Recent Advances in Obesity in Children
Abstract
Chapter 3
Interpersonal Characteristics in the
Home Environment Associated with
Childhood Obesity
Jennifer Martin-Biggers1, John Worobey1 and Carol ByrdBredbenner1*
Department of Nutritional Sciences, Rutgers University,
USA
1
Corresponding Author: Carol Byrd-Bredbenner, Department of Nutritional Sciences, Rutgers University,
New Brunswick, NJ 08901, USA, Tel: 848-932-0960; Fax:
732-932-6522; Email: [email protected]
*
First Published May 10, 2016
Copyright: © 2016 Jennifer Martin-Biggers, John
Worobey and Carol Byrd-Bredbenner.
This article is distributed under the terms of the Creative
Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which
permits unrestricted use, distribution, and reproduction
in any medium, provided you give appropriate credit to
the original author(s) and the source.
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Recent Advances in Obesity in Children
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Childhood obesity remains a leading cause of health
problems that tend to persist into adulthood. The environment is increasingly noted as an important component of
obesity prevention and treatment. For children, the home
is a key shared environment where diet and activity behavioral patterns develop. The interpersonal home environment includes parenting styles and feeding practices,
parent modeling of food behaviors, family meal environments, parent and child eating styles, as well as family
functioning and organization. Numerous measures have
been created to assess the food-related aspects of the interpersonal home environment and are discussed in this
chapter.
Introduction
Obese children are at immediate risk for health problems, including asthma, cardiovascular problems, diabetes, low-grade inflammation, as well as musculoskeletal
injury, sleep apnea, and non-alcoholic fatty liver disease
[1-9]. In addition to these health consequences, obese
children experience increased rates of social stigmatization [10] and depression [10-14]. Obesity in childhood
is particularly problematic because obesity status during
childhood tracks into adulthood, thereby setting up children for lifelong weight problems [15-19].
To adequately provide treatment for and prevention
of obesity in children and adults, it has become increasingly apparent that the environment must be considwww.avidscience.com
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ered [20,21]. For children and their parents, the prevailing shared environment is at the micro level—the home.
Parents function as role models and ‘gate keepers’ in the
home, strongly influencing weight-related behaviors of
children [22-29], and establishing practices that may increase or decrease their children’s obesity risk [11,30]. For
instance, parents decide which foods are permitted in the
home, prepare food, allow and deny children to eat certain
foods, establish meal patterns, provide snacks, set portion
sizes, model eating behaviors, discuss foods, and convey
attitudes about foods [31]. Changing the home physical
and social environment may help children avoid obesity
[32-34] in the present, as well as in the future, because
the eating and physical activity patterns developed during childhood tend to serve as the basis for later behaviors
[35-39].
The home is where parents teach children, intentionally or not, the most about food and eating. This chapter
will explore key interpersonal food related-aspects of the
home environment, including parenting styles and practices related to feeding, parent modeling of healthy food
behaviors, family mealtime environment, parent eating
styles, child temperament and eating styles, and family
functioning and organization. In addition, this chapter
will briefly review instruments for assessing the interpersonal food-related aspects of home environments.
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Parenting Styles, Feeding Styles, and
Practices
Parenting style is an overall philosophy about how
children should be raised and goals parents have for their
children [31,40,41]. Parenting style reflects parent attitudes and beliefs that create the broad emotional climate
for parent-child interactions [40,42-44]. Parenting style
classifications are based on parental responsiveness and
demandingness [45-47]. Responsiveness is conceptualized as parental warmth or supportiveness [48], and refers to “the extent to which parents intentionally foster
individuality, self-regulation, and self-assertion by being
attuned, supportive, and acquiescent to children’s special
needs and demands” [46], p.62. Demandingness is conceptualized as behavioral control [48] and refers to “the
claims parents make on children to become integrated
into the family (as a) whole, by their maturity demands,
supervision, disciplinary efforts, and willingness to confront the child who disobeys” [46], p.61-62.
Parents may be categorized according to how demanding and responsive they are, which results in these
parenting styles: indulgent/permissive, authoritarian,
authoritative, and uninvolved [47]. Each style is a different, naturally occurring pattern embodying parental values and practices [46]. These parenting styles have been
adapted to address specific feeding practices or strategies
that a parent uses to influence food intake in children, and
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thus, child weight.
Ventura and Birch have conceptualized the mutual
influences of parent feeding practices and styles and child
eating and weight [41] as having 3 bi-directional pathways: parenting and child eating, parenting and child
weight, and child eating and child weight. This conceptual
model emphasizes that parents not only influence child
behaviors and weight, but child behaviors and weight in
turn influence parenting [41]. Strategies parents use to influence food intake, and ultimately child weight, include
pressure to eat, food restriction, control of child’s dietary
intake, and use of incentives to promote food intake or reward good behavior [40]. Parental behaviors surrounding
feeding of their children also include the amount of foods
served to the children, as well as the actual foods that are
available, accessible, and consumed within the home. A
parent may fall into a style with regard to feeding, however, she or he does not automatically have the same style
across other domains of parenting [31]. Regarding feeding
styles, the parenting styles as defined by Baumrind [46]
and Maccoby and Martin [47] are:
• Indulgent/Permissive: High responsiveness and
low demandingness. Parents have lax or few rules
or expectations for child’s dietary intake (either
quality or quantity), with food availability being
the only limit on intake (parent may be indulgent
or neglecting).
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• Authoritarian: Low responsiveness and high demandingness. Mealtimes focus on disciplinary
encounters rather than harmonious interactions.
Specific strategies authoritarian parents use to
influence child dietary intake are pressuring children to eat and controlling feeding practices.
• Authoritative: High responsiveness and high demandingness. Parents have high expectations
for child’s dietary intake and usually engage in
modeling expected behavior, communicating and
negotiating with the child, and providing warm
emotional feeding environment.
• Uninvolved: Low responsiveness, low demandingness. Parents tend to use fewer child-centered
parenting techniques, such as allowing children
to determine amount of food to eat, and generally
uses more physical punishment [40,49-51].
