Do Appetite Traits Mediate the Link Between Birth Weight and Later Child Weight in Low-Income Hispanic Families?

Abstract

Background:

Birth weight and appetite traits (ATs) are important early life determinants of child weight and obesity.

Objectives:

The aim of this study is to examine whether (1) birth weight-for-gestational age z-scores (BWGAzs) were associated with ATs at child age 2 years and (2) ATs mediated the link between BWGAzs and weight-for-age z-scores (WFAzs) at child ages 3 and 4 years among Hispanic children.

Methods:

We conducted a secondary longitudinal analysis of data from the Starting Early Program of low-income, Hispanic mother–child pairs. ATs were assessed using the Child Eating Behavior Questionnaire at age 2 years. Child birth weight was obtained from medical records. Birth weight, sex, and gestational age were used to generate BWGAzs with Fenton growth curves. WFAz was calculated based on the CDC 2000 growth charts. Regression and mediation analyses were used to explore associations between BWGAzs, ATs, and WFAzs.

Results:

Infants with higher BWGAzs had significantly lower Satiety Responsiveness (B = −0.10) and Food Fussiness (B = −0.13) scores at age 2 years and higher WFAzs at ages 3 (B = 0.44) and 4 (B = 0.34) years. Lower Satiety Responsiveness at age 2 years was associated with higher WFAzs at ages 3 (B = −0.11) and 4 (B = −0.34; all p < 0.01) years. Lower Satiety Responsiveness partially mediated the positive relationship between birth weight and child WFAzs at ages 3 and 4 years.

Conclusions:

Children with higher birth weight and lower Satiety Responsiveness scores may be at higher risk of developing obesity in childhood. Further research is needed to understand the mechanisms through which birth weight influences child appetite. Clinical Trial Registration: ClinicalTrials.gov: NCT01541761

Introduction

High rates of obesity in the United States and worldwide make understanding the etiology of excess weight gain in early life imperative.¹ Higher birth weight is a well-documented perinatal factor known to be associated with higher child weight and obesity risk.^2–7 Mechanisms of how higher birth weight leads to increased obesity risk across the life course are less clear and likely multifactorial, influenced by both genetic predisposition and environmental factors.^8–10

Identifying potentially modifiable early childhood risk factors for later obesity,¹¹ which mediate the linkage between birth weight and later child weight, is important for developing effective obesity prevention. While much research has focused on parent–child feeding styles and practices (e.g., responsive feeding styles, breastfeeding, sugary drink intake), fewer studies have addressed potentially modifiable child characteristics.

Child appetite traits (ATs) describe individual patterns of eating that are more food-approaching traits (e.g., Food Responsiveness) or more food avoidant traits (e.g., Satiety Responsiveness).¹² Studies have found that food avoidant ATs are associated with lower risk of excess weight gain and obesity, while food approach traits are associated with higher obesity risk.^13–16 ATs may be related to infant weight gain and obesity risk through their association with parenting and feeding practices^17,18 and thus child energy intake.¹⁹ ATs are potentially modifiable risk factors for early onset of obesity¹¹ influenced by both genetic predisposition and environment (e.g., obesogenic food environment, parental).⁸

The Behavioral Susceptibility Theory (BST) hypothesizes that differences in appetite may mediate the interaction between genetic susceptibility to obesity and environmental exposure and therefore ATs may serve as a potential mediating mechanism for the link between higher birth weight and later child weight and obesity.⁸ Although the literature on associations between birth weight and later child weight and obesity risk is clear, evidence on early life determinants of ATs (e.g., Satiety Responsiveness and Food Responsiveness) is limited.

To our knowledge, only a few of studies with inconsistent results have explored the association between birth weight and later child ATs,^20–22 and none have examined the potential role that ATs may play in the pathways linking birth weight and later child weight in low-income and racial/ethnic minority families. Therefore, this study aimed to assess (1) associations between birth weight and child ATs at child age 2 years and (2) whether ATs at age 2 years mediate associations between birth weight and later child weight in low-income Hispanic families.

