N = 138)
Variable
B
SE B
ΔR2
β
Step 1
.06**
Child Age
-.65
.21
-.25**
Step 2
.09*
Child Age
-.59
.21
-.23**
Instrumental Feeding-behaviour
-.02
.05
-.04
Instrumental Feeding-eating
-.02
.07
-.02
Emotional Feeding
-.04
.50
-.01
Pressure to Eat
.08
.05
.15
Maternal Emotional Eating
.03
.02
.17
Maternal External Eating
.06
.04
.13
1
*p<.05; **p<.01; 1Square root Transformation
The next model examined child slowness in eating. Summary statistics for the
hierarchical regression analysis are shown in Table 20. Step 1 accounted for .2% of the
variance in child slowness in eating, and was found to not be significant, F(1,135) = 2.30, p =
.13. After the entry of child feeding practices and maternal eating variables at Step 2, the total
variance explained 17.1% of the model as a whole, R squared change = 15.5, F(7,129) =
CHILD OVEREATING BEHAVIOURS
101
3.81, p < .001. As shown in Table 20, two child feeding practices, instrumental feedingeating and pressure to eat, and maternal emotional eating were significant unique predictors
of slowness in eating. Pressure to eat was shown to have the highest beta value (β = .24, p <
.01), then instrumental feeding-eating (β = .23, p = .02) and maternal emotional eating (β =
.20, p =.04).
Table 20
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Maternal
Eating Style as Predictors of Child Slowness in Eating (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.02
Child Age
-.32
.21
-.13
Step 2
.16**
Child Age
-.28
.20
-.12
Instrumental Feeding-behaviour
-.05
.05
-.13
Instrumental Feeding-eating
.15
.07
.23*
Emotional Feeding
-.28
.47
-.07
Pressure to Eat
.12
.04
.24**
Maternal Emotional Eating
.03
.02
.20*
Maternal External Eating
.03
.04
.07
1
*p<.05; **p<.01; 1Square root Transformation
The final model examined child food fussiness. Summary statistics for the hierarchical
regression analysis for food fussiness are shown in Table 21. Step 1 accounted for 1.9% of
the variance in child food fussiness, and was found to not be significant, F(1,135) = 2.63, p =
.11. In Step 2, after the inclusion of child feeding practices and maternal eating variables the
total model accounted for 14.4% of the variance in food fussiness, R squared change = .13,
CHILD OVEREATING BEHAVIOURS
102
F(7,129) = 3.09, p < .001. As can be seen in Table 21, pressure to eat was the only significant
unique predictor of food fussiness (β = .28, p < .001).
Table 21
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Maternal
Eating Style as Predictors of Child Food Fussiness (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.12
Child Age
-.75
.46
-.14
Step 2
.13**
Child Age
-.65
.45
-.12
Instrumental Feeding-behaviour
-.08
.10
-.10
Instrumental Feeding-eating
.20
.15
.13
Emotional Feeding1
.60
1.06
.07
Pressure to Eat
.31
.10
.28**
Maternal Emotional Eating
.05
.04
.12
Maternal External Eating
-.03
.09
-.04
*p<.05; **p<.01; 1Square root Transformation
Hypotheses 3: Predictors of child BMI
The primary hypothesis explored child feeding practices and food approach eating
behaviours as positive predictors of child BMI. The first model controlled for child age at
step 1, and was found to be non-significant F(1, 124) = 1.64, p = .20. With the inclusion of
emotional feeding, instrumental feeding-behaviour, restriction, as well as food approach
eating behaviours, including emotional overeating, food responsiveness, and external eating
at Step 2, the total variance was 4.6%, R squared change = .033, F(7, 118) = .87, p = .58.
Whilst instrumental feeding-behaviour was shown to be a significant negative predictor of
CHILD OVEREATING BEHAVIOURS
103
child BMI (β = -.24, p = .05), the model as a whole was not significant. Summary statistics
are shown in Table 22.
Table 22
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Child Food
Approach Eating Behaviours as predictors of Child BMI (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.01
Child Age
.17
.13
.11
Step 2
.03
Child Age
.17
.14
.11
Instrumental Feeding-behaviour
-.06
.03
-.24*
Emotional Feeding1
.44
.36
.17
Restriction
.01
.04
.02
Emotional Overeating
-.03
.07
-.06
Food Responsiveness
.03
.05
.06
External eating
.01
.03
.03
*p<.05; **p<.01; 1Square root Transformation
The secondary hypothesis examined child feeding practices and food avoidant eating
behaviours as predictors of lower child BMI. Similarly, child age was entered at Step 1 as a
control variable. This step was not significant, F(1, 124) = 1.64, p = .20. At step 2,
instrumental feeding-eating, pressure to eat, and the food avoidant eating behaviours,
including satiety responsiveness, slowness in eating and food fussiness, were entered. This
step was shown to be significant, and the model accounted for 11.2% of the variance in child
BMI, R squared change = .10, F(6, 119) = 2.49, p = .03. As can be seen in Table 23, slowness
in eating was shown to be a significant unique predictor of child BMI (beta = -.20, p = .04).
CHILD OVEREATING BEHAVIOURS
104
Table 23
Summary of Hierarchical Regression Analysis for Child Feeding Practices and Child Food
Avoidance Eating Behaviours as predictors of Child BMI (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.01
Child Age
.17
.13
.11
Step 2
.10*
Child Age
.15
.13
.10
Instrumental Feeding-eating
-.06
.04
-.13
Pressure to Eat
.01
.03
.03
Satiety Responsiveness
-.08
.06
-.14
Slowness in Eating
-.13
.06
-.20*
Food Fussiness
.04
.03
.13
*p<.05; **p<.01; 1Square root Transformation
Discussion
This study investigated cross-sectional relationships between maternal eating styles,
child feeding practices, child eating behaviours and child weight status in young children. It
was proposed that maternal eating and child feeding practices would be associated with child
eating behaviours. This association was partially supported. The proposed role of child
feeding and child eating behaviours on child BMI was not supported. The specific variables
found to be associated with child feeding and child eating behaviours will be discussed in
greater detail in the following sections. In this chapter the way in which these data relate to
previous literature will be considered. A deeper discussion of theoretical and clinical
implications, methodological limitations, considerations for future research, and concluding
remarks will be addressed in Chapter 10, the General Discussion.
CHILD OVEREATING BEHAVIOURS
105
Predictors of Child Feeding Practices
The first hypothesis that maternal eating styles (emotional, external and restrained
eating) would be positively associated with child feeding practices (instrumental feedingbehaviour, instrumental feeding-eating, emotional feeding, and restriction) was partially
supported in this sample. Maternal emotional eating predicted instrumental feeding-behaviour
and emotional feeding; however, neither maternal external eating nor restrained eating were
significant unique predictors of any child feeding practice. Additionally, maternal BMI was
found to be a unique predictor of instrumental feeding-behaviour.
Whilst there is only a small number of existing studies that have explored
relationships between maternal eating and child feeding, these finding are partially consistent
with this research. Results indicated that mothers who tended to eat in response to negative
emotions were likely to feed their child in a similar way. In particular, mothers who have a
tendency to eat in response to their feelings rather than hunger (emotional eating), were likely
to give food to calm or comfort their child (emotional feeding) or used food rewards to
encourage good behaviour (instrumental feeding-behaviour), but did not use food to shape
eating-specific behaviour (instrumental feeding-eating). This finding is consistent with past
research by Brozovic (2009) and Wardle and colleagues (2002) who found positive
relationships between maternal emotional eating and emotional feeding in children aged 2 to
4, and 3 to 5 years respectively. The current sample was of children aged 4 to 6 years and
therefore results suggest that these relationships continue to be observed as children move
toward the school years. Whilst this finding suggested mothers who were emotional eaters
tended to feed their children in a similar way to their own eating, another explanation could
be that mothers have a greater tendency to respond to their children as they would
themselves, in response to negative emotions. As these findings are cross-sectional, it could
CHILD OVEREATING BEHAVIOURS
106
also be that emotional feeding may be in response to child eating behaviours. The proposition
that emotional feeding mediates these relationships is discussed in Study 2, Chapter 8.
The finding that maternal emotional eating positively predicted instrumental feedingbehaviour and that maternal BMI negatively predicted instrumental feeding-behaviour is in
contrast to existing literature. One explanation for the lack of consistency with past research
for instrumental feeding may be related to age. When explored in the younger sample (2 to 4
years) by Brozovic (2009), neither maternal eating styles uniquely predicted instrumental
feeding; however both instrumental feeding-behaviour and instrumental feeding-eating were
predicted by child age. This may be a reflection of the child’s level of comprehension in this
age group, as providing rewards essentially requires some level of bargaining on behalf of the
child (Brozovic). Child characteristics may be more likely to influence the use of
instrumental feeding in an older age group to manage their behaviour (i.e., good/bad
behaviour). If mothers use food to manage their own emotional discomfort, then food may
resemble a way to cope with other stressors, such as offering food to the child as a strategy to
entice good behaviour.
The finding that maternal BMI negatively predicted instrumental feeding-behaviour
is contrary to that of Wardle et al. (2002) who found that obese mothers were no more likely
than normal weight mothers to use food rewards. Maternal BMI was added as a control
variable due to significant weight differences found across all maternal eating styles. In this
sample, a large magnitude of difference (12.45% of variance) was found for emotional eating.
Obese mothers were much more likely to report emotional eating compared to normal weight
mothers. An inverse relationship between maternal BMI and instrumental feeding-behaviour
suggested that mothers of a higher weight status were less likely to use food rewards to
modify behaviour, or it could be interpreted that mothers of a normal weight were more likely
CHILD OVEREATING BEHAVIOURS
107
to use food rewards to modify behaviour. In this case, the latter is probably more likely.
Further research is required to explore this finding.
Contrary to findings by Brozovic (2009) who reported that maternal external eating
uniquely predicted emotional feeding, maternal external eating did not significantly predict
any child feeding practice in the current study. Maternal external eating was correlated with
instrumental feeding-behaviour, emotional feeding and restriction; however when maternal
external eating was added to the regression model with maternal emotional eating, the unique
contribution of maternal external eating was not significant. The association between
maternal external eating and instrumental feeding is consistent with that of Wardle and
colleagues (2002).
No association was found between any of the maternal eating styles and instrumental
feeding-eating. This indicated that the mothers own eating was not related to using food
rewards for eating specific behaviour. This is not surprising given that this feeding practice
tended to be related to food avoidant eating behaviours, in which it is likely to be confined to
mealtimes and used as a strategy for fussier eaters to get them to eat more or for children who
take a long time to eat their meals. This will be discussed in greater detail in the following
section.
Contrary to the prediction that restrained eating would be positively associated with
restriction and negatively associated with pressure to eat, correlational analyses revealed no
association with either feeding practice. This is in contrast to previous research that has found
that mothers who restrained their own food intake were more likely to impose greater
restriction on their child’s intake of high-fat foods (Birch & Fisher, 2000). An explanation for
the lack of consistency between the findings of the current study and that of Birch and
Fisher’s (2000) study may be due to different methodologies applied. Birch and Fisher (2000)
undertook laboratory research using a free access procedure, whereas the current research
CHILD OVEREATING BEHAVIOURS
108
was questionnaire based. Furthermore, the study by Birch and Fisher (2000) also included a
measure to assess mother’s perception of their daughter’s risk for overweight, in that mothers
who perceived their daughter to be at risk were more likely to use greater restrictive feeding
to control their child’s food intake. Furthermore, risk for overweight appeared to moderate
the relationship between restrained eating and restrictive feeding in that study.
Predictors of Child Eating Behaviours
The second hypothesis was that maternal eating styles (emotional, external and
restrained eating) and child feeding practices would be positively associated with child food
approach eating behaviours (emotional eating, food responsiveness and external eating). This
hypothesis was partially supported. Maternal external eating, instrumental feeding-behaviour
and restriction positively predicted child external eating; emotional feeding uniquely
predicted child emotional overeating; and instrumental feeding-behaviour uniquely predicted
child food responsiveness.
In the literature to date there is very little data about the influence of maternal eating
on child eating behaviours in preschool-aged children. The current findings lend support for
the hypothesised familial transmission of eating behaviours. In particular, our findings
indicate the transmission of external eating from mother to child. This finding is consistent
with that of Brozovic (2009) who reported an association between maternal external eating
and child external eating from the same cohort of children when they were then aged 2 to 4
years. Therefore, this suggested that mothers who ate in response to external food cues also
reported that their child ate more when exposed to palatable foods at age 2 to 4 years, and
that this eating behaviour was maintained when the child was aged 4 to 6 years. The crosssectional support for this association at different ages is a new research finding and suggests
that these relationships continue to be observed as children move towards school years.
CHILD OVEREATING BEHAVIOURS
109
The hypothesized positive association between maternal emotional eating and child
emotional overeating was supported; however when it was entered into the regression model
it did not provide a unique contribution to child emotional eating. In contrast to the present
study, a unique contribution was found between maternal emotional eating and child
emotional eating in a sample of 2 to 4 year old children (Brozovic, 2009). On the other hand,
when this relationship was explored in a similarly aged sample (3 to 6 year olds) by Jahnke
and Warschburger (2008), an association was found in boys but not in girls. The transmission
of eating behaviours from parent to child is a relatively new research area and no unique
contribution found in this study might suggest that other factors are contributing to this
relationship. As previously noted, one mechanism that may influence the transmission of
eating behaviour from parent to child could be child feeding practices. Child feeding
practices were explored as a potential mediator between maternal eating and child eating in
Study 2. A summary of findings can be found in Chapter 8.
Instrumental feeding-behaviour was associated with child external eating and food
responsiveness. This result corresponded with that of past research reported by Carnell and
Wardle (2008a) who conducted a series of studies exploring associations between various
child feeding and child eating behaviours. Children may be learning, through modeling of
parental behaviours, to respond to cues other than appetite for eating. One example could be a
child who is given a chocolate bar for an achievement may learn to associate chocolate with
doing things well. Therefore, it seems plausible that through a positive association of pairing
food with a reward for a particular behaviour, then this behaviour is reinforced and the child
is likely to engage in this behaviour again in order to get the reward.
The finding that emotional feeding uniquely predicted emotional overeating is
consistent with past research by Brozovic (2009). While this feeding practice is used least
commonly, this finding suggests that when it occurs children may learn to associate food with
CHILD OVEREATING BEHAVIOURS
110
comfort. For example, if a child is given a sweet snack as a strategy to stop them from crying,
the child may learn to associate sweet snacks with comfort. Therefore, this can lead to food
consumption being associated with cues other than hunger. This finding is consistent with
research from this study’s cohort at aged 2 to 4 years (Brozovic, 2009). This demonstrated
that cross-sectional relationships between emotional feeding and child emotional overeating
are maintained at different ages including children at age 2 to 4 years, and again when the
child is aged 4 to 6 years. Whilst it is assumed that emotional feeding leads to greater
overeating in children, the cross-sectional nature of this study cannot infer causality.
Prospective research conducted in Study 3 will examine the predictive ability of emotional
feeding of 4 to 6 year old children that was assessed two years previously.
Instrumental feeding-behaviour and instrumental feeding-eating were both
significantly correlated with emotional overeating. However, the unique contributions of
these constructs were minor once they were included into a regression model with the other
feeding practices. Upon inspection of these variables, there is likely to be some overlapping
variability between instrumental feeding and emotional feeding. In light of the theory
underlying instrumental and emotional feeding, this may offer insight for understanding the
overlap between these constructs. That is, for each of these feeding practices food is
provided to the child for reasons other than hunger. Therefore, a food reward could
potentially be paired with negative behaviour or negative emotions. For example, an angry
child is offered their favourite food for calming down. This could be seen as a reward for
changing behaviour or a tool to comfort the child when distressed. In this instance, mothers
may reflect on a recent occasion when answering these questions and could potentially
answer according to their views of this being rewards based or comfort based that underlie
their motivation for providing food.
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111
The finding that restrictive feeding was positively associated with external eating is
consistent with laboratory findings by Fisher and Birch (1999), in which restriction was
associated with higher levels of snack food intake in children aged 3 to 5 years. Fisher and
Birch conducted laboratory research where children were given ten minutes of free access to
ten snack foods following a normal lunch. After this time children were then asked to rate the
extent to which their parents restrict access to the snack foods provided. Few studies have
replicated the proposed positive association between restricting access to high caloric snack
foods and concern for overconsumption of these foods when the child is not monitored by
their parents. It could be that parents are restricting access to these foods in response to their
child’s eating behaviour in an effort to moderate eating patterns. On the other hand, it could
be derived from mothers own difficulties regulating food, and therefore may become
particularly concerned about their child’s intake of energy dense foods (Fisher & Birch,
1999b). The cross-sectional nature of this study does not shed light on the direction of this
relationship. Findings may suggest that contrary to its appeal, restriction may not be effective
in discouraging the child’s preference for unhealthy foods. To help disentangle the direction
of this relationship restriction will be examined as a prospective predictor of external eating
in Study 3, Chapter 9.
