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Controlling Feeding Practices: Cause or Consequence of Early Child Weight?

^a School of Psychology, Keele University, Keele, Staffordshire, United Kingdom
^b School of Psychology, University of Birmingham, Edgbaston, Birmingham, United Kingdom

	ABSTRACT

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INTRODUCTION. The exertion of control during child feeding has been associated with both underweight and overweight during childhood. What is as-yet unclear is whether controlling child feeding practices causally affect child weight or whether the use of control may be a reactive response to concerns about high or low child weight. The aims of this study were to explore the direction of causality in these relationships during infancy.

METHODS. Sixty-two women gave informed consent to take part in this longitudinal study that spanned from birth to 2 years of child age. Mothers completed the Child Feeding Questionnaire at 1 year, and their children were weighed at 1 and 2 years of age. Child weight scores were converted into standardized z scores that accounted for child age and gender.

RESULTS. Controlling for child weight at 1 year, the use of pressure to eat and restriction at 1 year significantly predicted lower child weight at 2 years.

CONCLUSIONS. Controlling feeding practices in infancy have an impact on children's weight at 2 years. The use of restrictive child feeding practices during infancy predicts lower child weight at age 2 years, which may reinforce mothers' use of this strategy in the longer term despite its potential association with disinhibition and greater child weight in later childhood.

Key Words: child • obesity • control • feeding practice • weight

Abbreviations: SDS—SD score

Parental control over a child's intake of food has been associated with disinhibited child eating and with extremities in child weight. Specifically, the use of pressure to eat has been associated with lower child fat mass, whereas the use of restriction has been linked with greater fat mass in children at age 11 years.¹ What is poorly understood is the nature of causality in these relationships. Although it may be that controlling feeding practices cause problems with children's eating and weight, it may also be that caregivers initiate controlling feeding strategies in response to perceived child overweight or underweight.

To date, there have only been a limited number of studies that have evaluated issues of causality in the relationship between child weight and the use of control during feeding. Using cross-sectional comparisons of children with different weights, caregivers have been shown to report using more pressure to eat with lighter sons² and daughters³ and to use more monitoring with heavier children.⁴ Moreover, in female children, maternal restriction of children's food intake has been associated with disinhibited eating, poor self-regulation, and greater child weight.^{5, 6} However cross-sectional studies comparing families of children of different weights make it difficult to ascertain whether the use of control reflects differences between individual caregivers or responses to different child weights.

Keller et al⁷ and Wardle et al⁸ have elucidated these issues by exploring within-family differences in the use of controlling feeding practices for different sibling or twin children aged from 3 to 7 years. Keller et al⁷ found that mothers reported greater concerns about overweight and less pressure to eat for their heavier compared with their lighter children. However, 2 other commonly cited controlling feeding practices, monitoring and restriction, were not associated with within-family differences in sibling weight. Moreover, perceived feeding responsibility and perceived child overweight showed significant family correlations irrespective of sibling differences in weight. Similarly, in a twin comparison study, Wardle et al⁸ found that there were no differences between monozygotic and dizygotic correlations of maternal feeding control, suggesting that these feeding practices are not a response to genetic properties of the child.

Similar relationships between parental control and child weight have also been found in younger children. In our previous analysis of this longitudinal study, we found that observed maternal use of control during feeding interactions can moderate patterns of infant weight gain across the first year of life.⁹ Specifically, when mothers allowed their infants autonomy and were less controlling during mealtime observations, infants seemed to regulate their weight gain across the first year of life with those with slow early weight gain (birth to 6 months) gaining more weight from 6 to 12 months and those with greater early weight gain (birth to 6 months) gaining relatively less weight from 6 to 12 months. Conversely, where mothers were observed to be very controlling during feeding interactions with their children at 6 months the opposite pattern emerged, and infants who were slow to gain weight continued to gain weight slowly, and those with rapid early weight gain continued to gain relatively more weight from 6 to 12 months.⁹ These findings suggest that observed maternal control of solid feeding can impact on the child's subsequent weight even during the first year of life.