Methods

Study Design

This is a secondary longitudinal analysis of data from the Starting Early Program (StEP), a randomized, controlled obesity prevention trial of low-income Hispanic mother–child pairs.^23,24 The StEP methodology, design, and recruitment protocol has been described in detail elsewhere.^23,24 Briefly, between August 2012 and December 2014, the StEP trial randomized 533 pregnant women during a third-trimester prenatal visit (baseline) in a large public hospital in New York City.

Pregnant women were randomized into two groups: (1) those who received standard prenatal and pediatric care (control) and (2) those who participated in StEP (intervention). Surveys were conducted in English or Spanish by trained research staff at the baseline prenatal visit, with follow-up at child ages 3 months, 10 months, 19 months, 2 years, 3 years, and 4 years.

The StEP trial is registered on clinicaltrials.gov and is approved by the institutional review boards of New York University Grossman School of Medicine, with approval from New York City Health + Hospitals.

Study Sample

The inclusion criteria were as follows: (1) women aged ≥18 years; (2) Hispanic/Latino ethnicity of any race; (3) a singleton uncomplicated pregnancy; (4) willing to receive prenatal and pediatric care at the study sites; and (5) fluent in English or Spanish. Women were excluded from the study if they had severe fetal anomalies, substance use disorder, significant medical or psychiatric illness, or were homeless.

The analytic sample is based on having birth weight data, child AT data at 2 years, weight data at 3 years (for analyses using 3-year weight), and weight data at 4 years (for analyses using 4-year weight).

Measures

Anthropometric measures

Infant birth weight, sex, gestational age, and child weight data at ages 3 and 4 years were obtained from medical record reviews.²⁵ Infant birth weight-for-gestational age z-scores (BWGAzs) were generated with Fenton growth curves using infant birth weight, sex, and gestational age. Child weight-for-age z-scores (WFAzs) at ages 3 and 4 years were calculated based on CDC 2000 growth charts.²⁶

WFAz and WFA percentiles correspond well with the BMI cutoff for obesity in children²⁷ and were used in this study, rather than BMI-for-age, due to biologically implausible variation identified in clinically measured lengths/heights.^24,28

AT measures

ATs at child age 2 years were measured using the Child Eating Behavior Questionnaire (CEBQ), a parent-administered validated scale. Eight ATs, with Cronbach's α estimates of 0.70 to 0.91,^29–31 are measured by the CEBQ. Satiety Responsiveness, Slowness in Eating, Emotional Undereating, and Food Fussiness are food avoidant/obesity-protective traits, and Food Responsiveness, Enjoyment of Food, Emotional Overeating, and Desire to Drink are food-approaching/obesogenic traits.¹² A total of 402 mothers completed the CEBQ at the 2-year assessment.

Table 1 displays the eight CEBQ ATs included in this study, sample questions for each trait, scales, and mean scores for each AT. The eight CEBQ subscales included in the present analysis had Cronbach's alpha estimates of 0.46–0.80 and six of these eight are considered to have moderate to high levels of reliability (Table 1).³²

Table 1.

Sample Questions and Mean and Cronbach's α Scores for Child Eating Behavior Questionnaire Factors Used in the Starting Early Program

ATs^a	No. of items	Sample question	Scores (mean ± SD)^b	Cronbach's α
CEBQ
Satiety Responsiveness	5	My child gets full up easily	3.28 ± 0.6	α = 0.56
Slowness in Eating	4	My child takes >30 minutes to finish a meal	3.37 ± 0.7	α = 0.46
Emotional Overeating	4	My child eats more when anxious	2.39 ± 0.5	α = 0.67
Food Fussiness	6	My child is difficult to please with meals	2.72 ± 0.7	α = 0.78
Food Responsiveness	5	If allowed to, my child would eat too much	3.03 ± 0.8	α = 0.80
Enjoyment of Food	4	My child enjoys eating	4.48 ± 0.5	α = 0.67
Emotional Undereating	4	My child eats less when upset	3.40 ± 0.8	α = 0.71
Desire to Drink	3	My child is always asking for a drink	3.80 ± 0.9	α = 0.70

The CEBQ³¹ assessed ATs of children at age 2 years.