Authoritative parent feeding has been generally
shown to be the most positively associated (and Authoritarian the most negatively) with availability and intake of
fruits and vegetables in homes with preschoolers (from
low-income families) [52] and adolescents [53]. Compared to Authoritarian parents, Indulgent/Permissive
and Uninvolved low-income parents have children with
the lowest intake of fruits and vegetables and less optimal
eating behaviors [54,55], and these parents also engage in
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less monitoring of children’s intake of lower nutrient density foods [51]. Evidence from diverse groups of families
has shown that young children with Indulgent/Permissive
parents tend to have a higher weight status [49,56,57]. The
four parent feeding styles also display ethnic variability,
with an Indulgent/Permissive feeding style being more
common in Hispanic and East Asian parents and Uninvolved style more typical of African American parents
[49,58]. However, many studies have shown that parent or
child weight status mediate parental feeding practices and
styles [59-62].
Although individual studies show some evidence that
parenting styles affect child weight status and eating behaviors, a recent review indicated that the evidence overall
is mixed. Differing findings may be a result of the need to
better conceptualize general parenting styles, or the interplay of specific parental feeding practices and child eating temperaments (discussed later) [31]. Another review
of parent feeding styles and child outcomes reported that
studies of parental feeding restriction, versus overall feeding control or other feeding domains, tended to report
positive relationships among feeding restriction, child
eating, and weight status.
Parental concern about children’s weight, as well as
pressuring and/or restricting child eating also is linked
with child eating behaviors and weight. Parents who put
more pressure on children to eat have children who eat
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fewer fruits and vegetables (parents themselves also consume fewer vegetables) [63,64]. Experimental research
supports that pressuring children to eat certain foods lead
to reduced intake of the pressured food items [65]. Indeed,
parents who restrict children’s food choices, pressure children to eat, or reward children with food may unintentionally encourage behaviors contrary to their intentions
[66].
Several studies report that mothers who pressure children to eat tend to have leaner children [59-61,67], possibly because child thinness precipitates parent pressure
on children to eat. For instance, mothers who have higher
weight concern put less pressure to eat on their heavier
than thinner children [68]. Parental use of feeding restriction also may influence child overweight [69]. An examination of parent feeding styles and child weight revealed
that parental feeding restrictions increased child weight
status [70]. In fact, 15% of the variance in children’s total
body fat was attributable to parental pressure to eat and
child weight concern [59].
Some evidence indicates that parental control over
child eating is associated with lower child BMIs [71] and
greater intake of healthy snacks [72]. Other evidence
suggests that parental control in general may not impact
some population groups [73]. Some experts believe that
high control of children’s dietary intake interferes with
theirdevelopment internal food regulation cues [74], yet
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others believe high control may facilitate obesity prevention [71]. A comparison of overt parent control (detectable by the child) and covert parent control (not readily
detected by the child; e.g., parent secretly limits children’s
access to low-nutrient density foods by avoiding certain
environments or by regulating intake of these foods) [75],
is associated with decreased intake of unhealthy snacks
compared to children whose parents used overt control
[76].
Parental control of child eating may be affected by
maternal and/or child weight. One study reported that
greater control of child eating by obese mothers (but not
non-obese mothers) is associated with higher BMI in the
children [61]. Other research, however, has found no difference between obese and non-obese mothers with regard
to feeding practices associated with using food to cope
with emotional upset, using food rewards, or encouraging children to eat greater amounts than desired [71], or
use of control [77]. Parents who perceive their children
are heavier tend to use covert control, whereas those of
a higher socio-economic status (SES) have a greater propensity to use overt control of snack food intake [76].
Recent Advances in Obesity in Children
tices or style measures, but accurately assessing the influence of parenting presents numerous challenges. Most
weight-related parenting practices are assessed via selfreport questionnaires [42-45,78-80], with few observational studies with younger children [78,79]. The cost of
performing observational studies often limits researchers,
thus resulting in the need for parental self-report questionnaires to assess parental feeding styles. A recent systematic
review yielded 56 unique instruments to measure parenting food practices [81]. Numerous instruments measure
food parenting, yet several decades of their use has failed
to yield a good understanding of ideal food parenting, or
explicit guidelines for parents to use [31,40]. Consensus
on the various types of parental influence on child eating behaviors is emerging to promote cohesive use of terminology and measurements. The most commonly used
methods to assess parenting feeding styles and specific
feeding behaviors are discussed below (Table 1).
Instruments for Assessing Parenting
Feeding Style and Practices
Parental influence on child dietary practices may be
classified and analyzed at several levels of parenting prac-
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Table 1: Feeding-Related Aspects of the Home
Environment.
Scale/Survey
Name
Caregiver’s
Feeding Style
Questionnaire
(CFSQ)
[49,50]
12
Original
Number of
Items
19 items
Answer
Choices
Scoring Methodology
Likert-type
frequency
responses
Items are scored
on dimensions of
demandingness
and responsiveness that
are scored to
categorize parent
feeding style
Child Feeding
Questionnaire
(CFQ) [83]
31 items
Likert-type
agreement
and frequency
responses
Parental
Feeding Style
Questionnaire
(PFSQ) [71]
25 items
Likert-type
frequency
responses
Feeding
Demands
Questionnaire
(FEEDS) [91]
8 items
Likert-type
agreement
responses
Overt and
10 items
Covert Parental
Feeding
Practices [76]
Likert-type
frequency
responses
Parental Dietary Modeling
Scale[99]
6 items
Likert-type
frequency
responses
Project EAT
survey [103,
127] Family
Mealtime
Environment
Characteristics
Sub-scale
Mealtime
Environment
Scale [131]
12 items
Likert-type
agreement
response
6 items
Likert-type
agreement
scale
Sub-scales may
be analyzed to
characterize
parents into one of
four feeding styles
(authoritative,
authoritarian,
indulgent/permissive, uninvolved),
or to assess other
feeding behaviors
(pressure, control,
restriction)
Scale scores
obtained by
calculating the
means of the
items comprising
each scale
Validity and Reliability Tests
Population(s)
Used for
Validity/
Reliability
Testing
Black, white,
and Hispanic
families with
children of
varying ages
Convergent validity established through associations with other validated
measures of parenting; Construct
validity evidence includes results that
parents with indulgent/permissive
feeding style were more likely to have
overweight children compared to
authoritarian parents.
