Parent Food-Related Behaviors and Family-Based Dietary and Activity Environments: Associations with BMI z-Scores in Low-Income Preschoolers

Abstract

Background:

In early childhood, the family dietary and activity environment and parent food-related practices have been found to be important predictors of children's weight. However, few studies account for both of these factors, or the interaction between the 2, when assessing BMI in early childhood. This study aims to examine the association between the family-based dietary and activity environment (including intake, physical activity, and structure) and children's BMI z-scores in the context of parent food-related behaviors in low-income families during the preschool years.

Methods:

Parents (n = 111) completed questionnaires assessing the family-based dietary and activity environment, including diet, physical activity, screentime and sleep, and their use of parent food-related behaviors including parent-centered (i.e., controlling) and child-centered (i.e., autonomy supportive) practices. Children's BMI z-scores were calculated from researcher-measured height and weight.

Results:

Parent-centered food-related behaviors were directly related to children's BMI z-scores and moderated the association between the family-based dietary and activity environment and children's BMI z-scores. Family-based behaviors were associated with lower BMI only when parents used fewer parent-centered behaviors.

Conclusions:

Findings indicate that programs working with low-income families to prevent child obesity should stress both the creation of a healthy home environment and the use of positive parent food-related behaviors with preschool aged children.

Introduction

Obesity continues to be a concern for preschool aged children in the United States,¹ with low-income children facing an increased risk.² While both the dietary environment and parenting behaviors have been found to be important factors of influence on weight status in early childhood, their joint influence is not well understood.

Dietary behavior surveys of young children have found that preschoolers tend to have inadequate access to, and consume less than, the recommended amounts of fruits and vegetables, and consume more than the recommended amount of fruit juice and sugar-sweetened beverages daily.^3,4 Overall, preschoolers' caloric intake exceeds the daily age-based recommendations.⁵ A recent examination of behavior changes that resulted in decreased BMI for preschoolers participating in a lifestyle and behavior change intervention found that decreases in caloric intake were associated with preschooler weight outcomes.⁶ However, caloric intake in early childhood is largely determined by caregivers who control environments and access. As such, it may be important to account for the family-based context that provides the structure for a healthy diet and weight, allowing healthy caloric intake and physical activity levels. For instance, researchers found that a pediatric obesity risk assessment tool covering family-based diet, activity, lifestyle, and parenting behaviors was predictive of BMI in 2- to 5-year-old children in a 2-year longitudinal study.⁷ These results indicate that the overall family-based environment in early childhood is a likely contributor to long-term weight outcomes in early childhood.

Evidence from longitudinal studies suggests that eating behaviors established in childhood persist into adulthood.^8,9 As such, the context in which children come to learn and adopt healthy behaviors is important to understand in order to inform intervention efforts aimed at preventing the development of obesogenic behaviors. Parent food-releated behavior is one contextual element that has received much of the research attention. The evidence for associations between parent food-related behaviors and children's diets has focused on specific behaviors, with the strongest evidence emerging for a positive association between parent use of controlling feeding practices and children's weight, and a negative association of pressure to eat and children's weight.¹⁰ However, the results across studies are not entirely consistent and appear to vary depending on a variety of factors, including the type of food and the weight status of the child.¹⁰ Across these studies there is little attention paid to associations of parent food-related behaviors and overall quality of the family environment and children's diets. Furthermore, the pattern of findings tends to be reversed in samples of preschoolers as compared to older children, indicating that parent food-related behaviors tend to operate differently in early childhood.¹¹ Several factors may account for this difference in patterns. First, early childhood marks a time when children's self-regulatory systems are forming.¹² As such, children largely rely on external controls, such as caregivers and daily routines, to regulate their behavior.¹³ Second, the majority of studies focus on specific parent food-related behaviors rather than constellations or patterns of behaviors. It may be more useful to consider patterns of behavior to capture the context in which children develop dietary behaviors.