1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = always.

AT, appetite trait; CEBQ, Child Eating Behavior Questionnaire; SD, standard deviation.

Baseline characteristics

Maternal demographic data, including age, country of birth, marital status, education, parity, participation in supplemental food assistance programs, household food insecurity (using the Core Food Security Module from the US Department of Agriculture),³³ and depressive symptoms (using the Patient Health Questionnaire-9)³⁴ were collected at the baseline prenatal visit.

The mode of delivery was obtained from the medical review. Maternal prepregnancy BMI and gestational weight gain were calculated using weight and height data from the medical record review.³⁵

Statistical Analyses

First, mean (standard deviation) scores for the eight ATs in children at age 2 years were calculated. Second, unadjusted simple linear regressions were used to test associations between BWGAzs and each of the eight ATs at child age 2 years. Third, unadjusted simple linear regressions were used to test associations between BWGAzs and child WFAzs at ages 3 and 4 years.

All linear regression models were subsequently adjusted for potential covariates (Table 3). These included child sex, maternal age, prepregnancy BMI, gestational weight gain, marital status, education, country of birth, depressive symptoms, household food insecurity, participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), mode of delivery, and intervention group status as potential covariates based on their known relationship with child weight.

Next, a regression-based mediation analysis developed by Hayes³⁶ was used to test whether ATs at age 2 years mediated the relationships between infant BWGAzs and child WFAzs at ages 3 and 4 years using the PROCESS macro for SPSS, version 25 (Model 4). Indirect effects were assessed using bootstrapping (5000 replicates). Statistical analyses were performed using SPSS, version 25.0, and Stata, version 15.0.

Results

Sample Characteristics

The StEP trial randomized 533 pregnant women into intervention and control groups. Of these, 402 women completed the CEBQ and 332 and 272 had complete child weight data at ages 3 and 4 years, respectively. Participants who had complete data on birth weight, ATs at age 2 years, and WFAzs at ages 3 (n = 297) and 4 (n = 253) years were included in the mediation analysis. Baseline maternal and child characteristics of StEP participants are presented in Table 2.

Table 2.

Baseline Maternal and Child Characteristics of Starting Early Program Participants

Characteristics^a	Analytic sample (n = 297)
Child
Male sex	146 (49.2)
Premature, <37 weeks gestational age	7 (2.4)
Birth weight (kg, mean ± SD)	3.4 ± 0.5
LGA	26 (8.8)
WFAz at age 3 years	0.53 (1.15)
WFAz at age 4 years	0.61 (1.13)
Intervention group status	152 (51.2)
Expectant mother sociodemographic factors
Age (years, mean ± SD)	29.1 ± 5.6
Primiparous	92 (31.0)
Married or living as married	220 (74.1)
Born outside of the United States	253 (85.2)
Completed high school	125 (42.1)
Expectant mother psychosocial factors
Depressive symptoms	93 (31.4)
Household food insecurity	93 (31.3)
SNAP participation	127 (42.8)
WIC participation	226 (76.1)
Expectant mother weight-related factors
Gestational weight gain (kg, mean ± SD)	9.8 ± 5.2
Prepregnancy BMI (mean ± SD)	28.0 ± 5.6
Expectant mother mode of delivery
Vaginal delivery	238 (80.1)

Values are n (%) unless otherwise stated.

LGA, large for gestational age; SNAP, Supplemental Nutrition Assistance Program; WFAz, weight-for-age z score; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Compared with those not included in the current analyses due to missing data, the analytic sample included a higher percentage of mothers who were primiparous, completed high school, and participated in the Supplemental Nutrition Assistance Program.