Test-retest reliability for the items has
been established as very good (0.82
and 0.85 for child- and parent-centered
directives).
Confirmatory factor analysis done to
refine original items.
Parents of 2to- 11-year old
children
Normal and
obese parents of
children (mean
age 4.4 years) in
U.K. residents
with diverse
education and
occupations;
Low-income
African American families
Items scored
Parents of
to characterize
3- to 7-year old
factors of parental children (from
feeding: anger/
diverse backgfrustration, food
rounds)
amount demandingness, and
food type demandingness
Parents (92.8%
Items summed
for each sub-scale mothers) of
4- to 11-year old
with higher frequencies indicaschool children
ting more use of
in England that
control feeding
were mostly
practices
white and
middle class
Individual items
African Ameriare summed and
can parents
divided by the
total to indicate a
score of parental
dietary modeling
behavior.
Items assessed
individually
to assess
agreement with
characteristics of
mealtimes
Items are summed Parents of preto create a total
school children
score of family
in Québec
conflicts during
mealtimes, with
a higher score
indicating more
conflicts
Good internal reliability coefficients
(Cronbach alpha ranging from 0.65
to 0.85 for each sub scale) and good
test-retest reliability (Pearson correlations ranging from 0.76 to 0.83) [71]
Good validity
Acceptable internal consistency (α ranging from 0.70 to 0.86)
Good reliability
Cronbach’s alpha=0.79 (overt) and 0.71
(covert) [76]
The full scale had an alpha of 0.59
The test-retest reliabilities for
individual items ranged from r =0.54
to r =0.70.
Internal consistency of the survey was
moderate with Cronbach’s Alpha = 0.55
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Caregiver’s
(CFSQ)
Feeding
Style
Questionnaire
This instrument assesses parental demandingness and
responsiveness to feeding practices and categorizes parent
feeding style as Authoritarian, Authoritative, Indulgent, or
Uninvolved [49,50]. This 19-item, Likert-type, self-report
survey assesses demandingness and responsiveness via 7
child-centered (e.g., encourage child autonomy such as
reasoning, praising, helping children eat) and 12 parentcentered feeding items (e.g., regulate child eating via external pressure, like demands, threats, and rewards). The
CFSQ has been validated with white, black, and Hispanic
families and is available in Spanish. Test-retest reliability
for the items is very good (0.82 and 0.85 for child- and
parent-centered directives), and convergent validity was
established by comparing it with extant validate parenting
measures (e.g., Parenting Dimensions Inventory PDI-S
[82], Child Feeding Questionnaire CFQ [83]). Evidence
for construct validity includes demonstrating that children of parents with indulgent/permissive feeding style
tend be overweight vs those with authoritarian parents
[49]. Scores near cut-off points for a certain feeding style
indicate that a style is less distinct in that parent [50]. Continuous measures based on this instrument may permitcomparisons of differences between parents with distinct
feeding styles and those who fall between two styles [50].
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Child Feeding Questionnaire (CFQ)
This is 31-item self-report, Likert-type survey measures parental beliefs, attitudes, and practices concerning
child feeding, and perceptions and worries regarding obesity in their children [83]. The CFQ also may be used to assess inappropriate child feeding practices [63,65,84].This
survey is based on the premise that parents do not have
a distinct, constant parenting feeding style, but that styles
differ within parents, across child development domains,
and among children in the same family [73]. It posits that
high levels of parental feeding control may impede children’s development of self-control and responsiveness to
hunger and satiety cues, thereby increasing their risk of
obesity [73]. CFQ subscales may be analyzed to characterize parents’ feeding styles (authoritative, authoritarian,
indulgent/permissive, uninvolved) or to assess other child
feeding behaviors (pressure, control, restriction). A brief
description of the subscales follows:
• Parent responsibility for child feeding: 3 items
measure the degree to which a parent feels responsible for feeding his or her children, determining
portion sizes, and providing a healthy diet.
• Parent perception of his or her own weight: 4
items assess the parent’s own weight during his or
her childhood, adolescence, twenties, and at present.
• Parent perception of child’s weight: 6 items assess
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parent perception of child weight during 6 ages
from the first year of life to 8th grade.
• Parent concern about child’s weight: 3 items assess the extent of parent concern about his or her
child being or becoming overweight and needing
to restrict calories.
• Parent restriction of child’s diet: 8 items measure
parent tries to constrain his/her child’s eating by
limiting access to palatable foods and food quantities.
• Parent pressure on child to eat: 4 items measure
how much the parent encourages child eating
though strategies, such as pushing the child to eat
all that is served to him or her.
• Parent monitoring of child’s diet: 3 items assess the
extent to which a parent tracks his or her child’s
ingestion of low-nutrient density foods (high sugar and/or high-fat foods).
The CFQ has been used with white, black, Hispanic,
Japanese, Australian, and Hmong parents [59, 60, 68, 75,
83, 85-88]. Ethnic and cultural differences have emerged
when using the CFQ to assess parental behaviors and attitudes surrounding child feeding. For example, compared
to white mothers, African American mothers indicated a
higher degree of monitoring, feelings of responsibility,
feeding restrictions, pressure to eat, and concern about
child weight [59]. Factor analysis indicates that the CFQ
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may benefit from modification when used with non-white
populations [61,83,87]. The CFQ is generally the most
widely used, studied, and validated survey of parental
feeding practices [70,89].