Parent food-related behaviors tend to fall into three main areas: coercive control, structure, and autonomy support.¹⁴ Coercive control strategies (e.g., pressure to eat, restriction) tend to be parent-centered, focused primarily on parents' goals without accounting for the individual child's needs. In contrast, structure (e.g., monitoring, meal routines) and autonomy support (e.g., reasoning, child involvement) tend to be child-centered, focused on the needs of the child and building their capacity to develop self-directed dietary behaviors. These two constellations of parent food-related behaviors, “parent-centered” and “child-centered,”¹⁵ may serve to differentially influence children's autonomous regulation of their dietary behaviors. Drawing from the literature on the development of children's self-regulation, children whose parents use autonomy supporting parenting strategies that focus on guiding, teaching, and support to control children's behavior tend to have children with higher levels of self-regulation.^16–18 In contrast, the use of more overt controlling strategies that focus on power-assertion are associated with lower levels of self-regulation. The use of autonomy supporting parenting strategies are believed to elicit internalization of values and expectations, helping the child to develop internalized self-regulation over time.^19,20 In the context of children's development of dietary behaviors, child-centered parent food-related behaviors that account for, and are responsive to, the child's needs may be more conducive to developing behaviors that are internally motivated and thus more sustainable over time. In contrast, dietary environments built upon parent-centered approaches may elicit the desired behavior in the short term, but be less sustainable over time and thus bear less impact on children's weight over time. For instance, evidence suggests that the use of pressuring to eat by parents undermines children's ability to self-regulate their food intake^21,22 and poor self-regulation in early childhood has been found to predict risk for obesity in early adolescence.^23,24 This process may be especially influential in early childhood, a critical developmental period for both regulation¹² and dietary behaviors.^8,9

With respect to children's dietary behaviors, both parent-centered and child-centered parent food-related behaviors have been found to be associated with children's dietary intake.^14,25 However, associations with children's weight are not consistent^10,25 indicating that the process by which parent behaviors influence the dietary environment and ultimately impact children's weight may be more complex. To account for this complexity, studies that test for interactions between diet and contextual variables are needed.^10,14 In early childhood, parent food-related practices may be an important context influencing the development of children's autonomous regulation of health promotion behaviors. To fully understand this process, both the family dietary and activity environment (what children eat and drink, how often children move, and structure of the day) and parent food-related behavior patterns (parent-centered and child-centered) must be taken into consideration when examining children's weight status in early childhood.

This study aims to examine the association of the family-based environment, including food behaviors, physical activity, and structure, and children's weight in the context of parent food-related behaviors during the preschool years. The study has two primary aims. First, we examine the joint associations of the family-based dietary and activity environment and parent food-related behaviors on preschool children's weight. It is hypothesized that healthier family-based dietary and activity environments and child-centered parent food-related behaviors will be associated with lower BMI scores, where parent-centered food-related behaviors will be associated with higher BMI scores. Second, we test for moderating effects of parent-centered and child-centered food-related behaviors on the association between family-based environments and weight. It is hypothesized that healthy family-based dietary and activity environments will be associated with lower child BMIs when in the context of higher child-centered, and lower parent-centered food-related behaviors. Importantly, the study is conducted with low-income, ethnically diverse families due to the higher prevalence of obesity in this population.²

Methods

Sample

Participants in this study were parents (91% mothers) and their preschool-aged children (mean age = 3.91 years) enrolled in the Healthy Kids (HK) longitudinal study of early risk factors for obesity development in low income families.⁷ Participants were recruited for HK through Head Start preschools and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) centers in the Sacramento region of California. All participant caregivers were older than 18 years, understood English as a first or second language, and had a child between the ages of 2 to 5 years. The full study sample enrolled 176 parent-child pairs into the study at the initial data collection point. The analytic sample for this article includes 111 parent-child pairs with complete data for all study variables drawn from the first six time points of data collection (24 weeks; n = 117), and excluding those with BMIs considered underweight (n = 4) or biologically implausible (n = 2). Sample size and attrition across the full study is described elsewhere.⁷ Tests for selective attrition between the retained and dropped families revealed no significant demographic differences on child's gender, parent's gender, marital status, parent education, household income, and ethnicity/race of child, nor were there any significant differences on the primary variables of analysis at the initial time point.

The final analytical sample is ethnically diverse, majority family income below $20,000 per year, and with education levels of some college or below (Table 1). There were slightly more female child participants (59%) than male.

Table 1.