Other research has extended these findings in older children and found that the relationships between self-reported parental control and child weight may be exacerbated by the child's risk of obesity. In one longitudinal study exploring monitoring, pressure, and restriction, Birch et al¹⁰ found that only maternal use of restriction at child age 5 years predicted child eating in the absence of hunger at ages 7 and 9 years and that this effect was exacerbated for girls who were already overweight at age 5 years. In support of these findings Faith et al¹¹ conducted a longitudinal study with American girls comparing the effects of controlling feeding practices at age 5 years on weight at 7 years, controlling for earlier child weight at age 3 years. Faith et al¹¹ compared children who were at high and low risk for obesity. They found that, in low-risk children, monitoring of the child's food intake at age 5 years predicted reduced child weight at age 7 years. Conversely, in children who were at a high risk for obesity, pressure to eat at age 5 years predicted reduced child weight at age 7 years, whereas the use of restriction at 5 years predicted increased weight at 7 years. Together these studies suggest that, in children at high risk, after controlling for earlier child weight, the use of pressure and restriction has polarized the effects on subsequent child weight.

These findings are consistent with a gene-environment interpretation. Restrictive feeding practices may promote overeating, whereas pressure to eat may encourage selective eating or fussiness or discourage overeating, and these effects may be strongest for children who may be genetically predisposed to higher or lower body mass indices. However, the majority of the longitudinal evidence to date concerning the effects of maternally reported restriction, monitoring, and pressure to eat on child weight pertains to high- risk or female children over the age of 3 years, and by this age a child's weight may have already been affected by previous parental use of control. Indeed, our previous data suggest that maternal control may be causal in influencing child weight as early as 1 year of age.⁹ The aims of the present study were to explore the longitudinal relationships between child weight and maternally reported control in a nonclinical sample of children under 2 years of age. To evaluate whether controlling feeding practices are causal in predicting child weight at this age, we assessed whether maternal control over child feeding at 1 year predicts weight at 2 years after statistically controlling for the variance accounted for by child weight at 1 year.

	METHODS

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The data presented here form part of a 3-year longitudinal study conducted from 2002 to 2005, data from which have been reported elsewhere.⁹ All of the women attending the Birmingham Women's Hospital antenatal clinic on a series of days during the autumn of 2002 were approached and invited to take part in this study exploring early child feeding and growth. Full ethical consent for this study was obtained from the South Birmingham Medical Ethics Committee.

Participant Details
Sixty-two women took part in the final stage of this 3-year longitudinal study spanning from pregnancy to 2 years of child age. Eighty-seven women participated at 1 year; thus, 25 women discontinued participation between these 2 time points, providing a retention rate of 71% from 1 to 2 years of child age. The reasons given for discontinuing participation included disinterest and lack of time, and many participants had relocated and their addresses could not be traced. Independent sample t tests indicated that there were no differences between the women who continued or discontinued participation between 1 and 2 years in their child's weight or in their use of controlling feeding practices at 1 year.

In the 2-year sample there were an equal number of boys and girls. For 41 women this was their first child, for 17 their second child, for 3 their third child, and for 1 her fourth child. Mean maternal age as recorded at the birth of the child was 32 years (SD: 5.03 years). Using the Office of National Statistics socioeconomic classification scheme,¹² women reported their most recent occupation before the birth of their child; the 2 highest modal occupation categories were category 2 (professional occupations, n = 24) and category 4 (administrative and secretarial occupations, n = 23). Nine women were unemployed and had never been employed.

Measures
Participants were asked whether they had breastfed their child and, if so, for how long. In addition, the measures described below were used.