Associations Between Birth Weight and Child ATs at Age 2 Years

In the unadjusted model, higher birth weight was associated with lower Satiety Responsiveness (B = −0.103, 95% CI = −0.18 to −0.02, p = 0.012) and lower Food Fussiness (B = −0.128, 95% CI = −0.21 to −0.04, p = 0.004) at age 2 years (Table 3). This association remained significant after adjusting for covariates [B = −0.107, 95% CI = −0.19 to −0.02, p = 0.013 (Satiety Responsiveness) and B = −0.151, 95% CI = −0.24 to −0.06, p = 0.001 (Food Fussiness)]. Birth weight was not associated with the other ATs at age 2 years.

Associations Between Birth Weight and Child Weight at Ages 3 and 4 Years

In the unadjusted model, higher birth weight was associated with higher child WFAzs at ages 3 and 4 years [B = 0.444, 95% CI = 0.31–0.58, p < 0.001 (WFAz at age 3 years); and B = 0.442, 95% CI = 0.29–0.60, p < 0.001 (WFAz at age 4 years)] (Table 3). After controlling for covariates, these associations remained significant [B = 0.412, 95% CI = 0.27–0.55, p < 0.001 (WFAz at age 3 years); and B = 0.386, 95% CI = 0.22–0.55, p < 0.001 (WFAz at age 4 years)].

Table 3.

Associations Between Birth Weight and Child Appetite Traits at Age 2 Years and Child Weight at Ages 3 and 4 Years^a

Main study variables	Unadjusted model				Adjusted model^b
Main study variables	B	SE	95% CI^c	p	B	SE	95% CI^c	p
ATs at age 2
Satiety Responsiveness
BWGAz^d	−0.103	0.040	−0.18 to −0.02	0.012	−0.107	0.043	−0.19 to −0.02	0.013
Slowness in Eating
BWGAz^d	−0.006	0.039	−0.08 to 0.07	0.88	−0.010	0.040	−0.09 to 0.07	0.80
Emotional Undereating
BWGAz^d	−0.038	0.055	−0.15 to 0.07	0.49	−0.012	0.058	−0.13 to 0.10	0.84
Food Fussiness
BWGAz^d	−0.128	0.044	−0.21 to −0.04	0.004	−0.151	0.046	−0.24 to −0.06	0.001
Food Responsiveness
BWGAz^d	0.022	0.048	−0.07 to 0.12	0.66	0.027	0.049	−0.07 to 0.12	0.58
Enjoyment of Food
BWGAz^d	0.024	0.030	−0.04 to 0.08	0.43	0.040	0.031	−0.02 to 0.002	0.19
Emotional Overeating
BWGAz^d	0.023	0.035	−0.05 to 0.09	0.52	0.044	0.036	−0.03 to 0.12	0.23
Desire to Drink
BWGAz^d	−0.042	0.058	−0.16 to 0.07	0.47	−0.061	0.061	−0.18 to 0.06	0.32
Child weight
WFAz^e at 3 years
BWGAz^d	0.444	0.070	0.31 to 0.58	<0.001	0.412	0.072	0.27 to 0.55	<0.001
WFAz^e at 4 years
BWGAz^d	0.442	0.079	0.29 to 0.60	<0.001	0.386	0.082	0.22 to 0.55	<0.001

Separate linear regression analyses were used to assess the associations between birth weight and (1) each AT at child age 2 years and (2) child WFAzs at ages 3 and 4 years.

Covariates: child sex, maternal prepregnancy BMI, gestational weight gain, age, education, marital status, country of birth (non-US born vs. US born), depressive symptoms, household food insecurity, WIC participation, mode of delivery, and intervention group status.

95% CI; dependent variables: ATs. Significant p values (<0.05) are shown in bold.

BWGAz: infant birth weight, sex, and gestational age were used to generate BWGAzs with Fenton growth curves.

WFAz: WFAz was calculated based on CDC 2000 growth charts.

BWGAzs, birth weight-for-gestational age z-scores; CI, confidence interval.