Demographic Data for Analytic Sample (n = 111)

	n	% of sample
Gender
Boy	45	41
Girl	66	59
Ethnicity
African American/Black	37	33
Asian/Pacific Islander	7	6
Caucasian/White	21	18
Hispanic/Latino(a)	25	23
Multiethnic	19	17
Another ethnicity	2	2
Household income
<$20,000/year	76	69
$21–$25,000/year	15	14
$26–$30,000/year	6	5
$31–$35,000/year	5	5
$36–$40,000/year	4	4
>$40,000/year	3	3
Missing	2	2
Parent education level
Less than HS	7	6
HS diploma or GED	31	28
Some college	62	56
Bachelor's degree	7	6
Graduate degree	4	4

GED, General Educational Development; HS, high school.

Parent Food-Related Behaviors

The my child at mealtime (MCMT)²⁶ self-report of parent food-related behavior was used to assess parent food-related behaviors. MCMT is designed for low-income audiences to measure “parent-centered” (12 items, Cronbach's α = 0.82 “I struggle with my child to get her to eat.”) and “child-centered” (14 items, Cronbach's α = 0.82, “I get my child to eat by explaining that food is good for him.”) parent food-related behaviors.²⁷ Parents report how often they engage in certain behaviors from “no/rarely” (1) to “very often” (4), and responses are averaged. The MCMT questionnaire has previously been tested and validated with parents of low-income preschoolers for use as a self-assessment of parent food-related behavior.^26,28 In this sample, parent-centered scores ranged from 1.00 to 3.67 (M = 1.59) and child-centered scores ranged from 1.79 to 3.86 (M = 2.82; see Table 2 for all descriptive statistics).

Table 2.

Descriptive Statistics for Analytic Sample (n = 111)

	n	Min	Max	Mean	SD
MCMT parent-centered food-related behaviors	111	1.00	3.67	1.59	0.42
MCMT child-centered food-related behaviors	111	1.79	3.86	2.82	0.44
HK	111	55.57	88.03	72.05	8.16
T4 BMI-for-age z-score	111	−1.54	3.43	0.55	0.99
Normal weight (BMI z-score <1.0)	83
At-risk of overweight (BMI z-score >1.0)	17
Overweight (BMI z-score >2.0)	10
Obese (BMI z-score >3.0)	1
T6 BMI-for-age z-score	111	−1.72	3.40	0.58	1.02
Normal weight (BMI z-score <1.0)	75
At-risk of overweight (BMI z-score >1.0)	24
Overweight (BMI z-score >2.0)	11
Obese (BMI z-score >3.0)	1
T3 child age (months)	111	13.80	70.60	46.88	12.36

HK, Healthy Kids; MAX, maximum; MCMT, my child at mealtime; MIN, minimum; SD, standard deviation.

Family-Based Dietary and Activity Environment

Children's family-based dietary and activity environments were assessed with the HK²⁹ obesity risk assessment tool for young children. This 19-item parent report (α = 0.76)⁷ tool is designed for low-income audiences to assess family-based behaviors identified as modifiable determinants of obesity risk in early childhood,^30,31 including diet, physical activity, screentime, and sleep. Scores are summed across items with a higher score indicating a healthier family-based environment. This measure has been validated in relation to health indicators and prospectively predicting BMI for age percentiles in a sample of low-income preschoolers.⁷

BMI z-Score

Child weight status was assessed with BMI z-score calculated with researcher-measured height and weight using CDC growth charts for age and gender. Calculations were completed using the CDC SAS program to standardize BMI to children's age and gender.^32,33 Two BMI z-score values calculated through the CDC SAS program were flagged as biologically implausible values (−6.94, −8.51) and thus removed from the data. Due to the focus on overweight/obesity in this study, children with a BMI z-score indicating underweight status (n = 4) for the dependent variable were not included in the final analytic sample. Children in the analytic sample had BMI z-scores ranging from −1.72 to 3.40 for the dependent variable, with an average of 0.58.

Procedure

This study was approved by the first author's Institutional Review Board and informed consent (for the parent) and parental consent (for the child) were obtained. The data collection timeline has been detailed elsewhere.⁷ Data used in the current study were collected across a 6-month period. Demographic information was collected via parent report at the first time point. The HK and MCMT questionnaires were completed at the third time point (week 12, T3). BMI z-score were measured at both the fourth (week 15, T4) and sixth time points (week 24, T6).

