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Attitudes, practices, and concerns about child feeding and child weight status among socioeconomically diverse white, Hispanic, and African-American mothers
RESEARCH Perspectives in Practice
Attitudes, Practices, and Concerns about Child Feeding and Child Weight Status among Socioeconomically Diverse White, Hispanic, and African-American Mothers BETTYLOU SHERRY, PhD, RD; JUDITH MCDIVITT, PhD; LEANN LIPPS BIRCH, PhD; FRANCES HANKS COOK, MA, RD; SUSAN SANDERS, MPH, RD; JENNIFER LYNN PRISH, MS, RD; LORI ANN FRANCIS, PhD; KELLEY SEAN SCANLON, PhD, RD
ABSTRACT Parents play an important role in the development of their children’s eating behaviors. We conducted 12 focus groups (three white, three African-American, and three HispanicAmerican low-income groups; three white middle-income groups) of mothers (N⫽101) of 2- to less than 5-year-old children to explore maternal attitudes, concerns, and practices related to child feeding and perceptions about child weight. We identified the following major themes from responses to our standardized focus group guide: 12 groups wanted to provide good nutrition, and most wanted children to avoid eating too many sweets and processed foods; 12 groups prepared foods their children liked, accommodated specific requests, and used bribes and rewards to accomplish their feeding goals (sweets were commonly used as bribes, rewards, or pacifiers); and 11 of 12 groups believed their children were prevaricating when they said they were full and mothers encouraged them to eat more. The common use of strategies that may not promote healthful weight suggests work is needed to develop culturally and socioeconomically effective overweight prevention programs. Further study is needed to verify racial/ethnic or income differences in attitudes, practices, and concerns about child feeding and perceptions of child weight. J Am Diet Assoc. 2004;104:215-221. B. Sherry, J. McDivitt, and K. S. Scanlon are with the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and Physical Activity, Atlanta, GA. L. L. Birch and L. A. Francis are with the Pennsylvania State University, Department of Human Development and Family Studies, University Park, PA. F. H. Cook and S. Sanders are with The Georgia Division of Public Health, Nutrition Section, Atlanta, GA. J. L. Prish is with the University of Southern Illinois, Carbondale, IL. Address correspondence to: Bettylou Sherry, PhD, RD, Maternal and Child Nutrition Branch, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K-25, 4770 Buford Hwy, NE, Atlanta, GA 30341-3717. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10402-0007$30.00/0 doi: 10.1016/j.jada.2003.11.012
© 2004 by the American Dietetic Association
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he increasing trend in prevalence of pediatric overweight is a major public health problem (1-3) because of the tracking of overweight (4-5) and its association with elevated health risks (6-9). Parents play an important role in the development of their children’s eating behaviors, food preferences, and energy intake (10). They commonly attempt to restrict children’s access to sweets, snack food, and other foods they believe are unhealthful, and attempt to encourage or pressure children to eat healthful foods at mealtimes (11). There is some evidence that parental child-feeding practices may actually contribute to the development of pediatric overweight (12). A cross-sectional study of white, middleincome families showed that parents who control their children’s food intake may potentiate children’s preferences for high-fat, energy-dense foods, limit their acceptance of a variety of foods, and disrupt their natural ability to self-regulate energy intake by altering their responsiveness to internal hunger and satiety cues (12). Although not yet conclusive, there is a growing body of evidence of an association between parental control of child feeding and the development of child overweight, particularly in regard to food restriction. Studies have revealed that parental restriction of certain high-preference snack foods was positively associated with children’s preference for these foods (13), a higher intake of these foods (13,14), higher child weight status (13,15), and daughters’ inability to regulate energy intake (14). A 2-year follow-up study of 5-year-old girls showed that parental restriction of intake was associated with a high snack intake in the absence of hunger at 7 years of age, and that eating in the absence of hunger at 5 and 7 years was associated with overweight (16). In contrast, a large population-based study did not find a significant association between parental restriction of feeding and body mass index in boys or girls (17). Associations between parental encouragement during feeding and child energy intake or weight are less clear (18,19). The goal of our study was to engage mothers of preschool children from culturally and economically different backgrounds in focus group discussions to explore maternal attitudes, concerns, and practices related to child feeding and to examine maternal perceptions and concerns regarding child weight. These findings can be used to develop appropriate questionnaires for further assessing associations between parental control of child feeding