Associations Between ATs at Age 2 Years and Child Weight at Ages 3 and 4 Years

Similar to our prior study¹³ in both unadjusted and adjusted models, lower Satiety Responsiveness and Slowness in Eating at age 2 years were associated with higher WFAzs at age 3 years [B = −0.106, 95% CI = −0.18 to −0.03, p < 0.001 (Satiety Responsiveness); and B = −0.316, 95% CI = −0.51 to −0.13, p = 0.001 (Slowness in Eating)] (Table 4). Lower Satiety Responsiveness and Slowness in Eating at age 2 years were also associated with higher WFAzs at age 4 years [B = −0.339, 95% CI = −0.56 to −0.12, p = 0.002 (Satiety Responsiveness); and B = −0.215, 95% CI = −0.49 to −0.28, p = 0.025 (Slowness in Eating)].

Table 4.

Associations Between Child Appetite Traits and Standardized Weight-for-Age z-Scores at Ages 3 and 4 Years in 297 Children Participating in the Starting Early Program

ATs^a	Unadjusted model				Adjusted model^b
ATs^a	B	SE	95% CI^c	p	B	SE	95% CI^c	p ^d
WFAz^c at 3 years¹⁸
Satiety Responsiveness	−0.422	0.103	−0.63 to −0.22	<0.001	−0.434	0.103	−0.64 to −0.23	<0.001
Slowness in Eating	−0.297	0.098	−0.49 to −0.11	0.003	−0.316	0.097	−0.51 to −0.13	0.001
Emotional Undereating	−0.096	0.079	−0.25 to 0.06	0.23	−0.078	0.078	−0.23 to 0.08	0.32
Food Fussiness	−0.119	0.098	−0.31 to 0.07	0.22	−0.129	0.096	−0.32 to 0.06	0.18
Food Responsiveness	0.044	0.081	−0.11 to 0.20	0.58	0.064	0.082	−0.10 to 0.23	0.43
Enjoyment of Food	0.167	0.124	−0.08 to 0.41	0.18	0.040	0.031	−0.06 to 0.43	0.15
Emotional Overeating	−0.063	0.123	−0.30 to 0.18	0.61	−0.031	0.125	−0.28 to 0.22	0.80
Desire to Drink	−0.028	0.075	−0.18 to 0.12	0.71	−0.049	0.075	−0.20 to 0.10	0.51
WFAz^c at 4 years
Satiety Responsiveness	−0.297	0.112	−0.52 to −0.08	0.009	−0.339	0.110	−0.56 to −0.12	0.002
Slowness in Eating	−0.198	0.098	−0.39 to −0.01	0.044	−0.215	0.095	−0.40 to −0.28	0.025
Emotional Undereating	−0.153	0.091	−0.33 to 0.03	0.09	−0.144	0.089	−0.32 to 0.03	0.11
Food Fussiness	−0.107	0.115	−0.33 to 0.12	0.35	−0.129	0.111	−0.35 to 0.09	0.25
Food Responsiveness	0.015	0.083	−0.15 to 0.18	0.85	0.027	0.083	−0.14 to 0.19	0.75
Enjoyment of Food	0.184	0.122	−0.06 to 0.42	0.13	0.241	0.121	0.01 to 0.48	0.048
Emotional overeating	−0.139	0.145	−0.42 to 0.15	0.34	−0.068	0.143	−0.35 to 0.21	0.64
Desire to Drink	−0.001	0.085	−0.17 to 0.17	0.99	−0.046	0.083	−0.21 to 0.12	0.58

Linear regression assessed the association between each AT and WFAz (dependent variable).

CEBQ^18,19 assessed ATs of children at age 2 years.

95% CI; significant p-values (<0.05) are shown in bold.

After Bonferroni adjustment, p-values <0.0125 are considered significant; 0.05/4 = 0.0125.

Additionally, children with higher Enjoyment of Food at age 2 years had higher WFAzs at age 4 years after adjusting for covariates (B = 0.241, 95% CI = 0.01–0.48, p = 0.048). The other ATs were not significantly related to later child weight.

ATs Mediate the Pathway Between Birth Weight and Later Child Weight

Because Satiety Responsiveness at age 2 years was the only AT associated with birth weight and child weight at ages 3 and 4 years, a mediation path analysis was used to determine whether Satiety Responsiveness mediated associations between birth weight and WFAzs at ages 3 and 4 years. Figure 1 displays the mediation effect of Satiety Responsiveness on the linkage between birth weight and WFAzs at ages 3 years (Fig. 1a) and 4 years (Fig. 1b).

