Restriction and Pressure to Eat Are Associated Cross-Sectionally,But Not Longitudinally,With BMI z-Score in a Longitudinal Cohort Study of Adolescents

Abstract

Background:

Parents can influence child weight through their use of food parenting practices, although data are limited in adolescents. The purpose of this study was to examine the cross-sectional and longitudinal relationships between BMI z-Score (zBMI) and restriction and pressure to eat in adolescents.

Methods:

Adolescents (12–14 years of age at baseline; N = 236) had their height/weight measured at baseline and 24 months and their parent completed the Child Feeding Questionnaire. Linear regressions examined relationships between food parenting practices and zBMI.

Results:

Cross-sectionally, restriction was positively associated with zBMI at both baseline (β = 0.28, p < 0.001) and 24 months (β = 0.141, p = 0.039). In contrast, pressure to eat was negatively associated with zBMI at both baseline (β = −0.30, p < 0.001) and 24 months (β = −0.31, p < 0.001). Neither restriction (β = −0.028, p = 0.446) nor pressure to eat (β = −0.027, p = 0.493) at baseline predicted 2-year changes in zBMI. zBMI at baseline did not predict 2-year changes in either restriction (β = −0.003, p = 0.965) or pressure to eat (β = −0.056, p = 0.611).

Conclusion:

Findings highlight that adolescents perceive moderate levels of restriction and pressure to eat, with levels differing by weight status. These findings suggest that the bidirectional relationships between child weight status and food parenting practices are likely established before adolescence, but persist throughout adolescence. Further longitudinal studies should examine the impact of restriction and pressure to eat early in childhood on weight trajectories into adolescence and adulthood.

Clinicaltrials.gov: NCT04027608.

Introduction

Parents play a critical role in the development of children's eating behaviors and weight status through their roles as providers, models, and regulators of the food environment.^1–3 One way parents influence their children's eating behavior and weight status is through their use of food parenting practices, which are the goal-oriented behaviors that parents use when feeding their child.^4,5 While there are three higher-order food parenting constructs (coercive control, structure, and autonomy support), coercive control has received the most attention to date as this was the aspect of food parenting originally expected to have the most influence on child self-regulation of food intake.⁶ Two food parenting practices within coercive control are restriction (i.e., when a parent restricts the child's access to or opportunities to consume certain foods) and pressure to eat (i.e., when a parent demands or insists that a child eats more food or a certain food).⁵

Research on the relationship between food parenting practices high in coercive control and weight status is mixed. Most studies, including a recent quantitative meta-analysis, show that parents are more likely to use restriction with children with overweight/obesity and are more likely to use pressure to eat with children at lower weights.^7–9 However, the data regarding the impact of restriction and pressure to eat on longitudinal weight outcomes are inconclusive.

A recent systematic review of prospective studies on the impact of food parenting practices on children's weight outcomes concluded that neither restriction nor pressure to eat was associated with children's weight outcomes over time.¹⁰ Of note, the majority of food parenting research has been conducted in children before adolescence (i.e., before age 12).¹ One reason for this is that adolescence is a developmental stage marked by increased autonomy and decreased parental influence as children begin spending more time with peers and alone. However, parents continue to affect adolescent eating and weight outcomes.^11–17 In fact, it is possible that some parents may attempt to exert more control over adolescent eating as a reaction to increased autonomy.

Given the limited data on the impact of food parenting practices on weight status among adolescents, the aims of this study were to examine (1) the cross-sectional associations between parental restriction and pressure to eat on adolescent weight status at baseline and after a 2-year follow-up; (2) whether parental restriction and pressure to eat at baseline predict changes in weight status between baseline and the 2-year follow-up; and (3) whether weight status at baseline predicts changes in parental restriction and pressure to eat between baseline and the 2-year follow-up.

Cross-sectionally, it was hypothesized that restriction would be positively associated with weight status and pressure to eat would be negatively associated with weight status. Longitudinally, it was hypothesized that restriction as baseline would predict increases in weight status and pressure to eat at baseline would predict decreases in weight status. Moreover, it was hypothesized that higher weight statuses at baseline would predict increases in restriction and decreases in pressure to eat.