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and overweight and to explore appropriate intervention strategies to improve child-feeding practices. METHODS We conducted 12 focus groups among mothers of children 2 to less than 5 years old. Nine groups (three white [total n⫽22], three African American [total n⫽24], and three Hispanic American [total n⫽27]) were recruited from low-income families participating in the Georgia Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Georgia Division of Public Health staff identified and obtained Health District permission to recruit from three Atlanta metropolitan area WIC clinics that had good representation of the racial/ ethnic groups of interest. Two to three weeks before the focus group sessions, for a few hours on several days, state Division of Public Health staff members approached all mothers with 2- to less than 5-year-old children seated in WIC clinic waiting rooms about participation in the focus groups. Interested mothers were screened for eligibility. Eligible mothers participated in WIC, indicating a family income ⱕ185% poverty level; did not work in the health field; were between ages 20 and 35 years; could communicate in English or Spanish; lived in an urban or suburban area; identified themselves as white, African American, or Hispanic American; had at least one child between 2 and less than 5 years old who lived with them and did not have a health condition that would affect his or her diet; and had the primary responsibility for feeding their child. An attempt was also made to balance child gender. Fifteen mothers were contacted by telephone and scheduled for each group to ensure a target attendance of nine mothers. We included three additional middle-income white focus groups (total n⫽28) to better understand our topics of interest in the socioeconomic and cultural group that had been used for previous studies on the association between child-feeding practices and child overweight (12,13). These groups, with the exception of one mother, were white and were recruited from a listing of mothers in the State College, PA, local area. This listing was generated by the Department of Human Development and Family Studies at The Pennsylvania State University from local area birth records and included only parents who indicated that they might be interested in participating in additional research projects on child development. Mothers of 2- to less than 5-year-olds were contacted two to three weeks before the focus group sessions by telephone, and if interested in participating, were screened for eligibility (criteria same as Georgia groups except that income was ⬎185% poverty level). Twelve mothers were recruited for each focus group to ensure a target attendance of nine mothers. Limited funding did not permit inclusion of additional groups. One moderator, an anthropologist, facilitated all focus group sessions, which were held between April and July 1999. The moderator was fluent in English and Spanish, and experienced in focus-group work among whites, African Americans, and Hispanics. Despite over–recruiting, we did not always have nine attendees for each focus group session (range⫽5 to 10 per group; mean⫽8.4 per group); however, all of those who came to their session participated and completed it. Each mother participated in only one session. All of the low-income focus groups
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were held in conference rooms at the health department clinics and each mother received $35 remuneration to help cover transportation and babysitting costs. The three Pennsylvania sessions were held in a classroom on The Pennsylvania State University campus; these mothers were not reimbursed for their participation. A structured focus-group guide (Figure 1) was used to query the mothers. The guide included a series of questions, adapted from the Child Feeding Questionnaire, which focused on parental child-feeding strategies regarding responsibility for feeding, pressure to eat, restriction of feeding, and the use of food as a reward or bribe (11). Questions that examined maternal concerns about their children’s weight and maternal perceptions of weight were also part of the guide. Mothers were also asked to look at two sets (boys and girls separate) of seven sequentially numbered schematic drawings of children whose weight status ranged from very thin to very overweight and to select the drawing number that defined the cutoff to identify as child as overweight. The 90-minute focus-group sessions were audiotaped and transcribed later by professional transcriptionists. The focus-group facilitator reviewed the transcripts and produced an edited transcript that included only the mothers’ responses to each question. One coauthor verified the accuracy and completeness of the initial transcriptions and the edited transcript of the mothers’ responses. To identify key themes in the responses to each question, four coauthors independently read the edited versions of the transcripts. Two coauthors read and coded each focus group. The coauthors typed these themes into a master table for comparisons within and among racial/ ethnic and income categories. Themes within a group were defined as issues raised or agreed on by several members of a group. Themes among groups were themes that arose in two or more groups within a racial/ethnic or income category. Key findings were defined as themes that arose in all three groups within a racial/ethnic or income category or across the majority of all groups. The coauthors met several times to review findings and reach consensus on the major group themes. To define maternal perceptions of overweight in each group, we calculated the proportion of mothers who selected each schematic drawing number as the cut point for overweight. RESULTS The six topic areas with their key findings are summarized in Figure 2. Additional themes, findings, and comments for each topic are described. Maternal Feeding Goals and Beliefs about What Constitutes Good and Bad Nutrition In addition to the findings in Figure 2, we found that having a child clean his or her plate was not a theme among any of the groups of mothers; and, most white mothers controlled children’s intake of or access to “foods they did not want children to eat excessively.” Key Perceived Determinants of Foods Available in the Home Only one Hispanic-American group specifically mentioned cost, the key determinant for all other groups; two
Question Are there things about feeding your child that you find fun or easy? Are there things about feeding your child that you find difficult or hard to deal with? What goals do you have when you are feeding your child? Think about the typical meal time you share with your child. What happens?