Statistical Analyses

To examine the joint associations between the family-based dietary and activity environment and parent food-related behaviors, linear regression models were fit to consider the outcome of BMI z-score at T6 including T4 BMI z-score as a control variable. To test the second aim of moderation effects of parent-centered and child-centered food-related behaviors on the association between family-based dietary and activity environment and weight, the PROCESS macro version 3 for testing moderation in SPSS was used.³⁴ This macro creates a cross-product interaction term between the MCMT parent-centered and child-centered subscales (separately for each model) and HK scale, with variables being mean centered by subtracting the mean value of each variable from the value for each participant for ease of interpretation for significant interactions. Variables and interaction terms were added into the models using a stepwise regression approach. Significant moderation effects were further probed for any interaction term p < 0.10, considering simple slopes at the mean and 1 standard deviation (SD) above and below the mean for the moderator variable. All models included child gender, child age (in months, at the time point the HK and parent food-related behaviors measures were collected), and maternal education as covariates given noted differences in previous research between child weight status in relation to these variables.^35–38 Analyses were conducted in IBM SPSS Statistics version 25. Missing data were handled using listwise deletion.

Results

In relation to the first study aim, step 2 of the models considered parent food-related behaviors and family-based dietary and activity environments as independent variables associated with child weight. Model results indicate that parent-centered behaviors, but not child centered behaviors (see Tables 3 and 4 for stepwise regression models), was a significant, negative predictor of BMI z-score at T6 controlling for T4 BMI z-score. HK was marginally (p = 0.08 and 0.05) negatively associated with BMI z-score in both models. In step 3 of the parent-centered model, the cross-product interaction between HK and parent-centered behaviors was significant (p = 0.02). The interaction between child-centered behaviors and HK was not significant. In reference to the second study aim, examination of the simple slopes for parent-centered behaviors indicated HK was related to lower child T6 BMI z-scores only for parents who reported low frequency of parent-centered behaviors (1 SD below the mean) but not parents who reported mean-level or high frequency (1 SD above the mean) of parent-centered behaviors (Table 3; Fig. 1).

Figure 1.

Simple slopes for 1 SD above and 1 SD below the mean for parent-centered My Child at Mealtime in relation to HK scores predicting BMI z-scores. HK, Healthy Kids; SD, standard deviation.

Table 3.

Stepwise Regression: T6 BMI z-Score Predicted by My Child at Mealtime Parent-Centered Food-Related Behaviors, Healthy Kids, and Interaction, Controlling for T4 BMI z-Score (n = 111)

	β (SE)	t-Value	p-Value	R²
Step 1				0.58
Intercept	0.30 (0.07)	4.53	<0.001
T4 BMI z-score	0.76 (0.05)	12.45	<0.001
Step 2				0.61
Intercept	0.32 (0.07)	4.88	<0.001
T4 BMI z-score	0.73 (0.05)	12.03	<0.001
MCMT parent-centered food-related behaviors	−0.14 (0.15)	−2.36	0.02
HK	−0.11 (0.01)	−1.79	0.08
Step 3				0.63
Intercept	0.35 (0.07)	5.34	<0.001
T4 BMI z-score	0.70 (0.05)	11.65	<0.001
MCMT parent-centered food-related behaviors	−0.16 (0.15)	−2.71	0.01
HK	−0.09 (0.01)	−1.53	0.13
HK × parent-centered	0.14 (0.02)	2.37	0.02
Step 4				0.63
Intercept	0.23 (0.30)	0.74	0.46
T4 BMI z-score	0.70 (0.05)	11.26	<0.001
MCMT parent-centered food-related behaviors	−0.17 (0.15)	−2.37	0.02
HK	−0.09 (0.01)	−1.42	0.16
HK × parent-centered	0.14 (0.02)	2.22	0.03
T3 child age (mos)	0.003 (0.01)	0.05	0.96
Child gender (female)	0.002 (0.13)	0.04	0.97
Maternal education^a
Less than HS	0.03 (0.32)	0.43	0.67
Completed HS or GED	0.07 (0.23)	0.66	0.51
Completed some college	0.04 (0.22)	0.40	0.69
Conditional effects for HK by parent-centered food-related behaviors
–1 SD (1.17)	−0.03 (0.01)	−2.83	0.01
Parent-centered mean (1.59)	−0.01 (0.01)	−1.48	0.14
+1 SD (2.01)	0.01 (0.01)	0.60	0.55

Completed bachelor's degree or above used as reference group.