Methods

Participants

The data presented are a secondary data analysis of 236 adolescents participating in a 2-year longitudinal study assessing predictors of weight change. Participants were recruited using a variety of methods (e.g., flyers, social media, advertisements distributed in schools in Western New York). Eligibility criteria included rating at least two study foods (one high-energy dense and one low-energy dense) as neutral or higher, reporting a willingness to eat a serving of the same study foods every day for 2 weeks, being able to attend five visits within a 6–8-week period; and having a BMI z-score (zBMI) between −1.5 and 2 (i.e., did not have underweight or have obesity per World Health Organization [WHO] standards).¹⁸

Participants were excluded if they reported a metabolic or endocrine disorder, used medications that could affect appetite or weight gain (e.g., prednisone), had an allergy to all study foods that prohibited engaging in study procedures, were unable to read at a fourth grade level, were unable to complete light physical activity without assistance, and had a non-English speaking parent to provide consent.

The complete study procedures and CONSORT diagram showing participant flow through the study are outlined elsewhere.^19,20 All parents gave informed consent and all adolescents gave written assent. Relevant to these analyses, the participants completed a series of baseline data collection visits. During the first visit, the participants completed questionnaires and had their height and weight measured by trained research staff. Twenty-four months later, the participants returned to the laboratory complete questionnaires and had their height and weight measured. All procedures were approved by the institutional review board of the University at Buffalo.

Measures

Demographics

Parents reported the following for their child: race, ethnicity, sex, and date of birth (used to calculate age). Parents reported their education and occupation, which were used to calculate socioeconomic status (SES).²¹

Anthropometrics

Weight and height were measured at baseline and the 2-year follow up. Weight was measured using a Seca digital scale (Hanover, MD). Height was measured in triplicate using a wall-mounted SECA stadiometer (Hanover) and the median height was used. z-BMI and BMI percentile values were calculated using age- and sex-specific CDC growth charts.²² BMI percentile was used to define participants as having either healthy weight (BMI <85th percentile) or overweight/obesity (BMI ≥85th percentile).

Food parenting practices

Food parenting practices were assessed using the Child Feeding Questionnaire (CFQ).²³ While the entire CFQ was completed, only restriction and pressure to eat are used in this study. Each item is assessed on a scale of 1 (disagree) to 5 (agree). Restriction is the average of eight items and pressure to eat is the average of four items, with higher scores indicating greater use of that food parenting practice.

Analytic Plan

The sample size for the parent study^19,20 was based on being able to detect a relationship between sensitization to high- and low-energy dense foods and weight change over time (i.e., statistical significance could be achieved with a total of 180 participants with an alpha of 0.05 and a power of 0.80). All data analyses were performed using SPSS version 28. Statistical significance was defined as p ≤ 0.05. All participants (N = 236) with complete food parenting and weight data at baseline were included in the analyses.

All demographic variables that are theoretically relevant to food parenting and/or weight status (e.g., age, sex, race, family SES) were considered potential covariates and were included in all models if the correlation between the demographic variable and zBMI, restriction, or pressure to eat was statistically significant (p < 0.05). No variable significantly correlated with any outcome of interest (ps > 0.093), and thus no covariate was included in the models.

Correlations were used to examine relationships between each food parenting practice at baseline and follow-up. Linear regression and analysis of covariance (ANCOVA) were both used to look at cross-sectional relationships between food parenting practices and weight. Linear regressions were used to examine the relationships between continuous zBMI and food parenting practices and ANCOVAs were used to examine differences in food parenting practices by weight status.

A series of linear regressions was used to examine how food parenting practices (separate models for restriction and pressure to eat) predicted changes in zBMI. In these models, the change was conceptualized as predicting zBMI at the 2-year follow-up, adjusting for zBMI at baseline. Similarly, to examine how baseline zBMI was related to changes in food parenting practices, a series of linear regressions was used to predict the food parenting practice (i.e., restriction or pressure to eat) at the 2-year follow-up, adjusting for baseline food parenting. Given the strong relationship between weight status and food parenting practices, all linear regression models were examined in three ways: (1) the full sample; (2) healthy weight only; and (3) overweight/obesity only.

Results

Sample Characteristics

At baseline, participants (N = 236, 50% female) were an average of 13.3 ± 0.8 (median 13.2) years of age. At follow-up, participants (N = 169, 50.3% female) were an average of 15.2 ± 0.8 (median: 15.1) years of age. The majority of the sample reported being non-Hispanic (93.2%) and White (76.4%) with 2.1% Asian, 12.2% Black/African American, 5.1% mixed race, and 3.8% other.