Instrumental feeding-eating was not a significant predictor of any food approach
eating behaviours. As previously discussed, the context for this feeding practice is likely to be
confined to mealtimes and is more likely to be associated with undereating behaviours rather
than overeating behaviours. Nonetheless, this does not necessarily imply that this feeding
practice may not promote overeating over time. It could be that whilst providing dessert to
encourage healthy eating due to concerns of the child’s disinterest in healthy foods or a
general lack of interest in food might be effective in the short-term, it may have longer-term
implications on weight outcomes, particularly, as research has indicated that this strategy
CHILD OVEREATING BEHAVIOURS
112
appears to increase the child’s liking for the food that was given as a reward and decrease the
liking of the desired food (Newman & Taylor, 1992). Consequently, over time children’s
cues for eating may be refocused to aspects other than hunger, which could potentially lead to
eating in excess of what is physiologically required.
The second part of the hypothesis that explored predictors of food avoidance eating
styles was partially supported. Instrumental feeding-eating uniquely predicted slowness in
eating and pressure to eat uniquely predicted slowness in eating and food fussiness. The
finding that pressure to eat was uniquely associated with slower eaters and more fussiness is
consistent with several other studies (Farrow, Galloway & Fraser, 2009; McPhie et al., 2011;
Powell, Farrow & Meyer, 2011; Webber, et al., 2010a). On the other hand, the finding that
parents who perceive their child to be eating too slowly, and so are likely to be offered a food
reward (i.e., dessert) to encourage eating, is a new research finding and adds to the current
body of literature.
Predictors of Child BMI
The third hypothesis proposed that instrumental feeding-behaviour, emotional feeding
and restrictive feeding practices, and child food approach eating behaviours would be
positively associated with child BMI was not supported. Additionally, the secondary
hypothesis that proposed instrumental feeding-eating, pressure to eat, and food avoidant
eating styles would be negatively associated with child BMI was partially supported.
Instrumental and emotional feeding practices have been examined the least in the
literature in the context of overeating behaviours and the relationship to child weight status.
Although these feeding practices have been implicated in the development of obesity, there is
very little evidence in the literature to date that supports this proposed theory. Whilst no
significant positive associations have been found with instrumental feeding, a recent study by
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113
Carnell and Wardle (2007) showed that higher scores on the Pushing the Child to Eat More
subscale were inversely associated with child BMI. Greater inspection of the subscale items
indicated that many of these items were related to rewards for eating specific behaviours. As
noted, findings from the current research suggest that when instrumental feeding is separated
into two factors, instrumental feeding-eating may not promote overeating behaviours as first
proposed and is likely to be associated with under-eating behaviours and children of a lower
weight status. It could be possible that the effects of instrumental feeding-behaviours and
emotional feeding on child weight take more time to become apparent. Alternatively, the
proposed impact of these feeding practices may have a much less direct influence in the
development of obesity than has been proposed.
Additionally, restrictive feeding was also found to have no association with child BMI
in this study. This finding is in accordance with numerous other studies (e.g., Crouch, O’Dea,
& Battisti, 2007; Keller et al., 2006; Montgomery et al., 2006; Webber et al., 2010b). In the
instance where restrictive feeding has predicted higher BMI z-scores, it has been in samples
with children aged 5 years or older, or in laboratory studies where restriction has been
associated with eating in the absence of hunger and increased risk for overweight (Fisher &
Birch, 1999a; 2002). Previous researchers have concluded that higher restriction and excess
weight may depend on the child’s genetic vulnerability to overweight (Faith, Berkowitz, et
al., 2004) or it could simply be that eating when in an unrestricted environment (as found in
laboratory studies) occurs occasionally and therefore a continuous pattern of overeating does
not occur as the theory would suggest.
Alternatively, discrepancies could be related to the measurement of restriction. Items
on the restriction subscale of the Child Feeding Questionnaire (CFQ; Birch et al., 2001)
reflect general beliefs that access to various energy dense foods should be limited, as well as
concern that if their child was allowed access to these foods that they would be unable to
CHILD OVEREATING BEHAVIOURS
114
regulate their own intake, and would eat too much. It is possible that mothers use many
strategies to restrict access to certain foods, which has been noted in past research. Different
types of restriction or “control” have been reported. For example other types of restriction
include, denying second helpings, not bringing palatable foods into the home and telling
children that a particular food is off limits and only to be eaten on special occasions (Birch et
al., 2001). It could be that some of these restrictive feeding practices are of more detriment to
child overeating behaviours than others. Alternatively, given that restriction was associated
with child external eating but no association was found with BMI, this might suggest that
while children have a desire to eat these foods they may not be eaten in excess as it has been
assumed. By the age of 5 years children have many influences other than their parents to
learn about food and to provide them with information about healthy eating, including school
and the community.
The secondary hypothesis that pressure to eat would be negatively associated with
child BMI was not supported. No association was found between pressure to eat and child
BMI. This finding was in contrast to numerous studies that have supported an inverse
relationship between pressure to eat and child BMI (Birch et al., 2001; Powers et al., 2006;
Spruit-Metz et al., 2002). Previous research has tended to show that parents use this feeding
strategy for children of lower weight status to encourage eating (Carnell & Wardle, 2007;
Keller et al., 2006; Matheson et al., 2006). In particular, this result is in contrast to findings
by Gregory, Paxton and Brozovic (2010a) who examined the same cohort at aged 2 to 4
years. In their study, lower BMI predicted greater pressure to eat and this relationship was
mediated by maternal concern for underweight. The discrepancy in the research findings is
not clear, however it could be related to age. The younger age group (M = 3.3 years) is during
a time when many new foods are being introduced and parents may still be establishing meal
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115
routines; therefore mothers may have greater concern for children who are underweight
during this time.
The prediction that food approach child eating behaviours would be positively
associated with child BMI was not supported. This finding is in contrast to previous research
(Braet & Van Strien, 1997; Sleddens, Kremers & Thijs, 2008; Viana, Sinde & Saxton, 2008;
Webber et at., 2008). Emotional eating, food responsiveness, and external eating have been
implicated in the development of obesity. Whilst the stability of child eating behaviour has
been shown to be consistent from between the ages of 4 to 11 years (Ashcroft et al., 2008), it
could be possible that overeating behaviours take time to influence weight. However, given
that nearly a quarter of children in this sample were overweight/obese, it is suggestive that in
accordance with the model proposed by Davison and Birch (2001) childhood overweight is
likely to be a complex interplay of many risk factors from multiple contexts. It could be that
the impact of overeating may be found across time. Several studies have shown associations
with food approach eating behaviours and BMI in older children (Viana, Sinde, & Saxton,
2008; Webber et al., 2008) compared to a younger sample.
The second part of this hypothesis, that food avoidant child eating behaviours would
be associated with lower weight status, was partially supported. In particular, satiety
responsiveness and slowness in eating were negatively associated with lower BMI. No
association was found between food fussiness and child BMI. This indicates that children of
lower weight status are more able to stop eating in response to satiety and tended to eat to
more slowly during the course of a meal. This finding is similar to many recently published
studies, including research by Carnell and Wardle (2008b), Sleddens, Kremers and Thijs
(2008), Viana, Sinde, and Saxton (2008), and Webber and colleagues (2008). The finding of
no association between food fussiness and BMI parallels with findings by Sledden, Kremers
and Thijs (2008).
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116
In concluding, findings from this study demonstrated that mothers’ own eating and
feeding practices are associated with child eating behaviours but not child BMI in this sample
of 4 to 6 year olds. Specifically, mothers’ emotional eating was related to emotional feeding,
and maternal external eating was associated with child external eating. Additionally,
instrumental feeding-behaviour, emotional feeding and restriction were associated with child
overeating behaviours including emotional overeating, food responsiveness and external
eating. Whilst no evidence was found to support an association between child overeating
behaviours and child BMI in this sample, it is well recognised that persistent overeating can
lead to weight gain, and requires further investigation.
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117
CHAPTER 8: Study 2 - Mediation Models: Exploring Interrelationships between
Maternal Eating, Child Feeding, Child Eating and Child BMI
Introduction
Research has indicated a relationship exists between maternal eating and child eating
behaviours (Brozovic, 2009; Jahnke & Warschburger, 2008), whereby, a child is proposed to
eat in a similar way to their mother or primary care giver. Evidence from Study 1 supports
this theory. While cross-sectional relationships have been found between particular maternal
eating styles and child overeating behaviours, it is possible that other environmental factors
influence this relationship. It has been proposed that how a mother feeds her child may
mediate this relationship. Evidence from a recent Australian study of 2 to 4 year old children
supported this hypothesis. Cross-sectional research by Brozovic (2009) identified that
emotional feeding mediated the relationships between maternal emotional eating and child
emotional eating, and between maternal external eating and child eating behaviours (food
responsiveness and external eating).
Another aspect that has been considered more recently is the link between child
feeding practices and child BMI. Child feeding is thought to influence child eating and
weight. More recently however, Ventura and Birch (2008) argued that child eating
behaviours may mediate the relationship between child feeding practices and child weight.
Few studies to date have explored interrelationships between child feeding, child eating
behaviours and child weight. Earlier studies found a positive association between restriction,
eating in the absence of hunger and child weight (Birch, Fisher, & Davison, 2003; Fisher &
Birch, 1999b; Francis & Birch, 2005a). Other studies have found no association between
parental feeding (restriction and pressure to eat), child eating behaviours (subscales from
CEBQ), and child BMI (Gregory, Paxton, Brozovic, 2010a; McPhie et al., 2011). Moreover,
no associations have yet been found between either instrumental or emotional feeding and
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118
child BMI (Brozovic, 2009; Carnell & Wardle, 2007). Nonetheless, these two feeding
practices are suspected to be associated with development of overeating behaviours in
children. Both of these feeding practices are proposed to interfere with the child’s ability to
self-regulate food intake, in which children turn to environmental cues for hunger rather than
internal cues (Wardle et al., 2002).
Aims and Hypotheses
The aim of the study reported in this chapter was to explore interrelationships
between maternal eating styles, child feeding practices, child eating behaviours and child
BMI using mediation analysis. The following two pathways were hypothesised:
Hypothesis 1: Indirect relationships with food approach eating behaviours.
(1) That child feeding practices (emotional feeding, instrumental feeding-behaviour,
instrumental feeding-eating, and restriction) would mediate relationships between maternal
eating styles (emotional eating and external eating), and food approach child eating
behaviours (emotional overeating, food responsiveness and external eating).
Hypothesis 2: Indirect relationships with child BMI.
(1) That food approach child eating behaviours would mediate relationships between
child feeding practices and child BMI.
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119
Method
Participants
There were 138 mother-child dyads at Time 3. Participants included 73 male (53%)
and 64 (47%) female children. Mothers were aged 24 to 50 years old (M = 37.61, SD = 4.95)
and children were aged 4 to 6 years old (M = 5.30 years, SD = 0.81).
Measures
Participants received a questionnaire package, which included an information sheet, a
consent form, and measures to assess demographic characteristics, maternal eating style,
child feeding practices, and child eating behaviours. A full summary of all measures can be
found in the General Method section in Chapter 5.
Procedures
Ethics approval was obtained by the La Trobe University Human Ethics Committee
(Project Number: UHEC 07-064) to perform this research. A full summary of the procedure
can be found in the General Method section in Chapter 5.
Data analysis
A detailed summary of the data analysis procedures can be found in the General
Method section in Chapter 5. Data were screened to ensure all assumptions of normality,
linearity, and homoscedasticity were met. To test for mediation, hierarchical regression
analysis using a simple mediation model was performed to explore indirection associations
between proposed variables. The analytic strategy is described in further detail in the
following section.
Overview of analytic strategy.
To investigate mediation among the aforementioned variables, hierarchical regression
using a simple mediation model was performed. Utilising regression to test for mediation was
appropriate in this instance. If there is more than one mediator proposed for each model, then
CHILD OVEREATING BEHAVIOURS
120
path analysis using AMOS should be considered (Pallant, 2009). Mediation was conducted
according to Baron and Kenny (1986), who state that all variables must a have a significant
association for hierarchical regression to be conducted for mediation analysis. For example,
the predictor variable (IV) is associated with the mediator (pathway a), the mediator is
associated with the outcome variable (DV) (pathway b), and the predictor variable is
associated with the outcome variable in the absence of the mediator (pathway c) (see figure
7).
Mediator
(a)
Predictor Variable
(b)
(c)
Outcome Variable
Figure 7. The Proposed Mediation Model by Baron and Kenny (1986). Note: Dashed line
indicates the indirect association being examined.
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121
Results
Associations between variables
Presented in Table 24 is a summary of zero order correlations from univariate
analyses for relationships between maternal eating, child feeding practices, and child eating
behaviours, for which significant associations (p = < .05) for all three pathways, (a), (b), and
(c) were revealed. Of particular interest were the outcome variables of child eating
behaviours, including emotional overeating, food responsiveness and external eating, and
child BMI. Notably, no associations were found between child feeding practices and child
BMI, or child eating behaviours and child BMI; therefore no mediation analyses were able to
be conducted with the outcome measure of child BMI. Furthermore, as no maternal eating
styles were associated with instrumental feeding-eating, this variable was also excluded from
further analyses.
For each predictor variable a two-step hierarchical regression analysis was performed.
In Step 1 the predictor variable and control variables were entered. This included child age,
child gender, and maternal BMI. At step 2, the proposed mediating variable was entered.
According to Preacher and Hayes (2008), for mediation, the following must occur: (a) the
predictor variable has a significant beta at Step 1, (b) the mediator has a significant beta at
Step 2, and (c) if the beta value for the predictor variable is reduced but remains significant
after the inclusion of the mediator at Step 2, then there is evidence for partial mediation. On
the other hand, if the beta value for the predictor variable is no longer significant after the
inclusion of the mediator, then it is full mediation. In other words, the predictor variable (IV)
affects the outcome variable (DV) indirectly. Thus, the predictor variable is causing an effect
through other intervening variables, or mediator (Preacher & Hayes, 2008).
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122
Table 24
Means, Standard Deviations, and Zero-order Correlations of all Proposed Variables for Mediation Models (N =138)
1
2
3
4
5
6
7
8
9
10
1. Maternal emotional eating
-
2. Maternal external eating
.52**
-
3. Emotional Feeding1
.28**
.27**
-
4. Instrumental feeding-behaviour
.18*
.19*
.67**
-
5. Instrumental feeding-eating
.01
.02
.36**
.56**
-
6. Restriction
.22*
.20*
.14
.07
.06
-
7. Child Emotional Overeating
.30*
.22*
.56**
.37**
.20*
.18*
-
8. Child Food Responsiveness
.12
.23**
.38**
.37**
.16
.15
.60**
-
9. Child External Eating
.19*
.43**
.34**
.34**
.13
.34**
.47**
.54**
-
10. Child BMI
.09
-.08
.01
-.11
-.14
.05
.02
.04
.03
-
Mean (SD)
2.45
2.86
1.59
2.24
2.41
2.67
1.91
2.49
3.07
-
(.95)
(.52)
(.52)
(.79)
(.77)
(.53)
(.62)
(.66)
(.49)
Note: * p< .05, ** p < .01; 1Square root Transformation
CHILD OVEREATING BEHAVIOURS
123
Child Feeding as a Mediator between Maternal Eating and Child Eating
Predictors of child emotional overeating.
The following models examined child feeding practices as a mediator between
maternal emotional eating and child emotional overeating. In particular, instrumental feedingbehaviour and emotional feeding were explored as potential mediators.
The first model explored instrumental feeding-behaviour as a potential mediator
between maternal emotional eating and child emotional eating. As shown in Table 25, at Step
1 maternal emotional eating accounted for 12% of the variance in child emotional overeating,
F(4, 128) = 4.38, p < .001. The beta value for maternal emotional eating and maternal BMI
were significant. At Step 2, instrumental feeding-behaviour was added as a mediator and
revealed a significant association with child emotional overeating beyond that offered by
maternal emotional eating, R squared change = .09, F(5, 127) = 6.59, p < .001. The total
variance explained by the model was 20.6%. The beta value for instrumental feedingbehaviour (the mediator) was significant. When instrumental feeding-behaviour was entered
at Step 2, the beta value for maternal eating reduced but remained significant (β = .30, p <
.001), indicating a partial mediation. The pattern of mediation is demonstrated in Figure 8.
CHILD OVEREATING BEHAVIOURS
124
Table 25
Summary of Mediation Model for Maternal Emotional Eating, Instrumental Feedingbehaviour and Child Emotional Overeating (N = 138).