Table 4.

Stepwise Regression: T6 BMI z-Score Predicted by My Child at Mealtime Child-Centered Food-Related Behaviors, Healthy Kids, and Interaction, Controlling for T4 BMI z-Score (n = 111)

	β (SE)	t-Value	p-Value	R²
Step 1				0.58
Intercept	0.30 (0.07)	4.53	<0.001
T4 BMI z-score	0.76 (0.05)	12.45	<0.001
Step 2				0.59
Intercept	0.31 (0.07)	4.76	<0.001
T4 BMI z-score	0.74 (0.05)	12.15	<0.001
MCMT child-centered food-related behaviors	0.11 (0.01)	1.50	0.14
HK	−0.14 (0.01)	−1.99	0.05
Step 3				0.60
Intercept	0.30 (0.07)	4.20	<0.001
T4 BMI z-score	0.74 (0.05)	12.11	<0.001
MCMT child-centered food-related behaviors	0.10 (0.17)	1.47	0.14
HK	−0.14 (0.01)	−1.97	0.05
HK × child-centered	0.03 (0.02)	0.44	0.66
Step 4				0.60
Intercept	0.22 (0.32)	0.70	0.49
T4 BMI z-score	0.74 (0.05)	11.73	<0.001
MCMT child-centered food-related behaviors	0.12 (0.17)	1.62	0.11
HK	−0.15 (0.01)	−2.06	0.04
HK × child-centered	0.03 (0.02)	0.49	0.63
T3 child age (mos)	−0.02 (0.01)	−0.32	0.75
Child gender (female)	−0.02 (0.13)	−0.28	0.78
Maternal education^a
Less than HS	0.001 (0.33)	0.01	0.99
Completed HS or GED	0.13 90.24)	1.16	0.25
Completed some college	0.09 (0.22)	0.79	0.43

Completed bachelor's degree or above used as reference group.

Discussion

This study examined the role parent food-related behaviors assume in the association between the family-based dietary and activity environment and children's weight. With regard to the first aim focused on the joint associations of family-based dietary and activity environment and parent food-related behaviors on children's weight, the results did not support the hypotheses. Instead, only parent-centered food-related behaviors were significant in the model, associated with lower BMI. While family-based environments failed to reach significance in either model, it was marginally associated with lower BMI in the context of both parent- and child-centered food-related behaviors. Testing of the second aim supported a moderating effect of parent-centered, but not child-centered, food-related parenting behaviors, whereby a healthy family-based environment was associated with lower BMI within the context of fewer parent-centered behaviors.

The findings support our theory that the process by which parent food-related behaviors impact children's BMI in early childhood is more complex than a direct association is able to capture. While associations between individual parent food-related behaviors and children's dietary intake are well established,^14,25 there is less consistency in the associations with children's BMI.^10,25 The current results suggest that previous inconsistent results may be in part due to the need to account for both the family-based dietary and activity environment and parent food-related behavior patterns to understand the context in which children's obesogenic behaviors are being formed.³⁹

Specifically, the results support the importance of preventing reliance on parent-centered food-related behaviors during the preschool years, with both a direct association and a moderating effect on children's dietary and activity-related behaviors. While the majority of the current sample had BMIs in the healthy range at both time points, the current results mirror recent empirical evidence for the benefits of a slower weight gain trajectory in early childhood. Similar to the results found here, decreases in BMI that remain in the healthy range in early childhood have been found to be associated with positive home environments.⁴⁰ These slower weight gain trajectories have also been found to be associated with reduced risk of developing obesity into adulthood.⁴¹ As such, factors that slow weight gain in early childhood may help maintain optimal weight gain over time.