Child Feeding Questionnaire
The control in feeding subscales of the Child Feeding Questionnaire were administered to mothers when children were age 1 year. These subscales assess maternal use of pressure to eat, restriction, and monitoring.¹³ The monitoring subscale is a 3-item measure reflecting how much the mother keeps track of the amount of sweet, snack, and high-fat food her child eats. The pressure to eat subscale consists of 4 items that assess to what extent the mother will encourage her child to eat beyond the child's chosen intake. The restriction subscale consists of 8 items that assess how much the mother feels she has to watch or restrict her child's intake of sweet, high fat, and favorite foods, in addition to maternal use of food as a reward. These subscales of the Child Feeding Questionnaire are widely used to assess parental control over child feeding,^{3, 14–16} and they have been shown to have good internal consistency.¹³

Child Weight
Child weight was ascertained at birth, 1 year, and 2 years of age. Weight at birth was established from hospital records, at 1 year children were weighed naked in their homes by the lead researcher with electronic scales, and weight scores at 2 years were obtained from child health records. Weight scores at 1 and 2 years were converted using the Child Growth Foundation Reference Curves Disk into standardized z scores, also termed SD scores (SDSs), which adjust for the child's gender and age. This package is based on the least mean squares data computations developed by Freeman et al¹⁷ and Cole.¹⁸ Weight was used rather than weight for length, because many mothers did not have reliable length or height scores measured at the same age as weight scores at 2 years.

Data Analysis
First, descriptive statistics for the sample were computed. Independent sample t tests indicated that there were no significant differences in the amount of monitoring (t₆₀ = –0.063; P > .05), pressure to eat (t₆₀ = 1.061; P > .05), or restriction (t₆₀ = –0.532; P > .05) used by primipara and multipara mothers. Moreover, there were no significant differences in the amount of monitoring (t₆₀ = –0.910; P > .05) or restriction (t₆₀= 1.787; P > .05) used by breastfeeding compared with nonbreastfeeding mothers, although breastfeeding mothers used significantly less pressure to eat (t₆₀ = 3.196; P < .01). Finally, there were no significant differences in the amount of monitoring (t₆₀ = –0.238; P > .05), pressure to eat (t₆₀ = 1.695; P > .05), or restriction (t₆₀ = 0.778; P > .05) used with boys and girls. Next, 2-tailed Pearson's correlations were used to examine the relationships between controlling feeding practices at 1 year and child weight scores at birth, 1 year, and 2 years. Hierarchical multiple regressions were used to establish whether, controlling for child weight at 1 year, the use of controlling feeding practices at 1 year would predict child weight at 2 years. Separate analyses were conducted for maternal use of pressure to eat, monitoring, and restriction.

	RESULTS

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Descriptive Statistics
Table 1 displays the mean and SDSs for the Child Feeding Questionnaire pressure, restriction, and monitoring subscales at 1 year, as well as the mean and SDSs for child birth weight and weight SDSs at 1 and 2 years. Forty-three women breastfed their infants for a period of 4 weeks, and 19 exclusively bottle fed; of the women who breastfed, the mean length of breastfeeding was 30 weeks (SD: 15.80).

Monitoring
In step 1, standardized child weight at 1 year significantly predicted standardized child weight at 2 years (R² = 0.34; F_1,46 = 23.99; P < .001). In step 2, monitoring at 1 year failed to significantly add to this regression (R² = 0.34; F_2,45 = 11.82; R² change = 0.002; P > .05) and monitoring was not a significant predictor (β = –.04; t₄₅ = –0.33; P > .05).

Pressure to Eat
In step 1, child weight at 1 year significantly predicted standardized child weight at 2 years (R² = 0.34; F_1,46 = 23.99; P < .001). In step 2, pressure to eat at 1 year significantly added to this prediction (R² = 0.45; F_2,45 = 18.49; R² change = 0.11; P < .01), and pressure to eat was a significant individual predictor (β = –.34; t₄₅ = –0.30; P < .01). After controlling for present standardized child weight, pressure to eat at 1 year predicted lower standardized child weight at 2 years.