Variable
B
SE B
β
Step 1
ΔR2
.12**
Child Age
.13
.24
.05
Child Gender
-.22
.41
-.05
Maternal BMI1
-5.58
2.87
-.19*
.08
.02
.39**
Maternal Emotional Eating
Step 2
.09**
Child Age
Child Gender
.11
.23
.04
.03
.40
.01
1
-3.51
2.79
-.12
Maternal Emotional Eating
.06
.02
.30**
Instrumental Feeding-behaviour
.14
.04
.31**
Maternal BMI
*p<.05; **p<.01; 1Logarithm Transformation
Instrumental Feeding-behaviour
.18*
Maternal Emotional Eating
.37**
.30** (.39**)
Child Emotional overeating
*p<.05; **p<.01
Figure 8. Mediation Model of Instrumental Feeding-behaviour as a Mediator between
Maternal Emotional Eating and Child Emotional Overeating
The next model explored emotional feeding as a mediator. As shown in Table 26, at
Step 1 maternal emotional eating accounted for 12% of the variance in child emotional
overeating, F(4, 128) = 4.38, p < .001. The beta value for maternal emotional eating and
maternal BMI was significant. At Step 2, emotional feeding was added as a mediator and
revealed a significant association with child emotional overeating beyond that offered by
CHILD OVEREATING BEHAVIOURS
125
maternal emotional eating, R squared change = .22, F (5, 127) = 13.10, p < .001. The total
variance explained by the model was 33.9%. The coefficient for emotional feeding (the
mediator) was significant. When emotional feeding was entered at Step 2, the beta value for
maternal emotional eating reduced but remained significant (β = 21, p = .02), indicating
partial mediation. The pattern of mediation is demonstrated in Figure 9.
Table 26
Summary of Mediation Model for Maternal Emotional Eating, Emotional Feeding and Child
Emotional Overeating (N = 138).
Variable
B
SE B
β
Step 1
ΔR2
.12**
Child Age
.13
.24
.05
Child Gender
-.22
.41
-.05
Maternal BMI1
-5.88
2.87
-.18*
.08
.02
.39**
Maternal Emotional Eating
Step 2
.22**
Child Age
.10
.21
.03
Child Gender
.06
.36
.01
-2.59
2.53
-.09
Maternal Emotional Eating
.04
.02
.21*
Emotional Feeding2
2.50
.39
.50**
Maternal BMI1
1
2
*p<.05; **p<.01; Logarithm Transformation; Square root Transformation
CHILD OVEREATING BEHAVIOURS
126
Emotional Feeding1
.28**
Maternal Emotional Eating
.56**
.21* (.39**) Child Emotional overeating
*p<.05; **p<.01; 1Square root Transformation
Figure 9. Mediation Model of Emotional Feeding as a Mediator between Maternal Emotional
Eating and Child Emotional Overeating
Predictors of child food responsiveness.
The following mediation models related to the relationship between maternal external
eating and child food responsiveness. Instrumental feeding-behaviour and emotional feeding
were explored as potential mediators in this relationship. Similarly, the same two-step model
was utilised, with the control variables of child age, child gender and maternal BMI and
maternal external eating being entered at Step 1, and the mediating variable being entered at
Step 2.
Demonstrated in Table 27 are summary statistics for instrumental feeding-behaviour
as a possible mediator between maternal external eating and child food responsiveness. At
Step 1 maternal external eating accounted for 7.3% of the variance in child food
responsiveness, F(4, 128) = 2.53, p = .04. The coefficient for maternal external eating was
significant. At Step 2, instrumental feeding-behaviour was added as a mediator and revealed
a significant association with child food responsiveness beyond that offered by maternal
external eating, R squared change = .10, F (5, 127) = 5.36, p < .001. The total variance
explained by the model was 17.4%. The beta value for instrumental feeding-behaviour (the
mediator) was significant. When instrumental feeding-behaviour was entered at Step 2, the
beta value for maternal external eating reduced but remained significant (β = .20, p = .02),
indicating a partial mediation. The pattern of mediation is demonstrated in Figure 10.
CHILD OVEREATING BEHAVIOURS
127
Table 27
Summary of Mediation Model for Maternal External Eating, Instrumental Feeding-behaviour
and Child Food Responsiveness (N = 138).
Variable
B
β
SE B
Step 1
ΔR2
.07*
Child Age
.32
.33
.08
-.03
.57
-.00
-5.18
3.52
-.13
.17
.06
.26**
Child Gender
1
Maternal BMI
Maternal External Eating
Step 2
.10**
Child Age
.24
.32
.06
.33
.55
.05
-3.32
3.37
-.08
Maternal External Eating
.13
.06
.20*
Instrumental Feeding-behaviour
.20
.05
.33**
Child Gender
1
Maternal BMI
*p<.05; **p<.01; 1Logarithm Transformation
Instrumental Feeding-behaviour
.19*
Maternal External Eating
.37**
.20* (.26**)
Child Food Responsiveness
*p<.05; **p<.01
Figure 10. Mediation Model of Instrumental Feeding-behaviour as a Mediator between
Maternal External Eating and Child Food Responsiveness
The second model explored emotional feeding as a mediator between maternal
external eating and child food responsiveness. As shown in Table 28, at Step 1 it was
revealed that maternal external eating was significant and accounted for 7.3% of the variance
in child external eating, F(4, 128) = 2.52, p = .04. Following the inclusion of emotional
CHILD OVEREATING BEHAVIOURS
128
feeding (the mediator) at Step 2, a significant association was found, R squared change =
.099, F(5, 127) = 5.28, p < .001. The total model accounted for 17.2% of the variance and
showed that maternal external eating reduced but remained significant (β = 17, p = .05),
therefore demonstrating partial mediation. Figure 11 shows this pattern of mediation.
Table 28
Summary of Mediation Model for Maternal External Eating, Emotional Feeding and Child
Food Responsiveness (N = 138).
Variable
B
SE B
β
Step 1
ΔR2
.07*
Child Age
.32
.33
.08
Child Gender
-.03
.57
-.01
Maternal BMI1
-5.18
3.52
-.13
.17
.06
.27**
Maternal External Eating
Step 2
.10**
Child Age
.24
.32
.06
Child Gender
.21
.54
.03
-3.99
3.36
-.10
Maternal External Eating
.11
.06
.17*
Emotional Feeding2
2.2
.57
.33**
Maternal BMI1
*p<.05; **p<.01; 1Logarithm Transformation; 2Square root Transformation
Emotional Feeding1
.27**
Maternal External Eating
.38**
.17* (.27**) Child Food Responsiveness
*p<.05; **p<.01; 1Square root Transformation
Figure 11. Mediation Model of Emotional Feeding as a Mediator between Maternal External
Eating and Child Food Responsiveness
CHILD OVEREATING BEHAVIOURS
129
Predictors of child external eating.
The following mediation models related to the relationship between maternal external
eating and child external eating. For these models emotional feeding and instrumental
feeding-behaviour, as well as restriction were explored as potential mediators. These models
were examined separately. The same two-step model was utilised, with the control variables
of child age, child gender and maternal BMI, and maternal external eating entered at Step 1,
and the mediating variable entered at Step 2.
In the first model it was predicted that instrumental feeding-behaviour would mediate
the relationship between maternal external eating and child external eating. As shown in
Table 29, at Step 1 maternal external eating accounted for 22.5% of the variance in child
external eating, F(4, 128) = 9.30, p < .001. The coefficient for maternal external eating was
significant. At Step 2, instrumental feeding-behaviour was added as a mediator and revealed
a significant association with child emotional overeating beyond that offered by maternal
external eating, R squared change = .062, F(5, 127) = 10.22, p < .001. The total variance
explained by the model was 28.7%.The beta value for instrumental feeding-behaviour (the
mediator) was significant. When instrumental feeding-behaviour was entered at Step 2, the
beta value for maternal external eating reduced but remained significant (β = .43, p < .001)
indicating a partial mediation. The pattern of mediation is demonstrated in Figure 12.
CHILD OVEREATING BEHAVIOURS
130
Table 29
Summary of Mediation Model for Maternal External Eating, Instrumental Feeding-behaviour
and Child External Eating (N = 138).
Variable
B
SE B
β
Step 1
ΔR2
.23**
Child Age
.78
.46
.13
.48
.78
.05
-8.78
4.84
-.15
.46
.08
.48**
Child Gender
1
Maternal BMI
Maternal External Eating
Step 2
.06**
Child Age
.69
.44
.12
.91
.76
.09
-6.61
4.70
-.11
Maternal External Eating
.41
.08
.43**
Instrumental Feeding-behaviour
.23
.07
.26**
Child Gender
1
Maternal BMI
*p<.05; **p<.01; 1Logarithm Transformation
Instrumental Feeding-behaviour
.19*
Maternal External Eating
.34**
.43** (.48**)
Child External Eating
*p<.05; **p<.01
Figure 12. Mediation Model of Instrumental Feeding-behaviour as a Mediator between
Maternal External Eating and Child External Eating
Displayed in Table 30 are summary statistics for emotional feeding included as a
mediator between maternal external eating and child external eating. At Step 1, it was
revealed that maternal external eating was significant and accounted for 22.5% of the
variance in child external eating, F(4, 128) = 9.30, p < .001. Emotional feeding was included
into the model at Step 2 and was shown to have a significant association with child external
CHILD OVEREATING BEHAVIOURS
131
eating, R squared change = .047, F(5, 127) = 9.51, p < .001. The model as a whole accounted
for 27.2% of the variance in child external eating. Emotional feeding (the mediator) was
significant, and maternal external eating also was significant at Step 2 (β = .42, p < .001),
suggesting that partial mediation occurred. Figure 13 demonstrates the mediation pattern.
Table 30
Summary of Mediation Model for Maternal External Eating, Emotional Feeding and Child
External Eating (N = 138).
Variable
B
SE B
β
Step 1
ΔR2
.23**
Child Age
.78
.46
.13
Child Gender
.48
.78
.05
-8.78
4.84
-.15
.46
.08
.48**
Maternal BMI1
Maternal External Eating
Step 2
.05**
Child Age
.69
.45
.12
Child Gender
.74
.76
.08
-7.56
4.72
-.13
Maternal External Eating
.40
.08
.42**
Emotional Feeding2
2.30
.80
.23**
Maternal BMI1
*p<.05; **p<.01; 1Logarithm Transformation; 2Square root Transformation
Emotional Feeding1
.27**
Maternal External Eating
.34**
.42* (.48**) Child External Eating
*p<.05; **p<.01; 1Square root Transformation
Figure 13. Mediation Model of Emotional Feeding as a Mediator between Maternal External
Eating and Child External Eating
CHILD OVEREATING BEHAVIOURS
132
In the final model it was hypothesised that restriction would mediate the relationship
between maternal external eating and child external eating. As shown in Table 31, at Step 1
maternal external eating accounted for 22.5% of the variance in child external eating, F(4,
128) = 9.30, p < .001. The coefficient for maternal external eating was significant. At Step 2,
restriction was added as a mediator and revealed a significant association with child external
eating beyond that offered by maternal external eating, R squared change = .063, F(5, 127) =
10.28, p < .001. The total variance explained by the model was 28.8%. The beta value for
restriction (mediator) was significant. When restriction was entered at Step 2, the beta value
for maternal external eating reduced but remained significant (β = .43, p < .001), indicating a
partial mediation. The pattern of mediation is demonstrated in Figure 14.
Table 31
Summary of Mediation Model for Maternal External Eating, Restriction and Child External
Eating (N = 138).
Variable
B
SE B
β
Step 1
ΔR2
.23**
Child Age
.78
.46
.13
.48
.78
.05
-8.78
4.84
-.15
.46
.08
.48**
Child Gender
1
Maternal BMI
Maternal External Eating
Step 2
.06**
Child Age
.64
.44
.11
Child Gender
.64
.75
.07
-8.78
4.65
-.15
Maternal External Eating
.41
.08
.43**
Restriction
.40
.12
.26**
Maternal BMI1
*p<.05; **p<.01; 1Logarithm Transformation
CHILD OVEREATING BEHAVIOURS
133
Restriction
.20*
Maternal External Eating
.34**
.43** (.48**)
Child External Eating
*p<.05; **p<.01
Figure 14. Mediation Model of Restriction as a Mediator between Maternal External Eating
and Child External Eating
Discussion
The primary aim of this chapter was to explore interrelationships between maternal
eating, child feeding practices, child eating behaviours and child BMI. The hypothesis that
child feeding practices would mediate the relationship between maternal eating and child
eating behaviours was supported. On the other hand, the proposed mediation of child eating
behaviours between child feeding practices and child BMI could not be tested. Neither child
feeding nor child eating variables were correlated with child BMI to enable mediation
analyses.
All of the proposed models between maternal eating and child eating were partially
mediated by child feeding practices. The finding that emotional feeding partially mediated
the relationship between maternal emotional eating and child emotional eating, and the
relationship between maternal external eating and child food responsiveness and external
eating are consistent with that of Brozovic (2009) who examined the same cohort of children
from The Child and Family Health Study at aged 2 to 4 years. Additionally, this research
found that instrumental feeding-behaviour partially mediated the relationship between
maternal emotional and external eating and all of the proposed child overeating behaviours.
Additionally it was found that restriction partially mediated the relationship between maternal
external eating and child external eating. This is a new research finding and adds to the
CHILD OVEREATING BEHAVIOURS
134
current body of literature of potentially modifiable risk factors for the development of child
overeating behaviours.
These findings suggest that mothers who eat in response to their feelings or who eat in
response to external triggers also feed their child/ren in a similar way and this in turn is
associated with increased overeating behaviours. Partial mediation implies that children may
begin to learn ways of eating directly through their mother, perhaps beginning from toddler
years, and that one aspect that contributes to this relationship is the way she feeds her child.
In this instance, emotional feeding appears to have a large role in the development of
emotional overeating and accounted for 22% of the variance compared to 9% that was
contributed by instrumental feeding-behaviour. With respect to the relationship between
maternal external eating and child external eating, the initial step accounted for 22.5% of the
variance. With the addition of instrumental feeding-behaviour and restriction, a further 6%
was contributed to the model. In the absence of other research to compare findings, this could
be interpreted as meaning that the transmission of external eating from mother to child is
influenced more by factors other than child feeding practices. The group of children in this
sample were aged 4 to 6 years and are on the cusp between preschool and primary school. It
is therefore likely that at this age children begin to have greater autonomy in eating, and their
food choices are influenced by many environmental factors in addition to their parents. These
influences may include peer groups, advertising, teachers, and so forth.
Overall, these findings suggest that maternal eating and child feeding practices can be
areas targeted in prevention as they both contribute to increased overeating behaviours in
children. Specifically, children appear to learn these behaviours both directly from their
mothers through modelling and through feeding practices related to using food as rewards or
for comfort. Therefore, prevention strategies could aim to educate parents to set up healthy
eating practices from early childhood. Furthermore, parents should be encouraged to use
CHILD OVEREATING BEHAVIOURS
135
alternative strategies to reward behaviour or to comfort their child, such as praise or physical
affection. A detailed discussion of the practical implication of these findings will be
addressed in the General Discussion, in Chapter 10.
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136
CHAPTER 9: Study 3 - Longitudinal Investigation of Relationships between Maternal
Eating, Child Feeding, Child Eating and Child BMI in Young Children
Introduction
Child feeding practices have received increased attention over the past decade as
potential risk factors for child overeating behaviours and overweight. It is proposed that some
child feeding practices interfere with the child’s ability to self-regulate energy intake by
affecting the development of appetite (Carnell & Wardle, 2008a). Nonetheless, research
findings have been inconsistent, particularly relating to the direction of this relationship.
Instrumental feeding and emotional feeding practices have been examined in
association with overeating behaviours in young children. In these feeding strategies, food is
provided to the child to reward good behaviour or to comfort and alleviate negative emotion.
Therefore, the theory concludes that the child learns to eat in response to cues other than
appetite, and thereby potentially consumes more food than required. These feeding styles
have been examined in a small number of cross-sectional studies with mixed findings. Some
studies have found an association with overeating behaviours (Baughcum et al., 2001; Carnell
& Wardle, 2008b); however no studies have examined this relationship with child BMI. The
nature of this relationship is not well understood. Whilst the theory would suggest that nonnutritious feeding is associated with appetitive traits, such as emotional eating, high
responsiveness to food cues and external eating, and are related to increases in child
adiposity, there is limited evidence to date that supports this theory. Longitudinal studies are
needed to confirm if emotional and instrumental feeding are prospective predictors of
overeating behaviours and increased BMI in young children.
Restriction has received more attention in relation to overeating behaviours and child
BMI. Cross-sectional studies have found a positive association between restriction and food
overeating behaviours and overweight (Birch et al., 2001; Francis, Hofer, & Birch, 2001;
CHILD OVEREATING BEHAVIOURS
137
Robinson et al., 2001), whilst other studies have found no association (Crouch, O’Dea &
Battisti, 2007; Saelens, Ernst & Epstein, 2000). The nature of this relationship is not clear, as
it is difficult to conclude whether parents use restrictive strategies in response to the child’s
weight, or whether parents’ use of restriction is causing increased food consumption (Fisher
& Birch, 1999b). Longitudinal research has found baseline restriction to be associated with
eating in the absence of hunger (EAH), and higher BMI in 5-year old children (Birch, Fisher
& Davison, 2003), and with lower BMI at three year follow-up in an Australian sample of
children aged 5 to 6 years old (Campbell et al., 2010). Appropriately designed longitudinal
research exploring prospective predictors of child over eating behaviours may offer further
insights into the direction of relationships amongst these variables.