Figure 1.

Path analysis—Satiety Responsiveness at age 2 years mediates the relationship between the BWGAz and child WFAz at ages 3 (a) and 4 (b) years. Values shown are unstandardized regression coefficients (standard errors). X = BWGAz; M = mediator (Satiety Responsiveness at 2 years); Y = WFAz at 3 years; BWGAz, birth weight-for-gestational age z-score; WFAz, weight-for-age z-score.

Mediation findings were as follows: (1) higher birth weight (X) was associated with higher child WFAzs (Y) at 3 years (B = 0.41, 95% CI = 0.27–0.55; p < 0.001) and 4 years (B = 0.39, 95% CI = 0.22–0.55; p < 0.001), establishing the total effects; (2) higher birth weight (X) was associated with lower Satiety Responsiveness (M; mediator) at age 2 years (B = −0.12, 95% CI = −0.20 to −0.04; p = 0.005), establishing the initial mediation path; (3) lower Satiety Responsiveness at age 2 years (M) was associated with higher child WFAzs (Y) at 3 years (B = −0.35, 95% CI = −0.54 to −0.16; p < 0.001) and 4 years (B = −0.26, 95% CI = −0.46 to −0.05; p = 0.016), adjusting for higher birth weight (X), establishing the remainder of the mediation paths (M → Y); and (4) the direct effect estimated as the association between birth weight (X) and child WFAz (Y), adjusting for the mediator at 3 years (B = 0.37, 95% CI = 0.23–0.51; p < 0.001) and 4 years (B = 0.35, 95% CI = 0.19–0.48; p < 0.001).

The overall indirect effect (mediation pathway, X → M →Y) was significant [B = 0.04, 95% CI = 0.01–0.08; p < 0.001 (3 years); and B = 0.04, 95% CI = 0.01–0.07; p < 0.001 (4 years)], demonstrating partial mediation.³⁷

Discussion

The results of the present analysis showed that higher birth weight was associated with lower scores for the obesity-protective ATs, Satiety Responsiveness and Food Fussiness, at age 2 years and that Satiety Responsiveness mediated the association of higher birth weight with higher child weight at ages 3 and 4 years. While higher birth weight is consistently associated with higher child weight in the literature,^2–7 less research has examined the role of ATs in the pathways between birth weight and later child weight.

The few studies that have examined the relationship between birth weight and child ATs^20–22 have inconsistent findings, and none to our knowledge have examined whether ATs mediate the association between birth weight and later child weight in low-income Hispanic families.

In line with our findings, the Generation R cohort study of 4350 predominantly Dutch mother–child pairs reported that higher fetal weight and growth were associated with lower Satiety Responsiveness and higher food approach trait scores at child age 4 years.²¹ However, the above study reported that child BMI at age 2 years partially mediated the link between fetal weight and Satiety Responsiveness and food approach trait scores at child age 4 years.

Similarly, a US study of 41 infants found that infants who were born with high birth weight (i.e., ≥4000 g) and maintained a high weight-for-length (≥85th percentile) at 7–8 months had lower Satiety Responsiveness during infancy.²² Of note, the above study included a small sample size (i.e., 21 infants with high birth weight and 20 infants with normal birth weight).

In contrast, 1 US study of 454, multiethnic, low-income mother–child dyads (307 preschoolers and 147 toddlers) found that higher birth weight was associated with higher Satiety Responsiveness among girls, but not boys.²⁰ The population sample for this study was different from ours, with only 10% Hispanic infants and over 13% with small for gestational birth weights.

The present study found that Satiety Responsiveness mediated the relationship between higher birth weight and increases in child WFAzs at ages 3 and 4 years. There is limited research on the underlying mechanisms explaining the associations between birth weight, child ATs, and later child weight. Our findings provide evidence for the Behavioral Susceptibility Theory (BST).⁸ According to BST, variation in body weight and obesity arises from an interaction between genetic predisposition and environmental exposure (e.g., obesogenic food environment).