Restriction
In step 1, standardized child weight at 1 year significantly predicted standardized child weight at 2 years (R² = 0.34; F_1,46 = 23.99; P < .001). In step 2, maternal restriction at 1 year significantly added to this prediction (R² = 0.43; F_2,45 = 17.10; R² change = 0.09; P < .05), and restriction was a significant individual predictor (β = –.31; t₄₅ = –2.66; P < .05). After controlling for present standardized child weight, restriction at 1 year predicted lower standardized child weight at 2 years.^*

	DISCUSSION

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The findings of this study demonstrate that, when controlling for child weight at 1 year, the use of maternal pressure to eat and restriction at 1 year negatively predict subsequent child weight at 2 years. Moreover, these findings remain significant when controlling for potentially confounding variables such as breastfeeding, birth weight, and child gender. A wealth of evidence has established the relationships between the use of control in child feeding and child weight,¹ but what has been poorly elucidated is whether control is causal in predicting child weight early on in life. These findings suggest that, from as early as 1 year of child age, in nonclinical boys and girls, the use of maternally reported control may impact on the child's subsequent weight.

Contrary to previous research, which has found that restriction is linked with heavier child weight,^{19, 20} the findings from these data indicate that maternal pressure to eat and restriction at 1 year both negatively predicted weight at 2 years. These findings may reflect the younger age sample used for this study. In children under the age of 2 years, the foods offered to and eaten by the child are primarily governed by the caregiver. As such, a restrictive caregiver would be able to enforce restriction of sweet and high-fat foods and would also be able, to some degree, to prevent the child from accessing these foods in the caregiver's absence. Restrictive feeding practices with 2-year-old children may, therefore, be relatively covert, and the use of restriction with children under the age of 2 years may be a successful strategy that prevents overweight and actually predicts lower child weight in the short term. It could be suggested that when children begin to be more autonomous with feeding and independent eating increases, the use of restriction may then begin to predict disinhibition, emotional overeating, increased consumption of restricted foods, and subsequent child overweight, as illustrated by previous research.^{5, 6} This is an important finding, because it may partly explain why many caregivers persist with their use of restriction: because in the short term it may be a successful strategy in preventing overweight. It is perhaps only as children develop and can demand and select their own foods that the negative repercussions of restriction may begin to emerge. These suggestions are of course speculative, and we cannot actually be sure how restrictive feeding practices influence child weight; additional research is required to examine these suppositions.

Although 2-year-old children are not necessarily capable of seeking out food without their caregiver's presence, they are very capable of refusing to eat and are able, therefore, to demonstrate resistance to the imposition of pressurizing feeding practices. Indeed, these data concur with previous research, which has found that, when mothers pressure their children to eat, their children subsequently weigh less,¹¹ and, furthermore, suggest that this effect is evident in early childhood. This relationship, however, is very likely to be bidirectional, and caregivers may use pressure to eat in response to perceived or actual child underweight. Indeed, pressure to eat was negatively correlated with weight at birth, 1 year, and 2 years, suggesting that women are pressuring infants who are born lighter or who grow more slowly than their peers.

The associations between pressure to eat and restriction with lower child weight at 2 years were significant after controlling for potentially confounding variables of breastfeeding, birth weight, and gender. That breastfeeding mothers used less pressure to eat with their children supports other similar findings in the literature that breastfeeding women are less likely to overcontrol their children's food intake.^{9, 20} One mechanism suggested by Taveras et al²⁰ to explain this relationship may be through the fact that a breastfeeding mother has less obvious control over her infant's intake of milk. In turn, she may be more likely to feed on demand and subsequently more likely to allow her child to regulate his or her own hunger and satiety when eating solid foods. Importantly, however, pressure to eat continued to predict child weight at 2 years after controlling for the variance accounted for by breastfeeding, suggesting that, irrelevant of whether a mother breastfeeds, the use of pressure to eat longitudinally predicts lower child weight.