Cross-sectional data in Study 1 were consistent with previous research and found that
instrumental feeding-behaviour, emotional feeding, and restriction were significantly
associated with food approach eating behaviours including emotional eating, food
responsiveness and external eating. Using a longitudinal design would provide insight into
prospective predictors of these eating behaviours. Specifically, whether child feeding
practices prospectively predict child eating behaviours and child BMI, or if child BMI and
child eating behaviours prospectively predict child feeding practices. Lastly, findings from
Study 1 showed that maternal emotional and external eating, but not restrained eating, were
associated with food approach eating behaviours. This finding is consistent with past research
that showed a relationship between a mother’s own eating style and her child’s eating
behaviour (Jahnke & Warschburger, 2008). Given that cross-sectional analyses in Study 1
indicated that maternal restrained eating was not significantly associated to any child feeding
practices or child eating behaviours, this variable was not included in the longitudinal followup.
CHILD OVEREATING BEHAVIOURS
138
Aims and Hypotheses
The primary focus of Study 3 was to explore prospective predictors of child eating
behaviours, particularly examining overeating behaviours including emotional eating, food
responsiveness and external eating, and child BMI at two year follow-up. Prospective
predictors included maternal eating styles (emotional and external eating) and child feeding
practices (instrumental feeding, emotional feeding, and restriction) examined two years
previously. Cross-sectional data from Study 1 as well as data obtained two years previously
in the Child and Family Health Study were included.
Based on previous research, the following hypotheses were proposed:
Hypothesis 1: Prospective predictors of Time 3 child eating behaviours.
(1) It was hypothesised that Time 1 maternal eating styles (emotional eating and
external eating) would predict an increase in Time 3 food approach child eating behaviours
(emotional overeating, food responsiveness and external eating); and (2) that Time 1 child
feeding practices (instrumental feeding- behaviour, instrumental feeding-eating, emotional
feeding, and restriction) would predict an increase in Time 3 food approach child eating
behaviours.
Hypothesis 2: Prospective predictors of Time 3 child BMI.
(1) It was hypothesised that Time 1 child feeding practices would predict an increase
in Time 3 child BMI-for-age z-scores.
Hypothesis 3: Prospective predictors of Time 3 child feeding practices.
(2) It was hypothesised that Time 1 food approach child eating behaviours and BMIfor-age z-score would predict an increase in Time 3 child feeding practices.
CHILD OVEREATING BEHAVIOURS
139
Method
Participants
The Child and Family Health Study recruited 184 mothers and their children aged 2 to
4 years old (M = 3.28 years, SD = 0.84) at Time 1. This included 87 male children and 97
female children. The same mother-child dyads were contacted two years following the initial
data collection and were invited to participate in the research again. The final sample
consisted of 138 participants (M = 5.30 years, SD = 0.81). This represented a 75% response
rate at two year follow-up. Participants who completed questionnaires at both Time 1 and
Time 3 were included in the present study.
Attrition
Of the 46 participants (25%) who did not return their questionnaire, some were not
able to be contacted due to change of contact details (address and/or phone number) and
others were lost at follow-up due to other reasons (e.g., lack of time, personal circumstances).
The full questionnaire package was lengthy, requiring approximately 30-40 minutes to
complete and may have been too demanding for some mothers.
The sample was examined to identify baseline differences between mothers who
completed the questionnaire at both Time 1 and Time 3 to those who withdrew after Time 1.
Using a series of independent samples t-tests, demographic variables were explored,
including marital status, maternal and paternal education, maternal and paternal employment,
and family income. No significant differences were found between mothers who completed
both time points and those mothers who withdrew after Time 1. Additionally, differences
between these groups on Time 1 child BMI z-scores, maternal BMI, child feeding, child
eating, and maternal eating were examined. Independent samples t-tests revealed a significant
difference for child BMI z-score. A significantly higher child BMI z-score was revealed for
mothers who completed Time 1 and Time 3 questionnaires (M = .44, SD = 1.23) than for
CHILD OVEREATING BEHAVIOURS
140
mothers who only completed Time 1 questionnaires (M = -.21, SD = 1.31); t (140) = -2.66, p
= .009 (two tailed). The extent of the difference was small (η2 = .042).
Measures
A summary of the psychometric properties of the major study variables can be found
in the General Method section in Chapter 5. The same questionnaire package was
administered at both time points. Internal reliability was calculated using Cronbach’s alpha.
Each of the measures was shown to be relatively stable at two year follow-up, with
acceptable levels of reliability found for most subscales (see Appendix D3). Maternal eating
styles ranged from .83 to .96; child feeding practices ranged from .74 to 94; and child eating
behaviours ranged from .59 to .91.
Procedure
Ethics approval was received from the Latrobe University Human Ethic Committee
(Project Number: UHEC 07-064) to conduct longitudinal research. Refer to the General
Method section for a detailed description of the procedure for this study.
Data analysis
A detailed summary of the data analyses procedures can be found in the General
Method section in Chapter 5. The dependent variables were measures of Time 3 child eating
behaviours (hypothesis 1), child BMI (hypothesis 2), and child feeding practices (hypothesis
3). The independent variables were measures of Time 1 maternal eating styles (hypothesis 1),
child feeding practices (hypothesis 1 and 2), and child BMI (hypothesis 3).
Descriptive information related to child and maternal BMI is reported. Pearson’s
product moment correlations and paired samples t tests were utilised to measure the stability
of variables across time. The same variable was correlated at different time points and then
examined to see if there was a significant difference between the subscale scores. Cross lag
correlations were used to identify bivariate associations between Time 1 predictors and Time
CHILD OVEREATING BEHAVIOURS
141
3 outcomes variables. Finally, to examine the predictive contribution of Time 1 variables on
Time 3 outcome variables, a series of multiple-regression models were utilised.
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142
Results
Descriptive Data
Data screening.
All Time 1 data were screened for errors and missing items. Several missing items
were identified across all measures. In this instance, the missing items were replaced with the
mean value of the other items in the subscale. For child BMI there were 33 participants
(24%) at Time 1, and 12 participants (9%) at Time 3 with either missing child height and/or
child weight, and thus were excluded from analysis involving those measures. Overall, 100
participants had complete child BMI data across Time 1 and Time 3. In regards to maternal
BMI, there were 16 participants (12%) at Time 1, and four participants (3%) at Time 3 with
either missing height and/or weight data, and thus were excluded from analysis involving
those measures. In total, 120 mothers had complete height and weight data across Time 1 and
Time 3.
Assumptions for parametric tests on Time 1 variables.
All Time 1 data were screened for normality, linearity, and homoscedasticity. By
using skewness and kurtosis as a measure of normality, in which > 3.30 indicates skewed
data, inspection of the scales revealed indicated that child BMI z-scores, maternal BMI, and
emotional feeding departed from normality. In these cases, the same transformations
performed for Time 3 variables in Study 1 were performed for Time 1 variables, which
improved the distribution.
Child BMI z-scores were negatively skewed with two extreme outliers revealed.
Using criteria recommended by Tabachick and Fidell (2007), these two items were replaced
with the next most extreme value. After addressing these outliers child BMI z-scores were no
longer skewed. Maternal BMI was slightly positively skewed but met assumptions following
a logarithm transformation. Furthermore, emotional feeding was positively skewed and met
CHILD OVEREATING BEHAVIOURS
143
assumptions following a square root transformation. The transformed variables were used in
subsequent analyses.
Gender differences in Time 1 child feeding and child eating measures.
To determine if any gender differences were found between male and female children
at Time 1, independent samples t-tests were performed on all measures. No significant gender
differences emerged.
Differences in Time 1 overweight and non-overweight children.
Independent samples t-tests were performed to examine if any differences emerged in
eating behaviours for overweight and non-overweight children at Time 1. No significant
differences emerged.
Stability and change in BMI, feeding and eating variables.
To assess the stability of child feeding and eating variables across time (from Time 1
to Time 3) Pearson’s product moment correlations were utilised. Child eating and maternal
eating variables were significantly correlated across time and revealed moderate correlations.
Pearson’s r ranged from .44 to .66 for child eating, and .69 to .80 for the maternal eating
variables.
For child feeding practices, Pearson’s r ranged from .35 to .73. Restriction was not
found to be significantly correlated across time. Exploration of the scatter between Time 1
restriction and Time 3 restriction revealed that 18% of the sample was more restrictive, 4%
had no change, and 78% were less restrictive. This pattern of change is not entirely clear but
suggested a less cautious and protective feeding style was exhibited by parents from preschool to school-age children.
The pattern of change in child BMI z-scores for age and gender is demonstrated in
Figure 15. As can be seen, the proportion of overweight and obese children has slightly
declined from Time 1 to Time 3. At Time 1, when children were aged 2 to 4 years old,
CHILD OVEREATING BEHAVIOURS
144
20.94% of the sample were classified as overweight or obese (M = .39, SD = 1.16). At twoyear follow-up, when children were aged 4 to 6 years old, 19.83% of the sample were
overweight or obese (M = .21, SD = 1.30). The proportion of overweight and obese children
in this study is lower than the national proportions. The 2007 Australian National Children’s
Nutrition and Physical Activity Survey (DoHA) found that 23% of children aged between 2
to 16 years old were overweight and obese.
16
15.23
14.28
14
Percentage %
12
10
Overweight
8
6
5.71
5.55
Obese
4
2
0
Time 1 (N = 105)
Time 3 (N = 126)
Figure 15. Proportion (%) of Children Classified as Overweight and Obese using the IOFT
Age and Gender-Specific Cut-offs (Cole et al., 2000; Cole et al., 2007) for Time 1 and Time
3 (n = 100).
The proportion of maternal BMI weight categories is demonstrated in Figure 16. As
can be seen, mother’s weight appeared to remain relatively stable across time, with 48.79%
of the sample who were overweight and obese at Time 1, and 47.76% of the sample who
were overweight and obese at Time 3. Although it is striking that almost half the sample are
overweight or obese, this is lower than the national overweight/obese proportion in Australia.
CHILD OVEREATING BEHAVIOURS
145
The Australian Bureau of Statistics (ABS) reported that in 2007-2008, 55% of women were
overweight or obese (ABS, 2010).
60
48.79 49.25
50
Percentages
40
31.92 32.09
Time 1
30
Time 3
20
16.87 15.67
10
2.4 2.98
0
Underweight
Normal
Overweight
Obese
Figure 16. Proportion (%) of mothers classified as underweight (BMI <18.5kg/m2), normal
(BMI ≥18.5 to <25 kg/m2), overweight (BMI ≥ 25 to < 30kg/m2), and obese (BMI ≥ 30
kg/m2) according to WHO weight categories for Time 1 and Time 3 (n = 120).
To evaluate if there was a significant difference in the pattern of change from Time 1
to Time 3 in BMI, maternal eating styles, child feeding practices, and child eating behaviours,
paired samples t-tests were conducted. As shown in Table 32, there was a statistically
significant decrease in child BMI-for-age z-scores, maternal emotional eating, and restriction
from Time 1 to Time 3. The effect sizes ranged from small to large. Notably, the magnitude
of difference for child BMI-for-age z-scores and restriction were large, indicating 85% and
44% of the variance was explained by age, respectively. Conversely, there was a statistically
significant increase in instrumental feeding-eating and emotional overeating from Time 1 to
Time 3. The effect sizes ranged from small to large.
CHILD OVEREATING BEHAVIOURS
146
Table 32
Paired Samples t-tests for Child and Maternal BMI, Maternal Eating Styles, Child Feeding Practices and Child Eating Behaviours from Time 1
to Time 3 (N = 138)
Variable
Time 1
Time 3
t(137)
M
SD
M
SD
.39
1.16
.21
1.30
2.45
25.54
4.87
25.48
5.14
Maternal Emotional Eating
2.54
1.03
2.43
Maternal External Eating
2.93
.57
Instrumental (Behaviour)
2.27
Instrumental (Eating)
p
η2
95% CI
Upper
Lower
.016
.06
.61
.85
.47
.641
-.01
.01
-
.97
2.22
.028
.17
2.99
.03
2.86
.52
1.41
.161
-.20
1.19
-
.83
2.23
.79
.62
.539
-.56
1.07
-
2.17
.81
2.41
.77
-3.77
.000
-1.50
-.47
.09
Emotional Feeding1
1.58
.53
1.59
.52
-.28
.778
-.07
.05
-
Restriction
3.56
.94
2.67
.53
10.28
.000
4.30
6.35
.44
Emotional Overeating
1.79
.61
1.91
.79
-2.69
.008
-.83
-.13
.05
Food Responsiveness
2.46
.72
2.49
.66
-.76
.451
-.68
.30
-
Child External Eating
3.15
.54
3.07
.49
1.84
.068
-.06
1.61
-
Child BMI z score (n = 100)
1
Maternal BMI (n = 120)
Maternal Eating Styles
Child Feeding Practices
Child Eating Behaviours
1
Untransformed variable; Note: η Eta Squared
2
CHILD OVEREATING BEHAVIOUR
147
Cross Lag Associations between Time 1 Predictors of Time 3 Outcome Variables
The first set of hypotheses examined Time 1 maternal eating and child feeding
practices as predictors of Time 3 child eating behaviours. Inspection of the data revealed
several significant associations. As shown in Table 33, maternal emotional eating was
significantly associated with child emotional overeating, and maternal external eating was
associated with all food approach child eating behaviours, including emotional overeating,
food responsiveness and external eating. Additionally, Time 1 instrumental feedingbehaviour, emotional feeding, and restriction were also associated with all food approach
child eating behaviours. Time 1 instrumental feeding-eating was positively associated with
external eating only.
The second hypothesis examined Time 1 instrumental feeding-behaviour,
instrumental feeding-eating, emotional feeding and restriction as predictors of Time 3 child
BMI-for-age z-scores (see Table 33). Contrary to previous research, no Time 1 child feeding
practices were associated with Time 3 child BMI-for-age z-scores. Therefore no multivariate
analysis were undertaken to test this hypothesis.
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148
Table 33
Cross Lag Correlations between Time 1 Maternal Eating Styles and Child Feeding Practices
and Time 3 Child Eating Behaviours and Child BMI-for-age z-scores (N = 138)
Time 3 Child Eating Behaviours
Time 3
EO
FR
EX
Child BMI
Time 1 Maternal Eating
Emotional Eating
-
.31**
.11
.15
External Eating
-
.36**
.30**
.45**
Instrumental (Behaviour)
.11
.36**
.33**
.31**
Instrumental (Eating)
.08
.15
.13
.17*
Emotional Feeding1
.05
.52**
.37**
.30**
Restriction
.07
.31**
.30**
.35**
Time 1 Child Feeding
*<.05; **<.01 (2 tailed).1Square root Transformation
Note: Emotional Eating (EO); Food Responsiveness (FR); External Eating (EX)
The third hypothesis explored Time 1 child BMI and child eating behaviours as
predictors of Time 3 child feeding practices. As shown in Table 34, Time 1 child emotional
overeating, food responsiveness, and external eating were positively associated with Time 3
instrumental feeding-behaviour and emotional feeding, and Time 1 child external eating was
also positively associated with Time 3 restriction. Additionally, Time 1 child BMI was
negatively associated with Time 3 instrumental feeding-eating.
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149
Table 34
Cross Lag Correlations between Time 1 Child BMI-for-age z-scores and Child Eating
Behaviours and Time 3 Child Feeding Practices (N = 138)
Time 3 Child Feeding Practices
Instrumental
Instrumental
Emotional
(behaviour)
(eating)
feeding1
.04
-.20*
-.00
-.18
Emotional overeating
.29**
.17*
.44**
.15
Food responsiveness
.27**
.14
.32**
.04
External eating
.23**
.14
.21*
.27**
Time 1 Child BMI
Restriction
Time 1 Child eating behaviours
*<.05; **<.01 (2 tailed). 1Square root Transformation
Hierarchical Regression Analyses
Hypothesis 1: Prospective predictors of Time 3 child eating behaviours.
The first set of hypotheses examined Time 1 maternal eating styles as a predictor of
Time 3 child eating behaviours. At step 1, Time 1 child age and gender, Time 1 maternal
BMI, and the corresponding Time 1 child eating behaviour were entered. Maternal emotional
eating and external eating were entered at Step 2.
The first model shown in Table 35 examined predictors of Time 3 child emotional
overeating. Step 1 accounted for 41.5% of the variance, F(4, 117) = 20.78, p < .001. Step 2
contributed a further .2% with the inclusion of maternal eating variables, F(6,115) = 14.84, p
< .001. Maternal external eating was shown to be a unique predictor of Time 3 child
emotional eating (β = .17, p = .04). However, although the model as a whole was significant,
Step 2 was found to not be significant.
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Table 35
Summary of Hierarchical Regression Analysis for Time 1 Maternal Eating Behaviours
Predictors of Time 3 Child Emotional Overeating (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.42**
Child Age
-.04
.21
-.01
Child Gender
.00
.35
.00
Maternal BMI1
.03
.04
.07
Time 1 Child Emotional Overeating
.65
.07
.65**
Step 2
.02(n.s.)