In addition, BST hypothesizes that variation in appetite mediates the interaction between genetic susceptibility to obesity and environmental exposure. Birth weight, which is affected by maternal genetic predisposition and prenatal exposures (i.e., maternal diet, prepregnancy BMI, and gestational weight gain), may influence parenting and feeding practices, which in turn influence the development of appetite and eating behaviors, impacting weight trajectories and obesity risk later in life.³⁸

Our findings that higher birth weight was associated with lower scores of the obesity-protective AT, Satiety Responsiveness,⁹ suggest a potential mechanism by which Satiety Responsiveness mediates the association between high birth weight and later child weight and obesity. In other words, children with high birth weight³⁹ may be predisposed to weaker satiety signals and thus more likely to overeat in response to an obesogenic food environment, leading to excess weight gain.⁸

Considering the partial mediation effect of Satiety Responsiveness on the link between birth weight and later child weight, and the lack of association of the other ATs with later child weight, larger longitudinal studies are needed to identify children at high risk of excess early weight gain and obesity.

This study has some limitations. First, child AT scores were calculated using data reported by mothers, therefore reporter bias might have occurred. In addition, similar to a recent study, with a population similar to our study,⁴⁰ the CEBQ Satiety Responsiveness and Slowness in Eating subscales showed poor internal reliability in our sample (Cronbach's α = 0.56 and Cronbach's α = 0.46, respectively; Table 1), which may account, at least in part, for the lack of an observed relationship between birth weight and Slowness in Eating as well as the partial mediation of Satiety Responsiveness on the link between birth weight and later child weight in our study and others. However, the CEBQ scale itself is known as a tool with good test–retest reliability and validity to measure ATs in Hispanic populations.⁴¹

Second, our findings may not be generalizable nationally since participants were exclusively low-income, Hispanic mother–child pairs from New York City. Finally, medical records were used to obtain anthropometric data, which prevented us from calculation of BMI percentiles mainly because of biologically implausible heights/lengths.²⁴

In summary, we found that among low-income Hispanic families, children with higher birth weight had lower levels of the obesity-protective ATs of Satiety Responsiveness and Food Fussiness at age 2, and higher WFAzs at ages 3 and 4 years, and that Satiety Responsiveness partially mediated the link between high birth weight and later child weight.

Additional longitudinal trials are needed to identify other factors associated with ATs, if ATs are modifiable in infancy and early childhood, and whether modifying ATs impacts feeding practices and child weight outcomes.

Impact Statement

This study showed the potential mediation effect of Satiety Responsiveness, the ability to regulate intake in response to fullness, on the link between birth weight and child weight. Appetite traits may represent a potential target of interventions aiming to mitigate the adverse effects of high birth weight on later risk of child obesity.

Footnotes

Acknowledgments

The authors would like to thank all the StEP participants for their contributions to this study and the StEP study team for all of their hard work in conducting the in-person research visits and other data collection.

Authors' Contributions

S.V. conceptualized and designed the study, carried out the initial analyses, reviewed the analyses, drafted the initial manuscript, and reviewed and revised the manuscript. M.J.M. conceptualized and designed the study, supervised data collection and acquisition of data, analyzed data, reviewed the analyses, and reviewed and revised the manuscript. M.A.S. substantially contributed to analysis and interpretation of data, conducted and reviewed data analyses, and revised the manuscript for important intellectual content. R.S.G. conceptualized and designed the study, supervised data collection and acquisition of data, analyzed data, reviewed the analyses, and reviewed and revised the manuscript.

All authors approved the final version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding Information

This study was supported by the National Institute of Food and Agriculture (USDA AFRI #2011-68001-30207 and USDA AFRI #2017-68001-26350 to M.J.M.) and the NIH/NICHD K23 Mentored Patient-Oriented Research Career Development Award (K23HD081077 to R.S.G.).

Author Disclosure Statement

No competing financial interests exist.

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