Monitoring has been associated previously with lower and higher child weight,^{4, 11} but in this sample, monitoring at 1 year was not associated with weight at 2 years. This could be because of the younger age sample; it may be that monitoring is a more common and adaptive strategy with 1-year-old children irrespective of their weight, because parents are more responsible for the provision of food in contrast to older children who may eat more often without their caregiver's presence. In addition, monitoring is a more covert form of control, and this may be especially true in younger children who may be less aware of being monitored. Covert control has been shown to predict less unhealthy snacking behavior²¹ and may, therefore, be less likely to be associated with extremes of weight.

	CONCLUSIONS

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The data presented here suggest that the use of pressure and restriction with child feeding at 1 year of age subsequently predicts reduced child weight at 2 years of age independent of earlier child weight. These findings are in contrast to studies with older children where restriction has been associated with heavier child weight, and this may reflect the fewer opportunities for younger children to eat out of the presence or influence of their caregivers. It is important to note that these findings do not support the use of restrictive feeding practices to control child weight in the long term, and we cannot conclude that such practices do not impede self-regulation of food intake at 2 years or in later childhood. It is possible that these children may have subsequent difficulties regulating their hunger and satiety but that these effects are not yet apparent because of a lack of autonomous eating and free access to foods. More generally these results support other research, which has suggested that controlling feeding practices are a counterproductive activity, with pressure to eat being associated with subsequently lower child weight. The general consensus from the research literature is that, in a naturally growing and healthy child, the use of overly controlling feeding practices is counterproductive. In a clinical setting, however, it would be irresponsible to suggest that a caregiver should not exert appropriate levels of control over the intake of a child who is either obese or malnourished. However, given that excessively controlling feeding practices can exacerbate the issues that they are designed to resolve, alternative feeding strategies are needed for caregivers to respond to child weight concerns. For example, more covert and implicit control over children's intake of foods (eg, not keeping restricted foods in the house) may be a more adaptive strategy.²¹

The findings of this study suggest that, as early as 1 year of age, controlling feeding practices can be causal in predicting child weight. As with most research of this nature, the sample is of self-selected, primarily white, middle class women, and the results cannot be generalized to other ethnic or social groups. Moreover, the sample size is relatively small, and, therefore, the results should be interpreted cautiously. It would have been beneficial to have had reliable length data from these children to establish weight for length rather than just weight and also to have parental BMI measurements to take into account the impact of parental weight on child weight. Finally, 1 year is not a sufficient time period to fully evaluate the impact of controlling feeding practices on child weight, and additional longitudinal research is necessary to establish the effects of these feeding practices on disinhibition, eating, and weight in older children.

	ACKNOWLEDGMENTS

 
We thank all of the women who took part in this study for their time and help.

	FOOTNOTES

 
Accepted Jun 5, 2007.

Address correspondence to Claire Victoria Farrow, PhD, Department of Human Sciences, Loughborough University, Leicestershire LE11 3TU United Kingdom. E-mail: c.v.farrow{at}lboro.ac.uk

The authors have indicated they have no financial relationships relevant to this article to disclose.

^* Given the previously identified relationships between weight and child gender with the use of controlling feeding practices¹⁹ and the fact that breastfeeding mothers have been shown to report using lower levels of controlling feeding practices,²⁰ all of the regressions were repeated controlling for child gender, breastfeeding, and birth weight in step 1 of the regression model: using these new models, the results were not significantly different.

	REFERENCES

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8. Wardle J, Sanderson S, Guthrie CA, Rapoport L, Plomin R. Parental feeding style and the inter-generational transmission of obesity risk. Obes Res. 2002;10 :453 –462[ISI][Medline]
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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Farrow, C. V. Articles by Blissett, J. Search for Related Content PubMed PubMed Citation Articles by Farrow, C. V. Articles by Blissett, J. Related Collections Nutrition & Metabolism

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