Child Age
-.01
.21
-.00
Child Gender
.09
.35
.02
Maternal BMI1
.02
.04
.04
Time 1 Child Emotional Overeating
.61
.08
.61**
Time 1 Maternal Emotional Eating
-.01
.02
-.05
Time 1 Maternal External Eating
.08
.04
.17*
*<.05; **<.01;1Logarithm Transformation; Note: n.s., not significant
The next model examined predictors of Time 3 child food responsiveness. As can be
seen in Table 36, the results showed that the model as a whole was significant, with 41.8% of
the total variance explained by predictor variables F( 4, 177) = 21.04, p < .001. In step 2,
maternal eating variables only accounted for an extra 0.2% of the total variance, which was
statistically not significant F(6, 115) = 15.03, p < .001.
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151
Table 36
Summary of Hierarchical Regression Analysis for Time 1 Maternal Eating Behaviours
Predictors of Time 3 Child Food Responsiveness (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.42**
Child Age
.18
.28
.04
Child Gender
-.02
.47
-.00
Maternal BMI1
1.37
3.00
.03
Time 1 Child Food Responsiveness
.59
.06
.65**
Step 2
.02(n.s.)
Child Age
.22
.28
.06
Child Gender
.10
.47
.02
Maternal BMI1
.67
3.30
.02
Time 1 Child Food Responsiveness
.55
.07
.61**
Time 1 Maternal Emotional Eating
-.02
.02
-.08
Time 1 Maternal External Eating
.10
.05
.18*
*<.05; **<.01;1Logarithm Transformation; Note: n.s., not significant
The final model examined predictors of Time 3 child external eating. Step 1
accounted for 29.6% of the model, F(4,117) = 12.32, p < .001. With the inclusion of maternal
eating variables at Step 2, a further 8.5% was added to the model, F(6, 115) =11.82, p < .001.
As shown in Table 37, Time 1 maternal external eating was shown to be a significant unique
predictor of Time 3 child external eating (β = .37, p < .001).
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152
Table 37
Summary of Hierarchical Regression Analysis for Time 1 Maternal Eating Behaviours as
Predictors of Time 3 Child External Eating (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.30**
Child Age
.32
.46
.05
Child Gender
-.31
.77
-.03
Maternal BMI1
1.89
4.88
.03
Time 1 Child External Eating
.50
.07
.54**
Step 2
.09**
Child Age
.43
.44
.07
Child Gender
.25
.74
.03
-1.64
5.07
-.03
Time 1 Child External Eating
.38
.08
.41**
Time 1 Maternal Emotional Eating
-.04
.03
-.10
Time 1 Maternal External Eating
.32
.08
.37**
Maternal BMI1
*<.05; **<.01; 1Logarithm Transformation
The following models investigated Time 1 child feeding practices as predictors of
Time 3 child eating behaviours. Based on previous research and the hypotheses of this study,
the child eating behaviours of interest were Time 3 child emotional overeating, food
responsiveness, and external eating. For each model, a two-step hierarchical regression was
performed. In Step 1, Time 1 child age, child gender, and the corresponding Time 1 child
eating variables were entered. In Step 2, Time 1 child feeding variables including
instrumental feeding-behaviour, instrumental feeding-eating, emotional feeding, and
restriction were entered into the model.
As shown in Table 38, in the first model Time 1 child feeding practices were
investigated as predictors of Time 3 child emotional overeating. Step 1 accounted for 41.1%
of the variance, F(3, 134) = 34.14, p < .001. After the inclusion of child feeding variables at
CHILD OVEREATING BEHAVIOUR
153
Step 2, the total variance explained by the whole model was 46%, F(7, 130) = 15.84, p <
.001. In the final model, Time 1 emotional feeding was found to be a significant unique
predictor (β = .23, p = .01) of Time 3 emotional overeating.
Table 38
Summary of Hierarchical Regression Analysis for Time 1 Child Feeding Practices as
Predictors of Time 3 Child Emotional Overeating (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.41**
Time 1 Child age
-.03
.20
-.01
Time 1 Child gender
.02
.33
-.00
Time 1 Emotional Overeating
.64
.07
.64**
Step 2
.05*
Time 1 Child age
.11
.22
.04
Time 1 Child gender
.04
.32
.01
Time 1 Emotional Overeating
.48
.08
.48**
Time 1 Instrumental (Behaviour)
.00
.04
.00
Time 1 Instrumental (Eating)
-.05
.06
-.06
Time 1 Emotional Feeding1
1.14
.45
.23*
Time 1 Restriction
.05
.03
.12
*p<.05; **p< .01; 1Square root Transformation
Results for the second model are shown in Table 39. Time 1 child feeding variables
were examined as predictors of Time 3 child food responsiveness. The overall model was
significant and explained 41.7% of the variance in Time 3 child food responsiveness, F(3,
134) = 32.00, p < .001. In step 2, child feeding variables accounted for a further 3.4% of the
variance but was statistically non-significant F(7, 130) = 15.23, p < .001.
CHILD OVEREATING BEHAVIOUR
154
Table 39
Summary of Hierarchical Regression Analysis for T1 Child Feeding Practices as Predictors
of Time 3 Child Food Responsiveness (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.42**
Time 1 Child age
.18
.26
.05
Time 1 Child gender
-.04
.44
-.01
Time 1 Food Responsiveness
.58
.06
.64**
Step 2
.03(n.s.)
Time 1 Child age
.00
.29
.00
Time 1 Child gender
.13
.43
.02
Time 1 Food Responsiveness
.52
.07
.58**
Time 1 Instrumental (Behaviour)
.07
.05
.12
Time 1 Instrumental (Eating)
.04
.08
.04
Time 1 Emotional Feeding1
.29
.57
.04
Time 1 Restriction
.04
.04
.06
*p<.05; **p< .01; 1Square root Transformation; Note: n.s., not significant
In the final model, Time 1 child feeding was explored as a predictor of Time 3 child
external eating. For Step 1, the total variance was 29.5%, F(3, 134) = 18.73, p < .001. The
proposed child feeding variables were entered at Step 2. The total variance of the model as a
whole was 34.3%, F(7, 130) = 9.69, p < .001. Restriction was shown to be a significant
unique predictor (β = .20, p = .01) of Time 3 child external eating. Summary statistics are
displayed in Table 40.
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155
Table 40
Summary of Hierarchical Regression Analysis for Time 1 Child Feeding Practices as
Predictors of Time 3 Child External Eating (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.29**
Time 1 Child age
.32
.43
.05
Time 1 Child gender
-.33
.72
-.03
Time 1 External Eating
.49
.07
.54**
Step 2
.05*
Time 1 Child age
.37
.47
.06
Time 1 Child gender
-.05
.72
-.01
Time 1 External Eating
.41
.07
.45**
Time 1 Instrumental (Behaviour)
.01
.09
.01
Time 1 Instrumental (Eating)
-.01
.13
-.00
Time 1 Emotional Feeding1
.73
.90
.07
Time 1 Restriction
.18
.07
.20*
*p<.05; **p< .01; 1Square root Transformation
Hypothesis 2: Prospective predictors of Time 3 child BMI.
No Time 1 child feeding practices were associated with Time 3 child BMI; therefore
no multivariate analyses were undertaken to test this hypothesis.
Hypothesis 3: Prospective predictors of Time 3 child feeding practices.
Time 1 child BMI-for-age z-scores and child eating behaviours were examined as
prospective predictors of Time 3 instrumental feeding-behaviour, emotional feeding, and
restriction. Instrumental feeding-eating was excluded from this analysis. Step 1 included
Time 1 child age and the corresponding Time 1 child feeding practice. At Step 2, child BMI
and child eating behaviours were added to the model.
CHILD OVEREATING BEHAVIOUR
156
The results for Time 1 child BMI and child eating behaviours as predictors of Time 3
instrumental feeding-behaviour is shown in Table 41. The model as a whole was significan,
with a total variance of 42.4% was accounted for by predictor variables, F(2, 102) = 37.51, p
< .001. An additional 1.7% was added to the model with the inclusion of instrumental
feeding-behaviour but it was statistically non-significant at Step 2, F(6, 98) = 12.90, p = .55.
Table 41
Summary of Hierarchical Regression Analysis for Time 1 Child BMI and Child Eating
Behaviours as Predictors of Time 3 Instrumental Feeding-behaviour (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.42**
Time 1 Child age
-.88
.51
-.13
Time 1 Instrumental feeding-behaviour
.63
.07
.69**
Step 2
.02(n.s.)
Time 1 Child age
-.88
.52
-.13
Time 1 Instrumental feeding-behaviour
.64
.08
.68**
Time 1 Child BMI
.14
.37
.03
Time 1 Emotional Overeating
-.06
.23
-.03
Time 1 Food Responsiveness
.23
.15
.15
Time 1 External Eating
-.10
.09
-.09
*p<.05; **p< .01; Note: n.s., not significant
For the second model, Time 1 child BMI and child eating were examined as
predictors of Time 3 emotional feeding. The overall model was significant, with a total
variance of 53.7% accounted for by Time 1 predictor variables, F(2, 102) = 59.18, p < .001.
In step 2, child BMI and child eating variables added an additional 4.48% of the total
variance, however this was statistically non-significant, F(6, 98) = 19.69, p = .73. Neither
child BMI nor child eating behaviours were found to be significant unique predictors of Time
3 emotional feeding.
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157
Table 42
Summary of Hierarchical Regression Analysis for Time 1 Child BMI and Child Eating
Behaviours as Predictors of Time 3 Emotional Feeding (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.54**
Time 1 Child age
.02
.04
.04
Time 1 Emotional feeding
.72
.07
.73**
Step 2
.09(n.s)
Time 1 Child age
.03
.04
.05
Time 1 Emotional feeding
.73
.08
.74**
Time 1 Child BMI
-.00
.03
-.01
Time 1 Emotional Overeating
-.00
.02
-.01
Time 1 Food Responsiveness
.01
.01
.08
Time 1 External Eating
-.01
.01
-.11
*p<.05; **p< .01; Note: n.s., not significant
The final model explored predictors of Time 3 restriction. Step 1 revealed a total
variance of 2.7%, F(2, 102) = 1.39, p = .25. An additional 11.5% was added to the model
with the inclusion of child BMI z-scores and child eating behaviours at Step 2, F(6, 98) =
2.69, p = .02. As can be seen in Table 43, there were two significant unique predictors of
Time 3 restriction. Child external eating showed a higher beta value (β = .29, p = .01) than
child BMI z-score (β = -.20, p = .04).
CHILD OVEREATING BEHAVIOUR
158
Table 43
Summary of Hierarchical Regression Analysis for Time 1 Child BMI and Child Eating
Behaviours as Predictors of Time 3 Restriction (N = 138)
Variable
B
SE B
β
Step 1
ΔR2
.03
Time 1 Child age
.36
.37
.10
Time 1 Restriction
.08
.05
.13
Step 2
.12*
Time 1 Child age
.38
.37
.10
Time 1 Restriction
.05
.06
.08
Time 1 Child BMI
-.54
.26
-.20*
Time 1 Emotional Overeating
.13
.16
.10
Time 1 Food Responsiveness
-.16
.11
-.18
Time 1 External Eating
.17
.06
.29*
*p<.05; **p< .01
Discussion
The present study aimed to explore longitudinal relationships between maternal
eating, child feeding practices, child eating behaviours and child BMI. The hypothesis that
Time 1 maternal eating styles and child feeding practices would prospectively predict Time 3
child over eating behaviours was partially supported. The second hypothesis, that Time 1
child feeding practices would prospectively predict Time 3 child BMI, was not supported.
The third and final hypothesis, that Time 1 child eating behaviours and child BMI would
prospectively predict Time 3 child feeding practices, was partially supported. The specific
Time 1 variables found to be prospective predictors of Time 3 variables will be discussed in
greater depth in turn. This will be followed by a general discussion (in Chapter 10) of the
implications and methodological limitations of the current study, suggestions for future
research, and concluding remarks.
CHILD OVEREATING BEHAVIOUR
159
Prospective Predictors of Time 3 Child Eating Behaviours
The first hypothesis that Time 1 maternal eating styles (emotional and external eating)
and child feeding practices (instrumental feeding-behaviour, instrumental feeding-eating,
emotional feeding and restriction) would predict an increase in Time 3 food approach child
eating behaviours (emotional eating, food responsiveness, and external eating) was partially
supported in this sample. Maternal external eating and restrictive feeding prospectively
predicted child external eating two years later, and emotional feeding prospectively predicted
child emotional eating two years later. Maternal emotional eating was not associated with
child eating behaviours over time. Furthermore, neither instrumental feeding-behaviour nor
instrumental feeding-eating prospectively predicted changes in child overeating behaviours at
two year follow-up.
The finding that Time 1 maternal external eating prospectively predicted Time 3 child
external eating is consistent with cross-sectional associations found in Study 1, and lends
further support for the proposed theory that there may be a familial transmission of eating
behaviours (Jahnke & Warschburger, 2008). Furthermore, this finding is consistent with that
of Brozovic (2009) who found that for children aged 2 to 4 years old, maternal external
eating prospectively predicted child external eating at one year follow-up. External eating
was the most frequently reported eating behaviour in children at Time 1 and at Time 3. Given
that external eating is an observable eating trait, it is not surprising to find an association
between these variables. This is particularly the case as external eating is likely to be
associated with family eating habits, verbal requests from the child for particular foods, and
environmental influences such as what foods are made available in the home. External eating
may therefore be more visible than other eating behaviours. One interpretation of this
relationship could be that children learn to eat more in response to external food cues through
modelling of parental eating behaviours. Further research is required to replicate this finding
CHILD OVEREATING BEHAVIOUR
160
and confirm that the apparent familial transmission of external eating is indeed commencing
in the toddler years.
The second part of this hypothesis explored child feeding practices as prospective
predictors of child eating behaviours at two year follow-up. This hypothesis was partially
supported. The finding that restriction prospectively predicted child external eating is
consistent with laboratory findings by Birch and colleagues (Birch, Fisher, & Davison, 2003;
Fisher & Birch, 2002). For girls, higher levels of restrictive feeding at age 5 years predicted
greater eating in the absence of hunger (EAH), a type of external eating, when girls were
aged 7, and again at aged 9 (Birch, Fisher, & Davison, 2003). The current study appears to be
the first to explore restriction as a prospective predictor of external eating in a young sample
of both boys and girls. The current findings provide new longitudinal evidence that using
restrictive feeding practices of limiting access to energy dense palatable foods may actually
promote greater eating in response to palatable foods in preschool aged children. The result
of such eating behaviour may consequently increase the risk for overeating and potentially
overweight if this eating pattern continued over time.
The finding that emotional feeding prospectively predicted child emotional overeating
is consistent with existing research by Brozovic (2009) who examined the same cohort of
children aged 2 to 4 years old and found that emotional feeding predicted child emotional
overeating at one year follow-up. Unlike external eating, emotional eating at this age is not
likely to occur unless this eating behaviour is reinforced by parents providing food to
alleviate negative emotions. Although there may be genetic factors involved, this finding is
also consistent with children learning to associate food with comfort as a way to alleviate
negative emotions. Furthermore, this finding lends supports for the theory proposed by
Wardle and colleagues (2002) in which emotional feeding may promote eating in response to
cues other than hunger and therefore may lead to overeating. Whilst this study did not include
CHILD OVEREATING BEHAVIOUR
161
a measure of food consumption, emotional eating in adults has been associated with nonnutritive consumption of foods such as sugary and high fat foods (van Strien, Frijters,
Bergers, & Defares, 1986); therefore it could be assumed that emotional feeding practices
may involve foods that are also high in fats and sugars, particularly as it has been shown in
present research that mothers who were emotional eaters tended to feed their child in a
similar way to their own eating. Once more, if this pattern of emotional eating were to persist
into later childhood it is likely to increase the risk for overweight.
Instrumental feeding-behaviour and instrumental feeding-eating were correlated with
all three food approach eating behaviours at two year follow-up, but when entered into the
regression analyses neither of these feeding practices were unique predictors of emotional
overeating, food responsiveness or external eating after controlling for the corresponding
Time 1 child eating behaviour. In Study 1, instrumental feeding-behaviour predicted child
external eating and also mediated the relationship between maternal emotional eating and
child emotional overeating, as well as between maternal external eating and child external
eating. One explanation for the lack of a prospective relationship in this study could be that
instrumental feeding-behaviour has a less direct influence on this relationship in a younger
age group (2 to 4 year olds). As noted in Study 1, instrumental feeding-behaviour requires a
certain level of comprehension and bargaining on behalf of the child (Brozovic, 2009). As
such, this feeding practice may be more relevant in an older age group and perhaps be elicited
in response to child characteristics as a way to manage their behaviour (i.e., good/bad
behaviour).