Parental Feeding Style Questionnaire (PFSQ)
This Likert-type parental self-report questionnaire assesses parental feeding style with 25-items in four scales
[71]:
• Emotional feeding: 5 items assess parent use of
food to help child cope with emotions.
• Instrumental feeding: 4 items assess parent use of
food to reward children for preferred behaviors
• Prompting and encouragement to eat: 8 items assess parent use of praise and encouragement to
entice child to eat more than the child wants
• Control over eating: 10 items assess parent control
over child’s dietary intake
The PFSQ was tested with normal and obese parents of
children (mean age 4.4 years) residing in the United Kingdom, having diverse education and occupations, and participating in the Twins Early Development Study (TEDS)
[90]. The PFSQ had good internal reliability and good
test-retest reliability [71]. Use of the PFSQ has shown that
obese mothers in the TEDS and normal-weight mothers
behaved similarly with regard to giving children food as a
means for coping with emotional upset, rewarding them,
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or encouraging them to eat more than wanted [71]. Additionally, there was no relationship between PFSQ subscale
scores and child weight status [71]. The questionnaire also
has been tested in low-income African American families
[61]. As with many surveys, the PFSQ does not appear to
be widely used in its full form in the literature. One study
using the control subscale found that in a low-income African American sample, maternal control was positively
linked with preschool children’s BMI z-score for obese
mothers, but not non-obese mothers [61].
Feeding Demands Questionnaire (FEEDS)
FEEDS is an 8-item questionnaire that assesses the
parents’ demand for certain child feeding behaviors. Its
subscales related to parental feeding are: anger/frustration, food amount demandingness, and food type demandingness [91]. FEEDS appears to be unique in its goal
to assess parental beliefs about child compliance with parental eating rules, a cognition that may be important for
elucidating parental drive to engage in restrictive feeding
practices [91].
Used with parents of 3- to 7-year old children (from
diverse backgrounds), FEEDS showed good internal consistency and validity. Convergent validity assessment
showed mothers with higher FEEDS scores tended to
pressure children to eat and to monitor their fat intake
[91]. Mothers with higher scores on the FEEDS food
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sure, and monitor child eating. Mothers scoring higher on
the food type demandingness subscale tended to monitor child fat intake [92]. Discriminant validity assessment
revealed that that FEEDS scores were not associated with
mother’s performance on the Fear of Fat Scale [92] or depression [91,93].
One study reported that FEEDS food amount demandingness and food type demandingness scores differed significantly among East Asian, African American,
and other races/ethnicities of parents. African American
parents scored higher on the food amount demandingness and food type demandingness subscales than other
parents, indicating they put greater feeding demands on
their young children [58].
Overt and Covert Parental Feeding Practices
This 9-item questionnaire expands conceptualization of parental control of feeding to incorporate parental “overt” control of feeding as ‘controlling a child’s food
intake in a way that can be detected by the child’ (5-item
subscale) and “covert” control as ‘controlling a child’s food
intake in a way that cannot be detected by the child’ (4item subscale) [76]. Testing with mostly white and middle
class parents revealed good internal consistency for both
the overt and covert subscales [76].
Parents with lower BMIs and who perceived their
children as heavier tended to use covert control more
so than those with higher BMIs or who did not perceive
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their children as heavier [76,94]. Parents from higher income groups also tended to use overt control [76]. Children whose parents used covert control were more likely
to consume less healthy snacks [76], yet no relationship
between the overt or covert control practices were associated with child BMI [94]. A study of an American Indian
population also found no association between parental
control and child BMI [77].
Parent Modeling of Eating
The food that parents consume has a direct effect on
the foods their children consume. Due to their function
as purchasers of food and gatekeepers, parents determine
the foods available and served in the home. Parents also
can influence children’s diets by acting as role models [9597]. Parental modeling of poor dietary habits, such as low
intake of fruits and vegetables, is linked to lower intake of
fruits and vegetables by their children [98].
The foods that parents typically consume in front of
a child may be used to determine how a parent models
his or her diet to his/her children. The 6-item Parental
Dietary Modeling Scale [99] assesses how often parents
model dietary behaviors to their children, in particular the constructs of modeling defined by Rosenthal and
Bandura[100] (i.e., observational learning, disinhibitinginhibiting behavior, facilitating similar responses, and setting cognitive standards for self-regulation). The full scale
has moderate reliability to measure parental modeling of
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diet. Other measures of covert and overt control [76] (described previously) may be used to determine how parents
overtly model healthy eating behaviors in front of their
children (Table 2).
Table 2: Parent Eating Styles and Behaviors.
Scale/Survey
Name
Original
Number of
Items
Answer
Choices
Scoring Methodology
Three-Factor
51 items
Eating Questionnaire [134]
True/false
Likert-type
responses
Eating Habits
Subscale from
the Project
EAT survey
[138]
Dutch Eating
Behavior
Questionnaire
(DEBQ)
[140]
90 items
Varies; Likert-type and
open-ended
responses
Scores for true
summed; higher
scores indicate
greater dietary
restraint, disinhibition, and
perceived hunger.
[134]
Varies
33 item
Likert-type
frequency
responses
Validity and Reliability Tests
Population(s)
Used for Validity/
Reliability
Testing
Middle-aged
Good reliability and validity [134]
men and women
[135].
N/A
N/A
College Students High validity (Cronbach alpha, respectively, 0.88 to 0.90)
Family Meal Environment
The effect of family mealtime environment on obesity and obesity-related health behaviors has been studied
mainly in older children/adolescents and parents. Among
adults, arguments during dinner about eating behavior
were linked with higher fat intake [101]. Adolescents who
reported positive family meal environments had fewer
disordered eating behaviors than those who did not have
positive family mealtime environments [102-104]. Yet,
among 4-year old children and their parents, never arguing at mealtimes was related to greater daily energy in-
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take compared with families who argue often or always
at mealtimes [105]. Among older children (ages 8 to 16
years), parents of obese youth report less positive family
mealtime interactions [106]. It appears that calm family
mealtime environments may be more beneficial for adolescents compared to young children, yet the results require further investigation.