Roughly half (54.5%) of the families reported a household income above $90,000. The mean zBMI at baseline was 0.41 ± 0.95 (median: 0.47) and was 0.47 ± 0.92 (median 0.48) at the 2-year follow-up. At baseline, 69.6% of the sample were classified with healthy weight, 20.7% with overweight, and 9.7% with obesity. At follow-up, 72.3% of the sample were classified with healthy weight, 16.5% with overweight, and 11.2% with obesity. There was no difference in age at baseline, sex, race, baseline zBMI, baseline restriction, or baseline pressure to eat between participants who did and did not complete the 2-year follow-up (ps > 0.302). Participants who completed the 2-year follow-up did have significantly greater SES scores than those who did not (p < 0.001).

Cross-Sectional Relationships Between Restriction and Pressure to Eat and Adolescent Weight Status at Baseline and 2-Year Follow-Up

As shown in Table 1, at baseline, restriction was positively associated with adolescent zBMI (p < 0.001). In contrast, pressure to eat was negatively associated with adolescent zBMI (p < 0.001). Similarly, at the 2-year follow-up, restriction was positively associated with adolescent zBMI (p = 0.037). In contrast, pressure to eat was negatively associated with adolescent zBMI (p < 0.001). The means for restriction and pressure to eat at baseline for the full sample and by weight status are shown in Table 2. At both time periods, adolescents with overweight/obesity had parents who reported greater restriction and less pressure to eat than their peers with healthy weight (ps < 0.020).

Table 1.

Cross-Sectional Relationships Between Restriction and Pressure to Eat and Adolescent Weight Status at Baseline and 2-Year Follow-Up

	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Restriction, baseline	0.284	0.158 to 0.409	0.064	4.458	<0.001

	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Pressure to eat, baseline	−0.305	−0.440 to −0.170	0.068	−4.463	<0.001

	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Restriction, follow-up	0.142	0.008 to 0.275	0.068	2.097	0.037

	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Pressure to eat, follow-up	−0.313	−0.462 to −0.163	0.076	−4.117	<0.001

Each variable was run independently.

CI, confidence interval.

Table 2.

Means for Restriction and Pressure to at Baseline and 2-Year Follow-Up

	Full sample	Healthy weight	Overweight/obesity	p
Baseline	(N = 236)	(N = 165)	(N = 71)
Restriction	2.83 ± 0.94	2.72 ± 0.92	3.09 ± 0.93	0.005
Pressure to eat	2.13 ± 0.87	2.28 ± 0.89	1.78 ± 0.72	<0.001
Follow-up	(N = 169)	(N = 123)	(N = 46)
Restriction	2.51 ± 1.03	2.40 ± 0.99	2.81 ± 1.09	0.020
Pressure to eat	1.97 ± 0.89	2.12 ± 0.92	1.60 ± 0.69	<0.001

Restriction and pressure to eat were assessed on a scale of 1 (disagree) to 5 (agree).

The correlation between restriction at baseline and the 2-year follow-up is 0.645 (p < 0.001). The correlation between pressure to eat at baseline and the 2-year follow-up is 0.485 (p < 0.001).

Relationships Between Baseline Restriction and Pressure to Eat and 2-Year Change in zBMI

Results from models with baseline restriction and pressure to eat predicting 2-year changes in zBMI are shown in Table 3. Neither baseline restriction nor baseline pressure to eat predicted changes in zBMI in the full sample or by weight status (ps > 0.494).

Table 3.

Results from a Series of Linear Regression Models With Baseline Food Parenting Practices Predicting 2-Year Change in BMI z-Score

Full sample
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
zBMI, baseline	0.856	0.785 to 0.927	0.036	23.704	<0.001
Restriction, baseline	−0.024	−0.096 to 0.048	0.036	−0.659	0.511

	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
zBMI, baseline	0.843	0.771 to 0.915	0.036	23.137	<0.001
Pressure to eat, baseline	−0.027	−0.104 to 0.050	0.039	−0.688	0.493

Normal weight
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
zBMI, baseline	0.764	0.639 to 0.889	0.063	12.105	<0.001
Restriction, baseline	−0.024	−0.119 to 0.072	0.048	−0.490	0.625

	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
zBMI, baseline	0.752	0.629 to 0.876	0.062	12.049	<0.001
Pressure to eat, baseline	−0.032	−0.127 to 0.062	0.048	−0.678	0.499

Overweight
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
zBMI, baseline	0.951	0.638 to 1.263	0.156	6.103	<0.001
Restriction, baseline	−0.025	−0.115 to 0.066	0.045	−0.545	0.588

	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
zBMI, baseline	0.958	0.641 to 1.274	0.158	6.075	<0.001
Pressure to eat, baseline	0.032	−0.098 to 0.161	0.064	0.490	0.626

zBMI change was conceptualized as predicting zBMI at the 2-year follow-up, adjusting for zBMI at baseline.

zBMI, BMI z-score.