Lastly, the lack of association between instrumental feeding-eating and food approach
eating behaviours is consistent with cross-sectional findings in Study 1. Findings from this
research have demonstrated that instrumental feeding-eating seems to be used more often for
children who are under-eaters (i.e., for children who were fussier eaters and/or ate more
CHILD OVEREATING BEHAVIOUR
162
slowly during the course of a meal). This was demonstrated by cross lag correlational finding
that Time 1 child BMI was negatively association with Time 3 instrumental feeding-eating,
suggesting that parents of leaner children are likely to use such feeding strategy to encourage
eating.
More research is needed to explore the prospective role of child feeding practices in
the development of overeating eating behaviours in preschool aged children. Our findings
point to maternal external eating, restriction and emotional feeding practices as potential
areas to target to modify child overeating behaviours. Additionally, further research is
needed to replicate these findings.
Prospective Predictors of Time 3 Child BMI
The second hypothesis that Time 1 instrumental feeding-behaviour, instrumental
feeding-eating, emotional feeding, and restriction would predict an increase in Time 3 child
BMI was not supported. In line with cross-sectional findings of Study 1, instrumental feeding
and emotional feeding practices were not associated with child BMI. This finding is also
consistent with previous research (Baughcum et al., 2001; Brozovic, 2009; Carnell & Wardle,
2007; Wardle et al., 2002). Although there is limited research data that have explored nonnutritious feeding practices in relation to BMI, no data to date have found an association with
increased weight from either cross-sectional or longitudinal research. This finding might
therefore suggest that the impact of non-nutritious feeding on child weight is perhaps
minimal in preschool-aged children.
Furthermore, contrary to the hypothesis that restriction would prospectively predict an
increase child BMI at two year follow up, this hypothesis was not supported. The lack of
positive association with child BMI is consistent with other longitudinal findings (Campbell
et al., 2010; Gregory, Paxton & Brozovic, 2010b; Spruit-Metz, Li, et al., 2006; Webber, et al.,
CHILD OVEREATING BEHAVIOUR
163
2010b). So far, however, the long term effects of restriction are not clear. In the instance
where an association has been found with higher weight status, this was in a sample of
children already at risk for overweight (Faith, Berkowitz, et al., 2004). Faith, Berkowitz, and
colleagues found that restriction at age 5 years predicted higher BMI at age 7 years in
children at risk for overweight. Conversely, two recent studies have shown that restriction
was associated with lower BMI (Blissett & Farrow, 2008; Campbell et al., 2010).
It may be that the acute effects of restriction in laboratory settings differ from the
more indirect forms of restriction that is captured in questionnaire-based research (Webber et
al., 2010b). As noted in Study 1, it could simply be that overeating when in an unrestricted
environment (as found in laboratory studies) occurs occasionally, such as children’s birthday
parties, and therefore a continuous pattern of overeating may not occur as the theory
proposes. More research is required to understand the context and motivation for restrictive
feeding, and how this is related to child eating and weight change over time.
Prospective Predictors of Time 3 Child Feeding Practices
The third hypothesis that Time 1 child food approach eating behaviours and child
BMI would predict an increase in Time 3 child feeding practices was partially supported.
Time 1 child BMI negatively predicted Time 3 restriction, and child external eating positively
predicted Time 3 restriction. Neither emotional overeating nor food responsiveness was
uniquely associated with child feeding practices at two year follow-up.
The implication of the finding that restriction was negatively predicted by child BMI
is unclear. In contrast to findings by Farrow and Blissett (2008) and Campbell and colleagues
(2010) who found that restrictive feeding prospectively predicted lower BMI in a toddler
sample and a school-aged sample, respectively, this study found that higher BMI at aged 2 to
4 years prospectively predicted lower restriction two years later. More research is needed to
CHILD OVEREATING BEHAVIOUR
164
replicate this finding and to explore what factors are influencing restriction, and how this
impacts on everyday eating behaviour in young children. One factor that has been considered
in the literature is maternal concern about weight. Rather than actual BMI being the driver of
restrictive feeding, recent studies have demonstrated that parents who are concerned about
their child becoming overweight were more likely to use restrictive feeding (Crouch, O’Dea,
Battisti, 2007; Gregory, Paxton, & Brozovic, 2010a; May, Donohue, Scanlon, Herry,
Dalenius, Faulkner, & Birch, 2007). Therefore, given that evidence shows parents are not
good at accurately estimating child overweight (Carnell, Edwards, Croker, Boniface, &
Wardle, 2005; May et al., 2007), the finding that higher child BMI at aged 2 to 4 predicted
lower restrictive feeding two years later may suggest that parents did not accurately assess
their child was overweight. Further research should consider including a measure of maternal
concern about child weight to help shed light on the relationship between child BMI and
restriction practices across time.
To the author’s knowledge, the current study was the first to explore bidirectional
longitudinal pathways between restriction and food approach eating behaviours. The results
from this study supported a bidirectional pathway between restriction and external eating.
The first hypothesis showed that restriction predicted an increase in external eating over two
years, and findings from the third hypothesis demonstrated that restrictive feeding is also in
response to child external eating behaviours. These findings extend upon previous
experimental and cross-sectional research and suggest that restriction both influences, and is
influenced by, child external eating. Given that these findings have not been reported in prior
literature, these findings should be interpreted at this stage with caution. More research is
needed to further explain and replicate these findings.
In concluding, this study is unique as it is the first to prospectively explore
relationships between maternal eating, child feeding, child eating, and child BMI over a two
CHILD OVEREATING BEHAVIOUR
165
year period in a preschool-aged sample. Whilst no maternal eating or child feeding practices
predicted increased child BMI at follow-up, this study found that maternal external eating and
restriction prospectively predicted child external eating, and emotional feeding prospectively
predicted emotional overeating. Furthermore, this study appears to be the first to find
bidirectional relationships between restriction and external eating over a two year period in
pre-school-aged children. Lastly, a unique yet interesting finding related to higher BMI
prospectively predicting lower restriction at two year follow-up. Further research is required
to replicate and clarify the findings of this study.
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166
Chapter 10: General Discussion
The aim of the studies reported in this thesis was to explore cross-sectional and
longitudinal relationships between maternal eating, child feeding practices, child eating
behaviours and child BMI across a two year period in young children. Childhood obesity is a
major health problem, with estimates that 25% of Australian children are overweight or obese
(ABS, 2010). The rise in childhood overweight is theorized to be a result of a complex
interplay of genetic, familial and environmental risk factors (Stang & Loth, 2011). A key
focus of the current research was to explore one aspect of environmental risk, in particular,
child feeding practices. Instrumental feeding, emotional feeding, restriction, and pressure to
eat have been linked with the development of overeating behaviours, and potentially excess
weight in children. It is proposed that these feeding practices interfere with the child’s selfregulatory ability, such that the child may associate eating with cues other than internal
hunger, thereby increasing the likelihood of eating more than physiologically required
(Wardle et al., 2002).
At the time that The Child and Family Health Study was evolving, studies in this area
were largely cross-sectional and conducted in primary school aged children. Although no
studies had demonstrated that non-nutritious feeding practices were associated with child
overweight, some data supported a positive association between restriction and child BMI
and a negative association between pressure to eat and child BMI. Therefore, other factors
that may influence child feeding practices were considered. For the current research, maternal
eating styles were included as potential predictors of child feeding practices, and child eating
behaviours were explored as a direct pathway to child weight status. Little was known about
eating behaviours of children. Some data supports an association between maternal eating,
child feeding, and eating, but the extent of this association was not clear. Moreover, very
little research had explored the proposed pathway of maternal eating and child feeding on
CHILD OVEREATING BEHAVIOUR
167
child eating and weight. To clarify the gaps identified, this research, conducted in 4 to 6 year
old children, explored cross-sectional relationships in Study 1, used mediation models to
examine the hypothesised pathways to child eating and weight in Study 2, and used a
longitudinal design to explore prospective relationships over a two year period in Study 3.
In this chapter, the key research findings are briefly summarised and then discussed in
relation to the theoretical and clinical implications. Finally, the strengths and limitations of
the research are presented and suggestions for future research are considered.
Summary of Findings
Study One.
The findings from this study make several contributions to the current literature.
Mothers’ eating and feeding practices were found to be related to child overeating behaviours
but not BMI in a sample of 4 to 6 year old children. Data revealed that mothers who eat in
response to their feelings were more likely to use non-nutritious feeding strategies, namely
instrumental feeding-behaviours and emotional feeding to shape their child’s general
behaviour and to comfort them. In turn, these feeding strategies were found to be associated
with overeating behaviours in children. In children, instrumental feeding-behaviour was
associated with eating in response to external cues, and emotional feeding was associated
with eating for comfort. Conversely, eating in response to external triggers by mothers was
not associated with child feeding practices, but with greater external eating in children.
Lastly, restriction of access to particular foods by mothers predicted greater child external
eating, and pressuring to eat predicted slowness in eating and food fussiness in children.
Study Two.
Extending upon Study 1, this study aimed to explore child feeding practices as a
mediator between maternal eating styles and child eating behaviours. Very little research had
CHILD OVEREATING BEHAVIOUR
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examined the pathway of maternal eating, child feeding and child eating behaviours. Data
revealed three partial mediation models. The first, that non-nutritious feeding (instrumental
feeding-behaviour and emotional feeding) partially mediated the relationship between
maternal emotional eating and child emotional eating. The second, that non-nutritious feeding
(instrumental feeding-behaviour and emotional feeding) partially mediated the relationship
between maternal external eating and child food responsiveness and external eating. And
third, that restriction partially mediated the relationship between maternal external eating and
child external eating.
Study Three.
Results from Study 1 and Study 2 supported cross-sectional relationships between
maternal eating, child feeding and child overeating behaviours. What had been less clear in
the research to date is the direction of these relationships. It could be possible that some
relationships are bidirectional, in which parental feeding may both influence, and be
influenced by, child eating behaviours and child weight. Additionally, very little research has
explored prospective predictors of child eating behaviours and child weight. Furthermore,
given the proposed familial transmission of eating behaviours this research also aimed to
explore maternal eating variables as prospective predictors of child eating behaviours and
child BMI that were examined two years previously.
The findings from this study provide valuable data and extend upon the current
literature. It was revealed that, in children aged 4 to 6 years, eating in response to external
food cues was predicted by maternal external eating and restrictive feeding. For children who
were emotional eaters, this eating behaviour was predicted by emotional feeding assessed two
years previously. Lastly, the use of restrictive feeding when children were aged 4 to 6 years
was predicted by child external eating behaviours that were assessed two years previously.
This suggests that parents may develop restrictive feeding of unhealthy food practices in
CHILD OVEREATING BEHAVIOUR
169
response to children’s external eating behaviour.
Theoretical Implications of Research Findings
Instrumental feeding as separate factors.
In review of the literature, it was contended that instrumental feeding may be better
represented as two feeding styles. In line with this hypothesis, data revealed that instrumental
feeding can be distinguished as two separate constructs. The first component was associated
with using food to reward good behaviour generally, and the second component was
associated with using food to reward eating-specific behaviour. Cross-sectional findings of
Study 1 revealed that instrumental feeding-behaviour was shown to have positive
associations with child overeating behaviours and instrumental feeding-eating was shown to
have stronger associations with child under-eating behaviours. These findings suggest that
instrumental feeding should be investigated as two separate constructs rather than as one
factor as it relates to two differing eating behaviours. As discussed in Chapter 6, the
underlying motivation for using food rewards in the current research appeared to vary.
Instrumental feeding-behaviour appeared to be associated with modifying behaviour in any
context regardless of hunger, while instrumental feeding-eating appeared to promote food
intake and was primarily confined to mealtimes. This is an important research finding and
more research is needed to replicate this to clarify if one feeding component is more
detrimental than the other, and to examine the long term implication of these feeding
practices.
The development of child feeding practices.
Maternal eating styles have been proposed to be associated with the development of
child feeding practices, such that mothers feed their child in a similar way to themselves
(Wardle et al., 2002). Findings from this study provide support for this theory, specifically for
CHILD OVEREATING BEHAVIOUR
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the influence of maternal emotional eating on non-nutritious child feeding practices. None of
the maternal eating styles prospectively predicted any of the other child feeding practices.
This finding suggests that although maternal eating styles may play a role in the way a
mother feeds her child, at least for instrumental feeding-behaviour and emotional feeding, it
also suggests that feeding practices may be driven by other factors. As such, this study
explored child feeding practices as a mediator between maternal eating and child eating
behaviours.
The mediation model posited by Ventura and Birch (2008) argued that instead of
there being a direct genetic influence on child weight, it may be environmental factors such
as feeding practices or eating-related behaviours that mediate this relationship. This was
demonstrated in the current study of child eating behaviours. Instrumental feeding-behaviour,
emotional feeding and restriction partially mediated the relationship between maternal
emotional and external eating and child overeating. This suggested that mothers who eat in
response to their feelings or who eat in response to external triggers also feed their child in a
similar way, which in turn is associated with increased overeating behaviours. One exception
was the relationship between maternal external eating and child external eating; prospective
data indicated a direct association between these variables. This finding supports the
proposed influence that genetics have on appetite (Jahnke & Warschburger, 2008). However,
it was also considered in this research that the transmission of external eating behaviours may
be learnt through role modelling of maternal eating behaviours. Separating genetic and
environmental risk factors, such as feeding practices, may be important for determining
children’s risk for developing obesity. At least for the time being, this finding suggests that
maternal external eating may be a risk factor for child overeating behaviour.
CHILD OVEREATING BEHAVIOUR
171
The development of child overeating behaviours.
As it has been discussed in this thesis, food approach eating behaviours, or overeating
behaviours, are considered risk factors for the development of overweight (Davison & Birch,
2001). Evidence suggests that appetitive traits are genetically influenced, and it is argued that
children who are more vulnerable to overweight have a greater susceptibility to
environmental influences (Carnell & Wardle, 2009). The present research did not find
significant differences in eating behaviours between overweight children and non-overweight
children. Nonetheless, several significant relationships with child overeating behaviours were
found. Cross-sectional data revealed that instrumental feeding, emotional feeding and
restriction were associated with food approach eating behaviours namely, emotional
overeating, food responsiveness, and external eating; and pressure to eat was associated with
food avoidant eating behaviours.
Findings for longitudinal analyses indicated that emotional feeding prospectively
predicted emotional overeating, and restriction prospectively predicted external eating, and
child external eating predicted restriction. This appeared to be the first study to support a
bidirectional pathway between restriction and external eating. Moreover, this finding extends
upon previous experimental and cross-sectional research, and suggests that restriction both
influences, and is influenced by, child external eating. As these findings have not been
reported in prior literature they should be interpreted with caution, however it provides
supporting evidence that restrictive feeding is a risk factor in overeating behaviours. More
research is needed to clarify what factors motivate the use of these feeding practices and how
this is related to child eating and weight change over a longer period of time.
Overall, findings suggest that the development of instrumental and emotional feeding
practices may originate from maternal emotional eating styles, and influence child eating
behaviours rather than be in response child eating. On the other hand, pressure to eat is likely
CHILD OVEREATING BEHAVIOUR
172
to be in response to child under-eating behaviours. Also as previously noted, restriction was
found to be bidirectional, and therefore supported the proposed hypothesis that this feeding
practice both precedes and predicts child external eating.
The development of overweight.
Whilst child feeding practices have been implicated in the development of obesity,
findings from this study, and that of others (Baughcum et al., 2001; Brozovic, 2009; Carnell
& Wardle, 2007; Crouch, O’Dea, & Bassisti, 2007; Gregory, Paxton, & Brozovic, 2010b;
Keller, Pietrobelli, Johnson, & Faith, 2006; Saelens, Ernst, & Epstein, 2000), have found no
association between child feeding practices and child BMI. It could be that the effects of such
feeding practices are minimal in preschool-aged children. It cannot be ruled out that nonnutritious feeding practices (instrumental and emotional feeding), are not used on a frequent
basis where caloric consumption would exceed the physiological requirement that would be
necessary for increased weight. More research is needed to explore the impact of instrumental
and emotional feeding over a longer period of time and that captures a period of more
autonomous eating in children.
The lack of association between restrictive feeding and BMI is inconsistent with past
research. However, in instances where an association has been found in past research, it has
been in children who are genetically more vulnerable to overweight (Faith, Berkowitz, et al.,
2004) or alternatively, restriction has been found to be a consequence of maternal concern
about overweight as opposed to the cause of overweight in children (Webber, Hill, Cooke,
Carnell, & Wardle, 2010c). It has been argued in this thesis that overeating when in an
unrestricted environment may occur occasionally and not a frequent basis to effect weight
status, as the theory suggests. More research is needed to clarify what is implied by the term
restrictive feeding and to explore whether some restrictive practices are more detrimental on
weight in preschool children, than in other age groups. It is noteworthy, however, that while
CHILD OVEREATING BEHAVIOUR
173
child feeding practices were not associated with child overweight in this study, the sample of
children in this study were essentially a healthy weight sample. Consequently the study may
not have had enough power to detect significant effects between child eating and child
feeding practices on overweight.
Practical Implications of Research Findings
The findings of this research contribute to the current body of literature on childhood
obesity, and have a number of important implications for public health intervention.