Mealtime distractions, such as watching TV during
meals may result in unhealthy eating patterns [107-111].
People may overeat while watching TV [112-120] and
learn unhealthy food habits from TV ads for sugary, fatty
foods [119-126].
Assessing Family Meal Environment
The Project EAT survey [103,127] includes three
4-point (strongly agree to strongly disagree) Likert-type
scales to assess family mealtime environment characteristics (Atmosphere at Family Meals; Priority of Family
Meals; Structure/Rules at Family Mealtimes). The scales
are scored by averaging responses on the scale. Item testretest reliabilities and subscale internal consistency were
acceptable
• Atmosphere at Family Meals: 4 items assess family member enjoyment of sharing meals with the
family.
• Priority of Family Meals: 5 items assess importance that members place on sharing meals.
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• Structure/Rules at Family Meals: 5 items assess
where family meals are consumed and how parents expect children to behave at mealtimes.
The 21-item About Your Child’s Eating survey uses
Likert-type scale rated from ‘never’ to ‘nearly every time’
to assess parent frequency of eating behaviors, as well as
family meal perceptions and interactions [128]. The survey’s 3 subscales (list below) have good Cronbach alpha
scores.
• Child Resistance to Eating: 11 items
• Positive Mealtime Environment: 5 items
• Parent Aversion to Mealtime: 5 items
Another study used a modified version with two subscales (Positive Mealtime Interaction and a revised Resistance to Eating scale that excluded 6-items about undernutrition), which showed adequate internal consistency
[106]. Mothers of obese 8- to-16-year-olds reported more
Mealtime Challenges (a revised sub-scale) and lower Positive Mealtime Interaction scores (using the About Your
Child’s Eating-revised scale [129,130]) than mothers of
normal weight children.
The Mealtime Environment Scale [131], developed
for the Québec Longitudinal Study of Child Development
[132], has 6 items answered using a 4-point Likert-type
scale that assesses mealtime conflicts. The items rate how
often mealtime can be described as:
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• Enjoyable for everyone
• Being in a rush
• Providing time to talk to each other
• Including arguments between the children
• Including arguments between adults and children
• Including arguments between adults
Internal consistency was moderate with 150 parents
of preschool children in Quebec [131].
A sample of children from the Québec Longitudinal
Study of Child Development found that more mealtime
conflicts were connected to higher weights and (unexpectedly) healthier eating habits [133]. Never arguing at
mealtimes was linked with a higher daily calorie intake vs
frequently arguing at mealtimes [105].
Parent Eating Styles and Behaviors
Parents eating styles are a part of the home food environment that can affect children’s eating behaviors, and,
in turn their weight patterns [23,95-97]. Additionally, parents who have difficulty regulating their own food intake
may embrace child feeding practices that they believe will
prevent their children from gaining excess body weight
[23].
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Measures of Parent Eating Styles and
Behaviors
Several assessment tools are available to characterize
parent eating styles. The Three-Factor Eating Questionnaire (TFEQ) assesses dietary restraint, disinhibited eating, and emotional eating [134,135].
• The Emotional Eating scale evaluates the impact
of emotions on desire to eat (e.g., When I feel
lonely, I console myself by eating).
• The Disinhibited Eating scale assesses uncontrolled eating behaviors (e.g., Sometimes when I
start eating, I just can’t seem to stop).
• The Dietary Restraint scale assesses intentions to
restrict or regulate food intake to prevent weight
gain (e.g., I avoid “stocking up” on tempting
foods).
The TFEQ has been used in samples of college students and middle-aged men and women [135,136] and
has demonstrated good reliability and validity [134].
Emotional and disinhibited eating has been shown to be
associated with obesity, and among obese people or those
currently or previously dieting for weight control, more
dietary restraint is associated with lower weight [137].
Recent Advances in Obesity in Children
cation where dinner was eaten, and frequency of grocery
shopping, eating at fast food restaurants, eating snacks,
and eating salty snacks. The survey was originally developed for adolescents, but has been used with samples of
low-income pregnant women with success [139]. In this
low-income postnatal parent sample, mothers with less
nutritious diets indicated less control over meal preparation and were more likely to skip meals [139].
The Dutch Eating Behavior Questionnaire (DEBQ)
[140] is a 33-item instrument developed to improve understanding of emotional and external eating patterns. It
includes three scales to measure types of eating behaviors
associated with excess weight gain: emotional eating (eating in response to negative feelings), external eating (eating in response to seeing or smelling food), and restraint
eating (eating less than desired). The DEBQ has been
translated into numerous languages and all show good
factorial validity and reliability. In addition to use with
adults, it can be used with young children to assess how
a child eats, including assessment of eating in the absence
of hunger, dietary restraint or disinhibited eating or pickiness, and has also shown high internal consistency with
college students [141].
The Eating Habits Subscale from the Project EAT survey [138] consists of 9 items concerning meal skipping, lo-
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Perceived Family Functioning and
Organization
Another aspect of the family environment that may
affect childhood obesity directly or affect behaviors in
family members that are associated with obesity is family functioning. Family functioning includes the physical,
emotional, and psychological activities of family members
and is typically defined by dimensions that include support, conflict, cohesion, and control in the family [142].
It is unclear exactly how poor family functioning may
lead to childhood obesity, or if it is the presence of a child
with obesity that affects family function. The data also are
mixed as to whether functioning in families with obese
youth differs from those with normal weight children
[106,142,143]. Poverty and low socioeconomic status have
been associated with poor family functioning, and is a potential confounder of associations with obesity [144].
The concept of “household chaos” describes an environment that is high in noise and crowding and low in
routines and organization [145]. A disorganized and chaotic home environment is a risk factor for poor child behavior that may work directly through the child or indirectly through the caregiver. Household chaos can have a
direct, negative influence on cognitive performance, and
is related to behavior problems in preschool-aged children
[146-148]. Among caregivers in households with high
levels of chaos, there is lower parenting self-efficacy [149]
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and caregivers are less responsive and involved with children and more negative parenting in general [150]. Focus
group data has indicated that in families with preschoolaged children, chaos among family members in the home
increases stress [151].