Relationships Between Baseline zBMI and 2-Year Change in Restriction and Pressure to Eat

Results from models showing the impact of baseline zBMI on changes in restriction and pressure to eat are shown in Table 4. Baseline zBMI did not predict change in either restriction or pressure to eat in the full sample or by weight status (ps > 0.066).

Table 4.

Results from a Series of Linear Regression Models with Baseline BMI z-Score Predicting 2-Year Change in Food Parenting Practices

Full sample
Restriction at follow-up
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Restriction, baseline	0.698	0.567 to 0.829	0.066	10.535	<0.001
zBMI, baseline	−0.004	−0.135 to 0.128	0.066	−0.053	0.958

Pressure to eat at follow-up
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Pressure to eat, baseline	0.462	0.321 to 0.602	0.071	6.492	<0.001
zBMI, baseline	−0.090	−0.220 to 0.040	0.066	−1.368	0.173

Normal weight
Restriction at follow-up
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Restriction, baseline	0.699	0.545 to 0.853	0.078	8.982	<0.001
zBMI, baseline	−0.188	−0.389 to 0.013	0.102	−1.852	0.067

Pressure to eat at follow-up
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Pressure to eat, baseline	0.423	0.255 to 0.590	0.085	4.995	<0.001
zBMI, baseline	−0.056	−0.272 to 0.160	0.109	−0.512	0.610

Overweight
Restriction at follow-up
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Restriction, baseline	0.700	0.453 to 0.947	0.123	5.703	<0.001
zBMI, baseline	0.107	−0.758 to 0.972	0.430	0.248	0.805

Pressure to eat at follow-up
	β	95% CI for β (lower bound, upper bound)	Standard error	t	p
Pressure to eat, baseline	0.603	0.335 to 0.871	0.133	4.529	<0.001
zBMI, baseline	−0.544	−1.206 to 0.119	0.330	−1.650	0.105

Change in the food parenting practice was conceptualized as predicting the food parenting practice at the 2-year follow-up, adjusting for the food parenting practice at baseline.

Discussion

This study examined the impact of food parenting practices high in coercive control (i.e., restriction and pressure to eat) on adolescent weight status and 2-year weight change. Parental restriction was positively associated with zBMI at both baseline and the 2-year follow-up, while pressure to eat was negatively associated with zBMI at both time points. In contrast, neither restriction nor pressure to eat at baseline predicted changes in adolescent weight over 2 years. Moreover, weight status at baseline did not predict changes in either restriction or pressure to eat over 2 years.

In addition, the high correlations between restriction (and pressure to eat) at the two time periods indicate that parents are using similar levels of these food parenting practices across a 2-year period in adolescence. There is a bidirectional relationship between parents and children (i.e., parents and children react to each other),²⁴ and thus it is critical to look at reciprocal associations with respect to food parenting and weight status.²⁵ However, in this study, baseline weight status also did not predict changes in either restriction or pressure to eat.

The significant positive cross-sectional relationships between zBMI and restriction are consistent with most (e.g., Robinson et al.,⁸ Faith et al.,²⁶ Joyce and Zimmer-Gembeck²⁷), but not all (e.g., Davison and Birch²⁸) extant findings. Furthermore, in a recent quantitative meta-analysis, the overall cross-sectional association between restriction and child weight was significant, but small (d = 0.22).⁹

Little information is available about this relationship among adolescents. In one known study, parents reported using greater restriction among adolescents with elevated weight statuses.¹⁶ In this study, baseline restriction was not associated with longitudinal changes in weight status. While this is the first known study to examine the impact of restriction on changes in weight status among adolescents, a recent systematic review of prospective studies on the impact of food parenting practices on weight outcomes in younger children (i.e., in early/middle childhood or preadolescence) concluded that restriction was not associated with changes in weight over time.¹⁰

The null longitudinal findings in this study are likely due to a combination of several factors. First, the impact of restriction on weight status may be established before adolescence. There is some experimental evidence indicating that initially, in early and middle childhood, restriction may occur before weight gain,^29–31 likely in response to concern over child actual or perceived weight status or parental concern over their own status.³² This leads to a cycle of increased weight gain and increased restriction, both of which persist over time. For example, children with overweight/obesity might have experienced greater restriction earlier in life, leading to decreased self-regulation^31,32 and elevated weight status over time. Since weight status tends to track over time,³³ this means that restriction is still associated with the elevated weight status, but not necessarily changes in weight status.