Probe
What strategies do you use to reach these goals? Who is there? What is the mood? Is there any interaction between you and your child? How often do you eat with your child?
Think about the times it has been difficult to feed your child. What was happening?
Were there other important things going on in the house?
What do you think your child is telling you when he/she says he/she is full?
When he/she is hungry? Or still hungry at the end of a meal? What do you do when your child eats nothing or not very much at a meal?
How do you feel about food left on your child’s plate?
When your child leaves food on his/her plate, what do you do? If your child says he/she is full, are there particular foods on the plate that you would prefer to see them finish? When serving a meal, who determines the portion size for the child?
Are there foods that you don’t want your child to eat too much of?
If yes, what are they? Why are you concerned about these foods? Do you try to keep your child from eating too much of these foods? If yes, how? Reward or bribe for good behavior? Reward or bribe for eating foods that you want them to eat? Are special snacks or treats given to your child to help him/her feel better, to keep them quiet, when bored, to stop crying? What are the special snacks or treats in your house?
When are special snacks or treats given to your child?
Did you have disagreements with your child?
What sorts of things affect the foods you have at home? Looking at these schematic drawings of girls and boys, how would you describe them in terms of their weight status? Circle those that are overweight.
For example, money, transportation, available at grocery, other?
Thinking about your child’s growth and weight, do you have any concerns?
What concerns, if any, do your have about your daughter’s/son’s growth? How do you feel about your daughter/son becoming overweight? How do you feel about your daughter/son becoming underweight?
Closing thoughts? Figure 1. Questions and probes for focus group sessions.
Hispanic-American groups were concerned about transportation and time to shop. Household Mealtime Environment and What Makes Feeding Young Children Easy or Difficult The middle-income mothers did not accommodate children’s mealtime requests for specific foods; however, among the other groups of mothers who did accommodate, it difficult for them to sit with their children for the entire meal. Two each of the low-income and middleincome white groups reported that it was fun when the children were involved in meal preparation. Several feeding challenge themes specific to the racial/ ethnic groups were reported. The middle-income white mothers reported the following challenges: tiredness of adults or children, the influence of older siblings, and keeping children on a breakfast time schedule that allows
mothers and children to get to work and school on time. All groups of African-American mothers noted difficulties with external factors such as company, playing outside with other children, limited food supply, and with children who are sick or picky eaters or those who drink fluids before meals. Additionally, the African American groups reported other feeding challenges, including dealing with conflicts about eating the food served at mealtime, attaining a balanced diet, and finding foods that are easy to prepare and that their children can eat without making a mess, but these did not emerge as major themes. Three groups (two African American and one Hispanic American) found this question difficult to answer and provided little information beyond the general themes. Several working mothers in both low-income and middle-income groups mentioned lack of time for meal preparation as a challenge, especially at dinner when
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Category Maternal feeding goals and beliefs about what constitutes good nutrition
Themes ● Primary feeding goals for all groups were “good nutrition” and getting their children to eat. Hispanics valued traditional foods. ● All groups did not want children to eat too many sweets; Hispanics were concerned about “processed foods”; middle-income whites were concerned about high-fat foods. ● Strategies for controlling intake of foods they did not want children to eat excessively included not purchasing, hiding, controlling portions, or giving an approved form of food (eg, fruit-flavored gelatin vs candy). ● Mixed responses were given about foods to finish at each meal, but low-income white and African-American mothers were concerned about vegetables and protein; Hispanics valued eating “enough”
Key perceived determinants of foods available in the home
● Cost was the key determinant in six of nine low-income groups and all middle-income groups. Key strategies used were purchasing sale items and using coupons. ● Hispanics concerned about having “what they needed” (eg, nutritious, liked by their children, easy and quick to prepare).