Measures of Family Functioning and
Organization
The most widely used questionnaires for documenting family functioning and household organization and
chaos are described as follows (Table 3). The 90-item
Family Environment Scale [152] has 10 subscales (9 items
in each): cohesion, expression, conflict, independence,
achievement-orientation, intellectual-cultural orientation, active-recreational orientation, moral-religious orientation, organization, and control. Each subscale has
adequate test-retest reliability and internal consistency.
Additionally, each subscale evaluates unique facets of the
familial environment. In a study of eating disorder associations with family environment low family cohesion was
associated with more disordered eating in female college
students [153]. Mothers of obese youth tend to characterize their family functioning as having higher interpersonal conflict and lower in cohesion and structure (conflict
subscale factors higher) than parents of non–overweight
children [106].
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Recent Advances in Obesity in Children
Table 3: Family Functioning and Environment.
Scale/Survey
Name
Family
Environment
Scale [152]
Original
Number of
Items
90 items
Family Assess- 12 items
ment Device-General
Functioning
Subscale [154,
155]
Confusion,
15 items
Hubbub, and
Order Scale
(CHAOS)
[146]
Answer
Choices
Likert-type
agreement
responses
Likert-type
agreement
responses
Likert-type
true/false
Scoring Methodology
Scores are summed for each
subscale, with
a higher score
indicating more
behaviors in that
area
Population(s)
Validity and Reliability Tests
Used for Validity/
Reliability
Testing
Mothers of
Each subscale displays adequate
obese 8- 16 year test-retest reliability over 8 weeks
olds.
(estimates average 0.80) and 12
weeks (estimates average 0.75) with
adequate internal consistency (average
alpha=0.73)
Intercorrelation between subscales
average .20, indicating that they each
measure distinct aspects of the family
social environment.
Scores summed to Various families Good reliability in various sample
provide a score,
(from psychiagroups (Cronbach alpha =0.92 [154])
with a higher
tric population, [155] Factor analysis shows that the
score better family stroke rehab,
subscale summarizes family functiofunctioning
and college
ning well [156]
students)
Scores summed to Children and
Coefficient alpha for the 15-item scale
provide a score,
families that
was 0.79.
with a higher
were mostly
score indicating
white, but varied A subsample showed test-retest correlation was 0.74 over a 12-month period
a more chaotic,
SES
and there was no significant change
disorganized, and
in the mean or variance for the score
hurried home
over the 12-month interval [146]. The
characteristic
correlations of observed home environment chaotic conditions with maternal
perceptions in the Twin study were also
correlated [146].
The Family Assessment Device-General Functioning
Subscale [154,155] is a 12-item scale measuring overall
family functioning. It has been used in numerous population-based surveys and has excellent psychometric properties in various sample groups [154-156]. A longitudinal
study of Australian mothers with varied demographic
characteristics reported that family functioning and many
maternal obesity risk behaviors (e.g., television viewing
time, soft drink intake, fast food intake) were significantly
related [157].
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The Confusion, Hubbub, and Order Scale (CHAOS)
assesses parental perceptions of the degree of “environmental chaos in the home” [146]. CHAOS and was created for the Louisville Twin Study that assessed children
and their families from infancy to adolescence [146]. This
15-item scale has good internal consistency and test-retest
correlation [146]. Observed home environment chaotic
conditions positively correlated with maternal perceptions of household chaos [146]. The scale was modified
by other researchers to include just 6 items that were used
in a study of English families with 4- to 6-year old children from a mostly white sample of varied education and
SES [158]. Within this sample, the internal consistency
was lower than the longer version of the scale and the correlation between mothers’ and fathers’ ratings was r=.52
[158]. Findings indicated that household chaos affected
children’s problem behavior “over and above parenting”
and exacerbated negative parenting [158]. The CHAOS
scale is also being used to assess general parenting practices in the MyParenting SOS obesity prevention study (no
results could be located at the time of this writing) [159].
Child Temperament and Eating Styles
Child temperament and eating styles influence how
parents choose foods and feed their children [160,161].
Temperament may reflect how a child eats, which then influences how a parent reacts to the child. For instance, difficult infant temperaments are linked with negative mealtimes and food refusal in young children [162], as well as
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Recent Advances in Obesity in Children
parent feeding practices [163]. Feeding difficulties have
been identified in unsociable, difficult, and demanding
children [164,165].
Children’s emotionality component of their temperament may be related eating behaviors that contribute to
increased obesity risk [166,167] and parent weight status
[132]. Prospective research findings suggest that child
temperament may not be an influencer of weight or obesity risk, and instead, parental attributes are the only influences on a child’s eating behavior. Duke et al [168]
followed 135 children from birth to age seven years and
reported that parental attributes related to disordered eating (i.e., maternal history of eating disorders, body dissatisfaction, drive for thinness, dietary restraint) at infancy predicted parental pressure on children to eat at age
seven [168]. Although research is increasingly supporting
the associations between temperament and weight [169],
there is still no indication of how temperament is directly
associated with obesity in children.
The quantity of food children eat is dependent on
parent sensitivity to children’s hunger and satiety cues
and children’s individual preferences and ability to selfregulate intake [41,170]. It is accepted that infants have an
inborn ability to self-regulate food intake, but parent feeding practices during the first years of life may affect their
children’s self-regulation ability [170]. A persistent incongruence between this inborn regulation and parent feed-
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ing practices may modify inborn eating self-regulation
abilities and elevate risk for overweight [171]. Early eating behaviors remain relatively stable as children get older
(from ages 4 to 10) [172] even as children lose their innate
ability to self-regulate. Children’s inability to self-regulate
eating behavior is associated with rapid weight gain and
excess body fatness in middle childhood [173].