However, future work is needed to examine this longitudinally from childhood to adolescence as this study started in adolescence. Relatedly, there is some evidence that age moderates the relationship between parental restriction and child weight status, which might help explain the null findings in this study. For example, Campbell et al. examined the impact of restriction on 3-year zBMI change in two different cohorts (5–6-year olds and 10–12-year olds).³⁴ They found that higher levels of restriction predicted lower zBMI at follow-up in the younger cohort, with no impact among preadolescents.

Moreover, there may be more salient factors influencing weight change among adolescents. Theoretically, parents become less influential in adolescence as other factors (e.g., peers, media) become increasingly impactful.¹⁴ However, null longitudinal findings from this study should not be interpreted as meaning that parents do not still play a critical role in adolescent eating behavior.^{12–14,17,35} For example, a recent qualitative study highlighted that adolescents reported still experiencing parental restriction over their eating, despite increased eating autonomy.¹⁷ Another study found that parent-reported restriction of high-energy dense food was associated with increased adolescent consumption of high-energy dense food.¹³

While there are fewer data on pressure to eat than restriction,^7,24 the significant negative cross-sectional associations between zBMI and pressure to eat are consistent with a recent meta-analysis that found a significant, but small effect size between the two among children in early or middle childhood (d = 0.33) with both age (i.e., stronger relationship as child age increased) and income (i.e., relationship only present among primarily higher income samples) moderating findings.⁹

There are limited data among adolescents, but evidence supports an inverse cross-sectional relationship between pressure to eat and weight status.^16,36 While there is no known study examining the impact of pressure to eat on weight change in adolescents, the null longitudinal findings are in agreement with findings from a recent systematic review of prospective studies in younger children that concluded the pressure to eat was not associated with weight outcomes.¹⁰ However, findings contrast with a recent study in low-income Hispanic mothers showing that pressure to eat was positively associated with zBMI increases over time,³⁷ suggesting that perhaps the impact of pressure to eat on weight status might differ based on the socioeconomic and racial/ethnic diversity of the sample.

Regardless of the potential impact on weight status, parents should be cautioned against using restriction or pressure to eat, as both have been associated, in children, with reduced dietary quality^30,38 and maladaptive eating behaviors such as increased eating in the absence of hunger, disinhibited eating, and dietary restraint.¹⁵ In addition, one study on adolescents highlighted the negative impact of restriction and pressure to eat on disordered eating behaviors.³⁹ There has been a shift in the food parenting field toward focusing more on the positive aspects of food parenting such as structure-based practices (e.g., rules and limit setting).¹ During adolescence, to help promote healthy eating and weight outcomes, parents should focus on using structure-based food parenting practices to help support the adolescent's development and need for increased autonomy.¹

This study has several strengths. This was a large sample of adolescents who completed a series of well-controlled laboratory measures and questionnaires. One strength of this study was the ability to examine bidirectional associations between food parenting practices and weight status.⁴⁰ Nevertheless, the findings should be interpreted in the context of some notable limitations. First, the diversity of the sample was relatively low, with most of the sample being White and middle to upper class. Second, adolescents with obesity per WHO cutoffs were not eligible for participation. As such, at baseline, there were only 23 participants with obesity according to the CDC definition²² and findings might be different with a broader weight range.

Conclusions

Findings from this longitudinal cohort study highlight that parents are still using restriction and pressure to eat during adolescence. Cross-sectionally, zBMI was associated with both restriction and pressure to eat (positively and negatively, respectively). However, none of the bidirectional longitudinal relationships between zBMI and restriction or pressure to eat was statistically significant. Further longitudinal studies should examine the bidirectional relationships between restriction and pressure to eat early and weight in childhood on weight trajectories into adolescence and adulthood.

Impact Statement

Cross-sectionally, restriction was positively associated with zBMI, while pressure to eat was negatively associated with zBMI. However, none of the longitudinal relationships between weight and restriction/pressure to eat was significant, suggesting that the bidirectional relationships between child weight and food parenting practices are likely established earlier, but persist throughout adolescence.

Footnotes

Acknowledgments

The authors thank the study participants.

Authors' Contributions

K.N.B.: Conceptualization, formal analysis, and writing—original draft. A.L.P.A.: Conceptualization and writing—review and editing. A.M.Z.: Project administration and writing—review and editing. J.L.T.: Funding acquisition, project administration, conceptualization, and writing—review and editing.

Funding Information

This work was supported grants K01 DK120778 (K.N.B.) and R01 DK106265 (J.L.T.) from the National Institute of Diabetes and Digestive and Kidney Disease.

Author Disclosure Statement

No competing financial interests exist

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