Overeating behaviours among children appear to be a key area to target in the development of
obesity. Whilst no association was found with BMI in the current study, the simple equation
for obesity is considered to be that energy intake exceeds energy expenditure. Therefore, the
long term implication of overeating behaviours is likely to result in overweight if this pattern
continues.
Over the past decade, Australia has seen a marked rise in the prevalence of obesity. In
particular, a large Australian study found that nearly 20% of pre-schoolers were overweight
or obese (Hardy, King, Hector, & Lloyd, 2012). This suggests that family-based interventions
may be a key area to target for early intervention, especially as parents are likely to provide
the primary context for children’s early learning experiences about food. A greater
understanding of the family-food environment and child eating behaviours is necessary. This
information could then be used to develop targeted interventions aimed to modify risk
factors.
Interventions to date have typically been aimed at dietary improvement and increased
physical activity within the school environment, such as projects related to planting
vegetables and developing healthy canteens. Unfortunately many of these intervention
programs have so far not produced long term effects (Ventura & Birch, 2008; NHMRC,
CHILD OVEREATING BEHAVIOUR
174
2003). Other recent initiatives to tackle obesity have included policies related to nutritional
information on food labels, for example. It seems, however, that eating behaviours may
fundamentally be established by school age.
Across the pathway explored in this research, that is, from maternal eating, child
feeding, and child eating, to BMI, several suggestions for intervention can be proposed.
Specifically, early home interventions are recommended to start by educating parents about
the role they have in modifying their child’s eating habits. For example, mothers may benefit
from a greater understanding of the influence that their own eating habits can have in the
development of child eating behaviours, and thus, teaching parents to promote healthy eating
practices from early childhood would be valuable. In other words, modelling healthy eating
habits may promote good eating practices in children.
Findings from this research also suggest that limiting the use of instrumental feedingbehaviours, emotional feeding, and restriction feeding practices may be another area of focus.
Ideally this would aid to first reduce the consumption of energy dense foods and second, to
potentially minimise the development of emotional eating, food responsiveness, and child
external eating. Specifically, parents should be encouraged to use non-food based rewards for
good behaviour. For example, evidence has supported an increase in fruit and vegetable
consumption when children were rewarded with stickers and pencils (Lowe et al., 2004).
Thus, other more tangible rewards could be recommended, or rewards could simply include
praise or physical affection for achievements or good behaviour. Furthermore, parents should
be encouraged to use alternate strategies other than food rewards to comfort their child when
they are emotionally distressed, or in response to other emotional stimuli such as boredom.
Two items on the emotional feeding subscale related to giving the child something to eat
when they are bored even when the child is not hungry. Therefore, it seems reasonable to
CHILD OVEREATING BEHAVIOUR
175
suggest that another strategy may be for parents to help children overcome boredom through
alternative activities rather than looking for something to eat.
With regard to the influence of restrictive feeding on overeating behaviours, the
messages are less clear. Results have been inconsistent across the research domain regarding
the use of this feeding practice. It would seem premature to encourage parents to make
energy dense food freely available (Campbell, et al., 2010). As previously noted in this thesis,
there appear to be various contexts for the use restrictive feeding strategies, and as yet, it is
not clear whether some contexts might be more detrimental than others (Campbell et al.,
2010). For example, clarifying the distinction between using restrictive feeding to manage
weight or using restrictive feeding for health concerns is needed. Perhaps the message should
simply be to encourage parents to promote healthy eating so that children learn healthy
habits.
Finally, despite the limited research support for the implications of instrumental
feeding and emotional feeding on weight status in children to date , it is noteworthy that a
number of professional websites have started to recommend similar strategies to those noted
above (for example, to encourage non-food based rewards for good behaviour and to avoid
comfort feeding) for prevention of overeating behaviours in infants and toddlers (e.g.,
www.summitmedicalgroup.com; www.wsupgdocs.org). Therefore, the findings of the current
study are valuable and provide further evidence to support such recommendations.
Research Strengths and Limitations
The use of a longitudinal design is a key strength of this research as it has allowed
prospective analyses to be examined. A further strength of the present research is the two
year follow-up period, which captured both preschool (2 to 4 year olds) and primary school
aged children (4 to 6 year olds). It should also be noted here that a prospective design does
CHILD OVEREATING BEHAVIOUR
176
not imply causation. The causal impact on child eating behaviours and BMI may be
confounded by variables that have not been assessed in this thesis, such as food consumption
and portion size. Experimental designs would offer the most powerful way to test causal
relationships.
The inclusion of both non-nutritious and directive feeding practices in a longitudinal
design is also a strength of this research. This research appeared to be the first to include all
variables in the proposed pathway from mothers’ eating style to child BMI. Lastly, the age of
the sample within the research design is also a noteworthy strength. Our sample captured
both preschool and primary school-aged children. Few studies have explored factors
associated with child eating behaviours during this crucial developmental period.
A number of limitations need to be considered when interpreting the study’s findings.
The sample characteristics of the research limit the generalisability of findings. Almost twothirds of parents in this sample were tertiary educated compared to a quarter of the general
Australian population (ABS, 2008a). The findings may, therefore, not be representative of
families who come from lower educational backgrounds. The Centre for Disease Control
(CDC: 2011) recently documented that higher education level of the head household earner
was associated with lower rates of obesity in boys and girls aged 2 to 19 years old.
Another limitation of the current study is that it utilised self-report measures which
will inevitably be influenced by some degree of response bias. Mothers may be reluctant to
report accurately on some items. For example, items related to using food to reward
behaviour could be viewed unfavourably and thus, mothers may respond in a socially
desirable way. Furthermore, child and maternal BMI were self-reported. A tendency has been
found where people overestimate height and underestimate weight, which therefore results in
an underestimate of BMI (Conner Gorber et al., 2007). Thus, some caution should be taken
when interpreting self-reported data. With respect to statistical analyses conducted, the
CHILD OVEREATING BEHAVIOUR
177
overall effect size (r2) for many of the regression models were small, and there were multiple
comparisons made, which increases the potential of finding a false positive relationship
(Tabacknick & Fidell, 2007). This is when a relationship is said to exist between variables
when the null hypothesis is true.
A further limitation relates to attrition. At two year follow-up, 25% of the sample did
not return their questionnaire package. Although there were no significant differences
between the mother’s on demographic variables who completed both Time 1 and Time 3
compared to those who withdrew after Time 1, a significant difference was found for child
BMI z-scores. Mothers who withdrew after Time 1 tended to have children with lower BMI
z-scores, which may be suggestive that the mothers of children with higher weight remained
in the study because they have an interest in learning more about their child’s eating
behaviours and risk factors for overweight.
Directions for Future Research
A number of areas highlighted in this chapter should be addressed in future research.
In order to develop a more accurate understanding of the factors that influence the
development of child overeating behaviours, further research is needed to replicate these
findings. In particular, it will be important for the sample to include a broad range of
educational levels to ensure that the sample is representative of the population, and also to
increase the generalizability of the findings. Also, where possible, height and weight data
should be obtained by the researcher to reduce response bias and errors.
The present study was the first to explore a range of child feeding practices in relation
to overeating behaviours and weight in young children. Given few studies have explored
instrumental feeding and emotional feeding, further longitudinal research is needed to
replicate the current findings. Furthermore, it seems that further clarification of what is meant
CHILD OVEREATING BEHAVIOUR
178
by restrictive feeding would assist to understand the varying contexts for its use, and whether
some restrictive practices are more problematic than others. Overall, a longer period of
follow-up with enough time points to capture bidirectional relationships is necessary to
determine the long term implications of these practices.
Lastly, factor analysis of non-nutritious feeding practices will need to be repeated on a
larger sample to replicate the finding that instrumental feeding is spilt across two factors. The
same applies for the DEBQ-P. This study appeared to be the first to use the external eating
subscale of the DEBQ-P in a young sample. While the subscale was shown to have
satisfactory scale properties including high internal reliability in this sample, findings need to
be replicated in order to confirm its use in a younger sample.
Conclusions
In concluding, this research provided support that child feeding practices are one
aspect of environmental risk that influences the development of overeating behaviours in
children. For children aged 4 to 6 years old cross-sectional analyses showed that instrumental
feeding-behaviour and restriction were associated with external eating, and that emotional
feeding was associated with emotional overeating. Conversely instrumental feeding-eating
was found to be related to slowness in eating, and pressure to eat was related to slowness in
eating and food fussiness. The differences between instrumental feeding-behaviour and
instrumental feeding-eating and child eating behaviours are promising research findings and
is suggestive that limiting the use of food to reward behaviour may be more relevant in
preschool aged children. The current findings also support a familial transmission of external
eating behaviour from mother to child. Prospective predictors of eating behaviours and BMI
that were assessed two years previously when children were aged 2 to 4 years old revealed
that emotional eating was prospectively predicted by emotional feeding, and that external
eating was prospectively predicted by maternal external eating and restrictive feeding.
CHILD OVEREATING BEHAVIOUR
179
Restrictive feeding was also found to be predicted by child external eating that was assessed
two years previously.
Overall, the findings identify a number of risk factors that could be targeted in public
health interventions. Child feeding practices were shown to increase the risk for overeating
behaviours, and although this study did not support an association with overweight,
overeating behaviours are a risk factor for overweight. Therefore, with further longitudinal
research over longer time periods, this may shed light on the long-term implications of these
feeding practices.
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180
Appendix A1: Letter of Invitation
School of Psychological Science
Faculty of Science,
Technology and Engineering
The Child and Family Health Study
Follow-up Questionnaire
Dear
Thank you for agreeing to participate in another follow up to the Child and Family Health
Study questionnaire which you completed this time last year. This questionnaire is almost
identical to the one you already completed, as we are interested in seeing how things have
changed as your child has grown older.
Please read the following information about the study.
This research is part of a larger research project that is now being conducted by Michelle
Noonan as part of the Masters of Clinical Psychology Program at La Trobe University, and
will follow-up with parents approximately two and three years after the initial questionnaire.
The project is under the supervision of Professor Susan Paxton, Associate Professor
Eleanor Wertheim, and Dr Helen Skouteris of the School of Psychological Science, La Trobe
University.
Understanding the factors involved in maximizing the wellbeing of mothers and young
children is important, both for early intervention programs and for making sure that the
advice given to parents is of the highest quality. This study aims to find out more about the
influence of eating, attitudes, and behaviours on the wellbeing of mothers and their children
aged 1-to-6 years.
Participation in the study will involve completing a series of questionnaires. These include
questions on your eating behaviour and on feelings about yourself, as well as your child’s
eating behaviours and family eating patterns. A General Information Questionnaire will ask
for demographic information about your child and your family.
The completion of the questionnaires should take approximately one hour. Upon completion
of this questionnaire, you will receive another $10 Coles voucher as a small token of our
appreciation for your time and go into a raffle to win either a $100 voucher or a one of five
$25 vouchers. You will also receive a voucher for any further follow up questionnaires. While
we very much appreciate your participation in this research, it is completely voluntary and
you are free to withdraw from the study at any time.
All information obtained during the course of this study is confidential. To ensure the
confidentiality of all participants, questionnaires and data are kept separately from identifying
information. The results of this research will be included in a thesis and may be presented at
meetings and published in scholarly journals but no identifying information will be presented
in these presentations and publications.
La Trobe University
Victoria 3086, Australia
Telephone +61 9479 1590
Facsimile: +61 3 9479 1956
CHILD OVEREATING BEHAVIOUR
181
Email: [email protected]
ABN 64 804 735 113
If the questionnaires raise personal concerns for you, you can call Professor Susan Paxton
on 9479 1736. La Trobe also has a Psychology Clinic in the School of Psychological Science
which can be contacted on 9479 2150 for counselling if any concerns arise as a result of
your participation in this study.
Any questions about this research project can be directed to either:
Michelle Noonan [email protected]
Professor Susan Paxton [email protected]
If you have any concerns, queries or complaints that the researchers have not been able to
answer to your satisfaction, you may contact the Ethics Liaison Officer, Human Ethics
Committee, La Trobe University, Victoria, 3086 (Phone 9479 1443, Email
[email protected])
Please complete the questionnaire and return it in the enclosed reply paid envelope as soon
as possible. If we have not heard from you within two weeks, we will contact you to see if
you need any help with the questions. You can also contact us on 9479-3292.
We thank you very much in advance for your time.
Yours sincerely,
Michelle Noonan
Professor Susan Paxton
Associate Professor Eleanor Wertheim
Dr Helen Skouteris
La Trobe University
Victoria 3086, Australia
Telephone +61 9479 1590
Facsimile: +61 3 9479 1956
Email: [email protected]
CHILD OVEREATING BEHAVIOUR
182
Appendix A2: Researcher Consent Form
School of Psychological Science
Faculty of Science,
Technology and Engineering
THE CHILD AND FAMILY HEALTH STUDY
FOLLOW UP STUDY
STATEMENT OF INFORMED CONSENT
(Researcher’s copy)
I ……………………………………………… consent to taking part in the study described in
the letter of invitation, which involves completing a set of questionnaires. I understand my
rights as a participant in this research. The objectives and procedures of this study have
been explained and I understand them. I have been advised that the results of the research
may be published but that my personal details will remain confidential. I understand that I
may withdraw from the study at any time.
Name of participant ………………………………..... Signature ……………………..
(Please print)
Address: ……………………………………………………………………………...…
 (H) ………………………… (W) ……………….….….. (M) ……….….………..….
Name of Researcher …………………………..……. Signature ………..…………….
Date …………………………..
We aim to continue to follow the development of the children who take part in this study. If
you are happy for us to contact you to ask your permission to take part in this follow up study
which will again involve completing a set of questionnaires, please sign the section below.
Name of participant ………………………………….. Signature ……………………
(Please print)
Date ………………
Thank you for your time and willingness to participate in this study.
PLEASE RETURN THIS PAGE ALONG WITH THE QUESTIONNAIRES IN THE
ENVELOPE PROVIDED
CHILD OVEREATING BEHAVIOUR
183
Appendix B1: Demographics
Please answer the following questions in relation to your child. This is the same child that
you completed the questionnaire about last time.
1.
Your Child
Your child’s initials: _______ (used for coding data confidentially)
2.
Sex of your child:
3.
Your child’s age:
4.
Your child’s date of birth: ______/_______/_______
5.
Your child’s country of birth: ____________________ Ethnicity:
__________________?
6.
What is your child’s current height in centimetres __________ OR in inches
_________?
7.
What is your child’s current weight in kilograms __________ OR in pounds:
_________?
8.
Years _______
Months ________
You
Are you the primary care giver of the child?
If no, please state who is: _________________
9.
Your gender:
10.
Your date of birth: ______/_______/_______
11.
Your country of birth: ____________________ Ethnicity:
_______________________?
12.
What is your current height in centimetres ____________ OR in inches
____________?
13.
What is your current weight in kilograms ____________ OR in pounds:
____________?
14.
Marital Status:
15.
Is your partner currently living with you and your child?
16.
Do you have any other children?
 please go to question
CHILD OVEREATING BEHAVIOUR
17.
Please fill in the following for your other children (i.e. not the one referred to in Q1):
Child 1:
Age:
Years: ________
Gender:
Is this child living in your household?
Months: __________
Child 2:
Age:
Years: ________
Gender:
Is this child living in your household?
Months: __________
Child 3:
Age:
Years: ________
Gender:
Is this child living in your household?
Months: __________
Child 4:
Age:
Years: ________
Gender:
Is this child living in your household?
Months: __________
Age:
Years: ________
Gender:
Is this child living in your household?
Months: __________
Child 5:
18.
184
No
What is your current employment status?
me Duties
 Please specify:
__________________________
19.
What is your occupation? _____________________________________
20.
What is the highest level of education you have completed?
de / Apprenticeship /
Certificate
equivalent)
If you do not currently have a partner, please go to question 24.
21.
What is your partner’s current employment status?
d, looking for work
Full Time Home Duties
Other
 Please
specify:
Part Time or Casual Employment
__________________________
22. What is your partner’s occupation? ______________________________
CHILD OVEREATING BEHAVIOUR
23.
185
What is the highest level of education your partner has completed?
Certificate
equivalent)
24.
What is your total current annual household income?
-40,000
-60,000
-80,000
25.
-100,000
$101,000-120,000
-140,000
Who cares for the child when you and your partner are both at work?
re
work
(specify): _______________
all times
26.
Does your child have any of the following special dietary requirements which
significantly affect what s/he can eat?
cify _________________________
specify _____________________
specify ____________________
____________________________
CHILD OVEREATING BEHAVIOUR
186
Appendix B2: Maternal Eating Styles
Dutch Eating Behaviour Questionnaire (DEBQ) (Van Strien et al., 1986)
Emotional eating
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Do you have the desire to eat when you
are irritated?
Do you have the desire to eat when you
have nothing to do?
Do you have the desire to eat when you
are depressed or discouraged?
Do you have the desire to eat when you
are feeling lonely?
Do you have the desire to eat when
somebody lets you down?
Do you have the desire to eat when you
are cross?
Do you have the desire to eat when you
are approaching something unpleasant to
happen?