Measures of Child Temperament
Few measures exist to assess a child’s temperament
in a concise parent-report survey (Table 4). One measure
is the Child Behavior Questionnaire (CBQ) [174,175],
which was developed for caregivers to assess temperament
of children aged 3- to 8-years old. The domains included
in the original 195-item instrument include positive and
negative emotion, motivation, activity level, and attention.
Short and very short forms of the CBQ are available [174].
The very short form includes 3 subscales (36-items total) that have good internal consistency: urgency (sample
item: “child seems always in a big hurry to get from one
place to another”), negative affect (sample item “child gets
quite frustrated when prevented from doing something s/
he wants to do”), and effortful control (sample item “child
is good at following instructions”). The CBQ has been
widely used in research focusing on children and obesityrelated behaviors [176-178].
The 20-item EAS (Emotionality, Activity, and Shyness) Temperament Survey [179] for children assesses
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these child temperament dimensions: shyness, emotionality, sociability, and activity. The survey shows good internal consistency with Cronbach’s alpha values [166] and
good internal consistency and interrater reliability [180].
A forerunner of the EAS by the same research group,
namely the Colorado Childhood Temperament Questionnaire, also includes a subscale for Reaction to Food [181].
Not to be ignored are the temperament instruments
that are conceptually based on the findings of the New
York Longitudinal Study (NYLS) [182]. True to the nine
dimensions of the NYLS, the Behavioral Style Questionnaire consists of 100 items that measure activity, rhythmicity, approach, adaptability, intensity, mood, persistence, distractibility, and sensory threshold [183]. Based
on combinations of subscale scores, children may be categorized as “easy,” “difficult,” or “slow–to-warm-up.” The
Temperament Assessment Battery for Children–Parent
Form also reflects the NYLS theoretical framework, but
contains only six subscales across 48 items, namely, activity, adaptability, approach/withdrawal, emotional intensity,
ease of management through distraction, and persistence
[184]. As reported by their developers, both of the scales
have more than acceptable reliability and internal consistency as well as good external validity [183,184]. Although
these NYLS instruments have been underutilized in child
obesity research, Carey [185] has reported that babies
rated by their mothers as difficult displayed more rapid
weight gain over the second six months of life, presumably
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due to their being fed more to quiet them.
Table 4: Child Temperament and Eating Styles.
Scale/Survey
Name
Original
Number of
Items
Population(s)
Validity and Reliability Tests
Answer
Choices
Scoring Methodology
Child Behavior 36 items
Questionnaire
(CBQ) [174,
175] Very
Short Form
Likert-type
agreement
responses
Scores summed to
provide scale scores, with a higher
score indicating
more behavior in
that area
EAS (Emotio- 20 items
nality, Activity,
and Shyness)
Temperament
Survey [179]
Likert-type
agreement
responses
Scores are summed and a mean
score is calculated
for each subscale,
with higher scores
indicating that a
trait is more typical of the child.
Colorado
Childhood
Temperament
Inventory
[181]
30 items
Likert-type
frequency
responses
1- to 6-year olds
Good internal consistency (0.73 to
0.88) and adequate test-retest reliability
(rs=0.43 to 0.80).
Behavioral
Style Questionnaire [183]
100 items
Likert-type
frequency
responses
3- to 7-year olds
Alpha coefficients of 0.60 or greater
for 7 of the 9 dimensions and test-retest
reliability coefficients at or above 0.67
for all 9 dimensions. Low adaptability
correlated with difficulty in problem
solving tasks [214].
Temperament
Assessment
Battery for
Children
[184]
48 items
Likert-type
frequency
responses
3- to 7-year olds
Alphas generally range from the 0.70
to 0.90 level. Test-retest stability was
in 0.43 to 0.70 for mothers and 0.37 to
0.62 for fathers. Ratings on persistence
and activity level correlated significantly with scholastic IQ measures [184].
Self-Regulation in Eating
[186]
8 items
Likert-type
agreement
responses
Scores summed
and higher scores
indicate more
energy regulation.
3-8 year olds
The internal consistency for this scale
was good (Cronbach alpha=0.87).
Likert-type
frequency
responses
Mean scores are
calculated from
the responses to
each subscale
and higher scores
indicate a greater
prevalence of that
particular eating
behavior
Children’s Ea- 35 items
ting Behavior
Questionnaire
(CEBQ)
[188]
Feeding
Problem
Questionnaire
[194]
8 items
Likert-type
frequency
responses
Food Neophobia Scale
[215]
10 items
Likert-type
frequency
responses
About Your
Child’s Eating-Revised
(AYCE-R)
[129]
questionnaire
25 items
Likert-type
frequency
responses
Used for Validity/
Reliability
Testing
Mixed demographic background
parents with
children ages
2-8 years
Dutch children
ages 4 to 13
years old and
U.S. children 3-8
years old
The very short form includes 3 scales
that have shown good internal consistency: urgency (0.70-0.76), negative
affect (0.66-0.70), and effortful control
(0.62-0.77)
Good reliability with Cronbach’s alpha
values ranging from 0.58 (sociability)
to 0.83 (emotionality) with a sample of
3 to 8 year olds [166].
Good internal consistency and interrater reliability with a sample of Dutch
children [180].
parents of young Good internal validity with child BMI
children who
and reliability [166, 188, 189].
vary in ethnicity
A longitudinal study found that the
and location
CEBQ subscales had significant
correlations between two time points,
but lower correlation coefficients with
satiety responsiveness, slowness in
eating, food responsiveness, enjoyment
of food, emotional overeating and food
fussiness ranging from r=0.44 to .55
and emotional under eating r=0.29
[166, 188].
A feeding problem Dutch sample
The pickiness items had relatively
severity score
of parents of
high factor loadings (range 0.59-0.74)
is based on the
children aged 1- and internal consistency (Cronbach
number of time
to 36-months
alpha 0.78), and disturbing mealtime
a parent chooses
behaviors had fair factor loading (range
the two highest
0.43-0.55) and good internal consistenfrequency rescy (Cronbach alpha 0.61).
ponses.