The fact that there was a direct negative association between parent-centered behaviors and children's BMI is notable given the general inconsistency in the field between parent food-related behaviors and children's weight. This finding is consistent with the idea that such parent-centered approaches may elicit the desired behavior in the short term. However, these behaviors may be difficult to maintain over time, and thus be less effective in the long-term than child-centered behaviors that foster internally motivated behaviors that are more likely to be sustained by the child over time. Moreover, the current study utilizes a constellation of behaviors rather than focusing on specific behaviors or categories of behaviors (e.g., pressure, restriction). This approach may capture more of the variability that exists in parents' patterns of behaviors across contexts.

Furthermore, the findings suggest that analyzing the use of these behaviors in the context of the home dietary and activity environment is important. The moderation effect of parent-centered food-related behaviors suggests that the presence of parent-centered behaviors may undermine the benefits of positive family-based dietary and activity environments for child weight and obesity risk. For instance, access to fruits and vegetables or limits on screen time may be less beneficial when in the context of a parent who exerts high control over the child's health-related decisions. While this study did not test an intervention to address parent behaviors, the results suggest that it may be important to help parents decrease their use of parent-centered behaviors not only because of the potential to have direct effects on child obesity via mechanisms such as developing self-regulation, but also because these behaviors may attenuate the positive effects of a healthy family-based environment.³⁹

Contrary to our hypothesis, autonomy supporting child-centered behavior was not a significant contributor or moderator related to children's BMI. Generally, there are few studies focused on the use of autonomy supporting behaviors in predicting diet or weight of preschool-aged children.⁴² As such, little is known about the role these behaviors assume in the development of children's dietary behaviors. It may be that these types of behaviors help build children's regulatory systems in early childhood, which may be beneficial as children enter the elementary school years and have more autonomous regulatory control.^12,39 Longitudinal studies examining these associations across multiple developmental periods are needed to better understand the role parents assume in the development of children's autonomous regulatory systems related to diet and weight. The current results indicate that such an approach provides a meaningful lens through which to understand how home environments may operate in early childhood to prevent the risk of children adopting obesogenic behaviors later in development.

Limitations

Given that this study was focused on low-income families due to their increased risk of obesity,² it cannot be ruled out that these patterns are specific to this particular population. For instance, it may be that the unique contexts of low-income families⁴³ create an environment whereby limited use of parent-centered strategies is more important than the use of child-centered strategies for children's weight. For instance, studies of parent-child interactions have found that high socioeconomic status (SES) parents engage in more autonomy building types of exchanges with their children overall, which may be in part due to limitations of time for lower SES parents to allocate focused attention to individual children.⁴⁴ In contrast, the current sample represents a specific demographic of low-income families that participate in Head Start and WIC (locations of recruitment). As such, it is likely that the diversity of patterns that are represented in low-income families is not fully captured here.

Additionally, parents with limited incomes tend to experience higher food insecurity,^45,46 which has been found to undermine parents ability to engage in quality parenting behaviors.⁴⁷ In these environments, a reduced emphasis on parent-centered food-related behaviors may be enough to shift children's weight outcomes in a more positive direction rather than the increased use of child-centered behaviors. Additional studies with more diverse SES samples are needed to further examine whether this is the case. Likewise, the small sample size and low rate of overweight/obesity in the current analytical sample prevent analysis stratified by weight status and thus preclude testing whether weight status changes as the result of factors in the family environment.

Finally, there is emerging evidence of the importance of children's individual characteristics, such as weight⁴⁰ and temperament,⁴⁸ in relation to parents' food-related behaviors. It may be that parent-centered behaviors are more likely to be used with children they perceive as overweight in an attempt to control intake or activity level, or in response to particular temperamental profiles to control behavior. Future research should consider children's contributions to these interactions to gain a more complete picture of the process through which parent-child interaction patterns influence the development of children's health behaviors.

Footnotes

Funding Information

Funding provided by National Institute of Food and Agriculture, USDA Award No. 2010-85215-20658. The authors thank Larissa Leavens and Christine Davidson for their valuable assistance with data collection, Lynn-Kai Chao and Kathi Sylva for photography work, SETA Head Start of Sacramento, CA and the families who participated in this research.

Author Disclosure Statement

No competing financial interests exist.

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