Do you have the desire to eat when you
are anxious, worried or tense?
Do you have the desire to eat when things
are going against you or when things have
gone wrong?
Do you have the desire to eat when you
are frightened?
Do you have the desire to eat when you
are disappointed?
Do you have the desire to eat when you
are emotionally upset?
Do you have the desire to eat when you
are bored or restless?
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Not
Relevant
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
External eating
14.
15.
16.
17.
18.
19.
If food tastes good to you, do you eat
more than usual?
If food smells and looks good, do you eat
more than usual?
If you see or smell something delicious, do
you have a desire to eat?
If you have something delicious to eat, do
you eat it straight away?
If you walk past the baker do you have the
desire to buy something delicious?
If you walk past the snackbar or a café, do
you have the desire to buy something
CHILD OVEREATING BEHAVIOUR
187
delicious?
20.
If you see others eating, do you also have
the desire to eat?
21. Can you resist eating delicious foods?
Do you eat more than usual when you see
others eating?
When preparing a meal are you inclined to
23. eat something?
22.
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very
Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Never
Seldom
Sometimes
Often
Very Often
Restrained eating
If you have put on weight, do you eat less
24. than you usually do?
Do you try to eat less at mealtimes than
you would like to eat?
How often do you refuse food or drink
26. offered because you are concerned about
your weight?
25.
27. Do you watch exactly what you eat?
Do you deliberately eat foods that are
28. slimming?
When you have eaten too much, do you
29. eat less than usual the following days?
Do you deliberately eat less in order not to
30. become heavier?
How often do you try not to eat between
31. meals because you are watching your
weight?
How often in the evening do you try not to
32. eat because you are watching your
weight?
Do you take into account your weight with
33. what you eat?
Not
Relevant
Not
Relevant
CHILD OVEREATING BEHAVIOUR
188
Appendix B3: Child Feeding Practices
Parental Feeding Styles Questionnaire (PFSQ) (Wardle et al., 2002)
Instrumental feeding
1
In order to get my child to behave him/herself I
promise him/her something to eat.
Never
Rarely
Sometimes
Often
Always
2
If my child misbehaves I withhold his/her favourite
food.
Never
Rarely
Sometimes
Often
Always
3
I use dessert as a bribe to get my child to eat
his/her main course.
Never
Rarely
Sometimes
Often
Always
4
I reward my child with something to eat when s/he
is well behaved.
Never
Rarely
Sometimes
Often
Always
Emotional feeding
1.
I give my child something to eat to make him/her
feel better when s/he is feeling upset.
Never
Rarely
Sometimes
Often
Always
2.
I give my child something to eat to make him/her
feel better when s/he has been hurt.
Never
Rarely
Sometimes
Often
Always
3.
I give my child something to eat if s/he is feeling
bored.
Never
Rarely
Sometimes
Often
Always
4.
I give my child something to eat to make him/her
feel better when s/he is worried.
Never
Rarely
Sometimes
Often
Always
5.
I give my child something to eat to make him/her
feel better when s/he is feeling angry.
Never
Rarely
Sometimes
Often
Always
Preschooler Feeding Questionnaire (PFQ) (Baughcum et al., 2001)
Pushing the child to eat more (instrumental feeding)
1
2
3
4
5
Did you make him/her eat all the food on his/her
plate?
Did you offer him/her a dessert after a meal to get
him/he to eat foods that were good for him/her?
Did you ever punish or remove privileges to get
him/her to eat more?
Did you use foods that s/he liked as a way to get
him/her to eat “healthy” foods s/he didn’t like?
Did you make him/her finish all his/her dinner
before s/he could have a dessert?
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
CHILD OVEREATING BEHAVIOUR
189
Using food the calm the child (emotional feeding)
1
2
3
When s/he got fussy, was giving him/her
something to eat or drink the first thing you would
do?
Did you give him/her something to eat or drink if
s/he was bored even if you thought s/he was not
hungry?
Did you give him/her something to eat or drink if
s/he was upset even if you thought s/he was not
hungry?
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Never
Rarely
Sometimes
Often
Always
Child Feeding Questionnaire (CFQ) (Birch et al., 2001)
Using food as a reward (included as instrumental feeding items)
1
I offer sweets (lollies, ice cream, cake, pastries)
to my child as a reward for good behaviour.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
2
I offer my child his/her favourite foods in
exchange for good behaviour.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
Restriction
1
I have to be sure that my child does not eat too
many sweets (lollies, ice cream, cake or
pastries).
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
2
I have to be sure that my child does not eat too
many high fat foods.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
3
I have to be sure that my child does not eat too
much of his/her favourite foods.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
4
I intentionally keep some foods out of my child’s
reach.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
5
If I did not guide or regulate my child’s eating
s/he would eat too many junk foods.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
6.
If I did not guide or regulate my child’s eating,
s/he would eat too much of his/her favourite
foods.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
CHILD OVEREATING BEHAVIOUR
190
Pressure to Eat
1
My child should always eat all of the food on
his/her plate.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
2
I have to be especially careful to make sure my
child eats enough.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
3
If my child says “I’m not hungry”, I try to get
him/ her to eat anyway.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
4
If I did not guide or regulate my child’s eating,
s/he would eat much less that s/he should.
Disagree
Slightly
disagree
Neutral
Slightly
agree
Agree
CHILD OVEREATING BEHAVIOUR
191
Appendix B4: Child Eating Behaviours
Child Eating Behaviour Questionnaire (CEBQ) (Wardle et al., 2001)
Food Approach Eating Behaviours
Emotional overeating
1.
My child eats more when worried
Never
Rarely
Sometimes
Often
Always
2.
My child eats more when annoyed
Never
Rarely
Sometimes
Often
Always
3.
My child eats more when anxious
Never
Rarely
Sometimes
Often
Always
4.
My child gets full before his/her meal is
finished
Never
Rarely
Sometimes
Often
Always
5.
My child eats more when s/he has nothing else
to do
Never
Rarely
Sometimes
Often
Always
Food Responsiveness
1.
My child is always asking for food
Never
Rarely
Sometimes
Often
Always
2.
If allowed to, my child would eat too much
Never
Rarely
Sometimes
Often
Always
3.
Given the choice, my child would eat most of
the time
Never
Rarely
Sometimes
Often
Always
4.
Even if my child is full up s/he finds room to eat
his/her favourite food
Never
Rarely
Sometimes
Often
Always
5.
If given the chance, my child would always
have food in his/her mouth
Never
Rarely
Sometimes
Often
Always
CHILD OVEREATING BEHAVIOUR
192
Food Avoidant Eating Behaviours
Satiety Responsiveness
1*.
My child has a big appetite
Never
Rarely
Sometimes
Often
Always
2.
My child leaves food on his/her plate at the end
of a meal
Never
Rarely
Sometimes
Often
Always
3.
My child gets full before his/her meal is
finished
Never
Rarely
Sometimes
Often
Always
4.
My child gets full up easily
Never
Rarely
Sometimes
Often
Always
5.
My child cannot eat a meal if s/he has had a
snack just before
Never
Rarely
Sometimes
Often
Always
*Reversed scored item
Slowness in Eating
1*.
My child finishes his/her meal quickly
Never
Rarely
Sometimes
Often
Always
2.
My child eats slowly
Never
Rarely
Sometimes
Often
Always
3.
My child takes more than 30 minutes to finish a
meal
Never
Rarely
Sometimes
Often
Always
4.
My child eats more and more slowly during the
course of a meal
Never
Rarely
Sometimes
Often
Always
*Reversed scored item
Food Fussiness
1.
My child refuses new foods at first
Never
Rarely
Sometimes
Often
Always
2*.
My child enjoys tasting new foods
Never
Rarely
Sometimes
Often
Always
3*.
My child enjoys a wide variety of foods
Never
Rarely
Sometimes
Often
Always
4.
My child is difficult to please with meals
Never
Rarely
Sometimes
Often
Always
5.*
My child is interested in tasting food s/he
hasn’t tasted before
Never
Rarely
Sometimes
Often
Always
6.
My child decides that s/he doesn’t like a food,
even without tasting it
Never
Rarely
Sometimes
Often
Always
CHILD OVEREATING BEHAVIOUR
193
Dutch Eating Behaviour Questionnaire – Parent Version (DEBQ-P) (Braet & Van
Strien, 1997)
External Eating
1.
If food tastes good to your child, does s/he eat
more than usual?
Never
Rarely
Sometimes
Often
Always
2.
If food smells good, does your child eat more
than usual?
Never
Rarely
Sometimes
Often
Always
3.
If your child sees or smells something delicious,
does s/he have a desire to eat it?
Never
Rarely
Sometimes
Often
Always
4.
If your child has something delicious to eat, does
s/he eat it straight away?
Never
Rarely
Sometimes
Often
Always
5.
If your child walks past the baker, does s/he
have the desire to buy something delicious?
Never
Rarely
Sometimes
Often
Always
6.
If your child sees others eating, does s/he also
have the desire to eat?
Never
Rarely
Sometimes
Often
Always
7.
Can your child resist eating delicious food?
Never
Rarely
Sometimes
Often
Always
8.
If your child walks past the snackbar or a café,
does s/he have the desire to buy something
delicious?
Never
Rarely
Sometimes
Often
Always
9.
Does your child eat more than usual when s/he
sees others eating?
Never
Rarely
Sometimes
Often
Always
When a meal is being prepared, is your child
inclined to eat something?
Never
Rarely
Sometimes
Often
Always
10
CHILD OVEREATING BEHAVIOUR
194
Appendix C1: Thank you letter
School of Psychological Science
Faculty of Science,
Technology and Engineering
The Child and Family Health Study
Phone:
Email:
9479-3292
Michelle Noonan [email protected]
Anna Brozovic [email protected]
Jane Gregory [email protected]
Dear
Thank you for taking the time and effort to participate in our study. You have made a
valuable contribution to understanding obesity in young children and promoting healthier
Australian families. To show our appreciation, we have enclosed a Coles Gift Voucher for
you to spend as you wish.
Yours sincerely,
Michelle Nooonan
Anna Brozovic
Jane Gregory
Professor Susan Paxton
Associate Professor Eleanor Wertheim
Dr Helen Skouteris
La Trobe University
Victoria 3086, Australia
Telephone +61 9479 1590
Facsimile: +61 3 9479 1956
Email: [email protected]
ABN 64 804 735 113
CHILD OVEREATING BEHAVIOUR
195
Appendix D1: Time 1 Factors Analysis of Instrumental and Emotional Feeding Items
Time 1 Factor Analysis with Oblimin Rotation of Three Factor Solution of Instrumental and Emotional Feeding
Items after removing items PFQ_P2 and PFQ_C4 (Brozovic, 2009).
Items
Pattern Matrix
Communalities
Instrumental
-behavior
Instrumental
-eating
Emotional
feeding
-.07
-.18
.71
.67
CFQ_R2
CFQ_R1
Offer my child favourite food in exchange for good behavior
Offer sweets as a reward for good behavior
.83
.83
.08
11
PFSQ_I1
To get him/her to behave, promise something to eat
.82
-.02
.06
.71
PFSQ_I4
Reward with something to eat when well behaved
.76
.01
.07
.63
PFSQ_E2
PFSQ_I2
Give child something to eat to make him/her feel better when hurt
If misbehaves, withhold favourite food
.67
-.10
.09
.28
-.03
.63
.38
PFSQ_E1
Give something to eat to make him/her feel better when upset
.02
.34
.60
PFQ_P1
Offer dessert after meal to get him/her to eat foods that were good
.56
.08
.84
-.06
.74
PFSQ_I3
Use dessert as a bribe to get him/her to eat main meal
.15
.80
-.11
.72
PFQ_P4
Make him/her finish all their dinner before s/he could have dessert
-.08
.73
.07
.52
PFQ_P3
Used foods that s/he liked to get him/her to eat healthy foods
.06
.15
.39
PFQ_C2
Give something to eat if s/he is feeling bored even when not hungry
-.12
.55
-.00
.82
.60
PFSQ_E3
PFQ_C3
Give something to eat if s/he is feeling bored
Give something to eat if s/he was upset even when not hungry
.09
-.01
-.12
.16
.75
.67
.60
.51
PFSQ_E5
Give something to eat to make him/her feel better when angry
.19
-.04
.56
.42
PFSQ_E4
Give something to eat to make him/her feel better when worried
.36
.03
.51
.56
PFQ_C1
When fussy, giving something to eat or drink is the first thing
-.00
.26
.49
.37
.59
Note: Major loadings are shown in bold. Item coding: Child Feeding Questionnaire – Restriction scale (CFQ_R); Parent Feeding Style Questionnaire –
Instrumental feeding scale (PFSQ_I) and Emotional feeding scale (PSFQ_E); Preschooler Feeding Questionnaire – Pushing the child to eat scale (PFQ_P) and
Using food to Calm the child scale
CHILD OVEREATING BEHAVIOUR
196
Appendix D2: Correlation Matrix of Time 3 Child Eating Behaviours
Time 3 Correlations between subscales from the CEBQ
EO
FR
EF
DD
SR
SE
EU
FF
Emotional Eating
-
Food Responsiveness
.60**
-
Enjoyment of food
.14
.41*
-
Desire to drink
.19*
.28**
-.00
Satiety responsiveness
.08
-.13
-.37** .13
-
Slowness in eating
.01
-.15
-.42** .14
.42**
-
Emotional under-eating
.47**
.21*
-.15
.33**
.18*
-
Food fussiness
-.02
-.07
-.56** .19*
.34**
.14
.25** -
-
.36**
*p<.05; **p<.01; Abbreviations: EO – Emotional Overeating; FR – Food Responsiveness; EF –
Enjoyment of Food; ; DD – Desire to Drink; SR – Satiety Responsiveness; SE – Slowness is Eating;
EU – Emotional Undereating; FF – Food Fussiness.
CHILD OVEREATING BEHAVIOUR
197
Appendix D3: Summary Table of the Significant Associations for Study 1
Summary of Significant Associations from the Hierarchal Regression Analysis for Predictors of Child Eating Behaviours and Child BMI
Child Eating Behaviours
Child BMI
Emotional
Food
Overeating
Responsiveness
-
-
Maternal Emotional Eating
External Eating
Satiety
Slowness in
Food Fussiness
Responsiveness
Eating
-
-
β = -.20*
-
-
-
-
β = .20*
-
Maternal External Eating
-
-
β = .39**
-
-
-
Instrumental Feeding-Behaviour
-
β = .24*
β = .23*
-
-
-
Instrumental Feeding-Eating
-
-
-
-
β = .23*
-
β = .50**
-
-
-
-
-
Restriction
-
-
β =.25**
-
-
-
Pressure to Eat
-
-
-
β = .24**
β = .28**
Emotional Feeding1
β = Beta value; *p<.05; **p<.01; 1 Transformed subscale
CHILD OVEREATING BEHAVIOUR
198
Appendix D4: Descriptive Data of Time 1 and Time 3 variables
Study 3 Mean and Standard Deviations for all Variables in Time 1 and Time 3 (N = 138)
Measures
T1
Range
Mean (SD)
Child Age (in years)
Maternal Age
T3
Range
Mean (SD)
3.28 (.84)
2-4.92
5.29 (.85)
3.83-7.0
35.47 (5.01)
22-48
37.61 (4.95)
24 - 50
.39 (1.16)
-3.16-3.55
.21 (1.30)
-3.69 – 3.73
BMI
Child BMI z score
Child BMI percentile
61.56 (29.23)
56.01
(n=105)
(31.40)
(n=126)
Maternal BMI
25.54 (4.87)
17.69-39.90
(n=122)
Child Feeding Practices (range 1-5)
25.48 (5.14)
17.75-41.78
(n=134)
Cronbach’s
Cronbach’s
α
α
Instrumental feeding (behaviour)
2.27 (.83)
.88
2.24 (.79)
.89
Instrumental feeding (eating)
2.17 (.81)
.75
2.41 (.77)
.74
Emotional Feeding
1.58 (.53)
.78
1.59 (.52)
.81
Restriction
3.56(.94)
.79
2.67 (.53)
.85
Pressure to eat
2.21 (.62)
.76
2.73 (1.03)
.76
Emotional overeating
1.79 (.61)
.74
1.91 (.62)
.79
Food Responsiveness
2.46 (.72)
.79
2.49 (.66)
.76
External eating
3.15 (.54)
.80
3.07 (.49)
.82
Satiety responsiveness
2.49 (.43)
.70
2.47 (.44)
.69
Slowness in eating
2.16 (.52)
.59
2.19 (.52)
.71
Food fussiness
2.79 (.66)
.91
2.87 (.76)
.91
Child Eating Behaviours (range 1-5)
Food Approach behaviours
Food avoidant behaviours
Maternal Eating Behaviours (range 1-5)
Emotional eating
2.54 (1.03)
.96
2.43 (.97)
.96
External eating
2.91 (.57)
.87
2.86 (.52)
.83
Restrained eating
2.72 (.80)
.92
2.72 (.73)
.89
Note: all means presented are untransformed
CHILD OVEREATING BEHAVIOUR
199
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