Mean scores are
Adults and
Factor analysis indicates that removal
calculated and
children in the
of 2 items results in a unidimensional scale.
a higher score
United States
indicates more
and Sweden
neophobia.
8- to 16-year
Good internal consistency (0.72
and 2- to 6-year to 0.91).
olds
Significant correlation with another
environment scale in expected directions showed that the AYCE-R factors
had good convergent validity.
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Measures of Child Eating Styles
Several questionnaires exist for assessing children’s
eating behaviors; however tools for assessing energy intake self-regulation in preschool-aged children, especially
using non-observational tools, are limited. The 8-item
Self-Regulation in Eating scale examines whether parents
feel their children stop eating when full [186,187]. The internal consistency for this scale is good. A study with 3- to
8-year olds found that parents who believe their children
are able self-regulate, tend to use less restrictive feeding
practices [186].
The 35-item Children’s Eating Behavior Questionnaire (CEBQ) [188] evaluates children’s food approach
and avoidant behaviors. Food approach subscales include: food responsiveness (e.g., given the choice, my
child would eat most of the time); emotional over-eating
(e.g., my child eats more when annoyed); enjoyment of
food (e.g., my child loves food); and desire to drink (e.g.,
if given the chance, my child would drink continuously
throughout the day). The food avoidant subscales are: satiety responsiveness (e.g., my child has a big appetite); slowness in eating (e.g., my child eats slowly); emotional under-eating (e.g., my child eats less when s/he is angry); and
fussiness (e.g., my child refuses new foods at first)”[188].
The CEBQ has good internal validity with child BMI and
reliability across parents of young children varying in ethnicity and location [166,188,189]. A longitudinal study
found that CEBQ subscales scores were fairly stable over
time [166,188], but were not associated with child BMI or
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temperament [166]. The CEBQ also shows some inability
to distinguish between food fussiness and food neophobia
[190].
The Food Neophobia Scale has 10 items which assess
how a child responds to new foods on a 1-7 scale (disagree
strongly to agree strongly), with higher scores indicating
more food neophobia (i.e., fear of trying new foods) [191].
The scale has been widely used and cited in studies of children and has been validated in samples from the United
States, Finland, and Sweden [192]. Recently, it was used in
a baseline obesity prevention intervention analysis [193].
Among preschool aged children, higher Food Neophobia
scores was significantly associated with lower vegetable
intake and less variety of foods eaten [193].
The Feeding Problem Questionnaire [194] assesses
food pickiness (4-items), defined as poor and selective
eating, and disturbing mealtime behaviors (4-items),
which measure the extent of disturbing behavior during
mealtime. The questionnaire was developed for use with
a mostly Dutch sample of parents of children aged 1- to
36-months. The pickiness items had relatively high factor loadings (range 0.59-0.74) and internal consistency,
and disturbing mealtime behaviors had fair factor loading
(range 0.43-0.55) and good internal consistency. No other
study could be located that used this questionnaire.
The 25-item About Your Child’s Eating-Revised
(AYCE-R) [129] questionnaire evaluates caregiver beliefs
and concerns about children’s eating and family mealtime
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exchanges. Caregivers indicate how often myriad situations related to children’s eating take place in their family using three subscales with good internal consistency:
Resistance to Eating, Positive Mealtime Interaction, and
Child Aversion to Mealtime. Significant correlation with
another environment scale in expected directions showed
that the AYCE-R factors had good convergent validity
[128]. Validity and reliability was assessed in samples of
children 8- to 16-years [129] and 2- to 6-year olds [195].
The AYCE-R has been used in a study of preschool-aged
children and their parents enrolled in an obesity-prevention program and has shown improved resistance to eating and positive mealtime interactions between baseline
and 6-months after the initiation of the intervention [196].
Conclusion
Research has increasingly provided evidence that environmental factors significantly influence diet, physical
activity, and obesity in adults [197-199] and children [80,
200-202], yet the causal relationships for many of these associations remain tenuous [80, 199]. In recent years, many
health behavior change theories have recognized the influence of environmental factors on health outcomes [203].
This ecological approach to public health issues posits
that an individual’s motivation and skills alone are not
adequate to facilitate behavior change; environments and
policies also need to support and facilitate the practice of
healthful behaviors [80,199,204]. Reciprocal determinism, a construct of Social Cognitive Theory, postulates
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that a person’s characteristics, actions, and environmental
milieu, concurrently and mutually affect each other [205].
Environments non-supportive of weight-management behaviors make it challenging for individuals to undertake
behaviors that allow them to avoid excess weight gain. Interventions to prevent overweight and obesity in young
children have thus far have failed to show an effect in reducing or limiting weight gain [206], perhaps because little attention has been given to social and environmental
factors [33].
Given its potentially great influence on the development of behaviors, the home deserves in-depth study to
increase our understanding of its role related to obesity
risk in children [207]; however, research focusing on the
home environment, especially the interpersonal environment, remains limited [80,208-210]. The studies that do
exist tend to focus on a small number of factors within the
home environment, leaving out potentially vital variables
and limiting the ability to explore interactions among variables. Research also is hindered by a lack of validated and
reliable environmental measures [207,211-213], which are
necessary to create an accurate understanding of potential
predictors and modifiers of obesity risk in young children
and their parents [210]. It is hoped that the information
in this chapter will spur new and expanded research questions that provide insights into how the home interpersonal environment can support or thwart healthy weight
status and lead to programs that enable parents to create
home environments supportive optimal child growth and
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Recent Advances in Obesity in Children
development while preventing childhood obesity.
Acknowledgements
An earlier draft of this manuscript was part of J. Martin-Biggers (2016) Home Environment Characteristics
Associated with Obesity Risk In Preschool-Aged Children
and Their Parents, unpublished doctoral dissertation, Rutgers, The State University of New Jersey, New Brunswick,
NJ.
Supported by United States Department of Agriculture, National Institute of Food and Agriculture, Grant
Number 2011-68001-30170.
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