Household mealtime environment and what makes feeding young children easy or difficult
● All groups reported food conflicts and chaos and stress during usual, structured family dinners, yet they wanted meal preparation and meal times to be easy. ● Feeding was considered fun and easy when the child liked the food and preparation was easy. ● Feeding was considered difficult when their children would not eat or did not like the food served. ● Reasons cited for difficult feedings were changing likes and dislikes (seven groups, including six white and one African American recognized this as part of normal development), growth spurts (low-income white), and introducing new foods (low-income whites and African Americans), breaking routines, and illness (only Hispanic groups). Six low-income groups cited watching television during meals as competition for their children’s attention to food and eating. ● Hispanics prepared traditional foods and focused on persuading their children to eat enough ● Middle-income whites were challenged to get their children to eat a balanced diet and enough, but not too much food ● Mothers determined portion sizes and reported that they knew how much their children would or needed to eat; however, several mothers requested advice on appropriate portion sizes.
Maternal strategies used to persuade their children to eat
● All groups reported considering children’s likes and dislikes in planning meals, and they commonly prepared foods their children liked. ● All groups encouraged their children to eat. ● Six low-income groups of mothers (two in each of the racial/ethnic groups) accommodated requests for specific foods during meals. ● Food and non-food bribes and rewards, or games were commonly used to attain desired behaviors, such as finishing a meal. ● Special snacks or treats were used as rewards, bribes, and as pacifiers. Common foods used included ice cream, fruit-flavored gelatin, popcorn, cookies, and fruit (Hispanics only).
Maternal reactions to their children’s assessment of being full or hungry
● Eleven groups said “full” usually meant wanting to do something else; one middle-income group believed their children were full. ● Mothers who did not believe their children were “full” encouraged or pressured them to eat. ● “Hungry” usually meant hungry, but could mean bored or to divert attention from undesired activity. ● Hispanic groups were concerned that “not hungry” meant ill.
Maternal concerns about children’s weight and general beliefs about child weight
● All low-income groups cited underweight as a concern. All white groups and one African-American group cited overweight as well. ● Hispanics believed that good health and what their children ate was more important than weight, yet they did not want their children to be either underweight or overweight. ● Middle-income white groups also concerned about eating disorders and the development of good eating habits early in life. ● African-American groups generally believed children would outgrow their overweight, or that having a high weight in childhood was healthy. ● Seven groups (3 low-income and 3 middle-income white, 1 African American), believed genetics and environment determined weight status; 2 African-American groups cited genetics as the key determinant; and 2 Hispanic groups reported environment as the key determinant. One Hispanic group did not comment.
Figure 2. Key findings from focus group discussions.
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Percent of mothers selecting cut point for overweight Racial/ethnic and income category Low-income whites Low-income African Americans Low-income Hispanic Americans Middle-income whites
Sample (N)
Child #5
Child #6
Child #7
22 24 27 28
32 4 33 15
59 75 59 67
9 21 7 18
Figure 3. Percentage of focus group mothers selecting specific child numbers from schematic drawingsa to define cut points for “overweight.” (aSource: Collins ME. Body figure perceptions and preferences among pre-adolescent children. Int J Eating Disord. 1991;10:199-208. Copyright 姝1991 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.) their children were hungry and tired, although this was not common enough to be a theme. Maternal Strategies Used to Persuade Children to Eat Two groups (low-income white and African American) mentioned withholding drinks at mealtimes until the required amount of food was eaten. All Hispanic-American groups mentioned using fruit as a special treat, in contrast with only one or two groups in each of the other racial/ethnic categories. African-American mothers reported that they did not offer snacks or special treats when their children were bored. Middle-income white groups cited using food as a pacifier in the car or when shopping, and they used sweets or salty treats as special treats or snack foods. Other specific strategies reported that were not common enough to emerge as themes were negotiation, using themselves or sibling as role models, involving children in meal preparation, or making mealtimes special by, for example, having a picnic. Maternal Reactions to Their Children’s Assessment of Being Full or Hungry In addition to the common themes listed in Figure 2, the low-income and middle-income white groups also re-
ported that they tried to understand what children meant when they said they were “full” or “hungry.” Maternal Concerns about Children’s Weight and General Beliefs about Child Weight There were racial/ethnic and income differences in mother’s perceptions of overweight, as shown by the schematic drawing number they chose to define overweight (Figure 3). The most commonly selected cutoff was the sixth category. About one-third of the mothers in each of the lowincome white and Hispanic-American groups (32% and 33%, respectively) defined the cutoff at the fifth category. In contrast, about one-fifth of the African-American groups (21%) and the middle-income white (18%) groups selected the highest category to define overweight. Thus, several mothers in these latter two categories defined overweight at a higher apparent weight than did lowincome white and Hispanic mothers. In addition to the specific topics addressed in our focus groups, several mothers asked for guidance on strategies for persuading their children to eat and about balancing convenience, variety, and food cost. They were also interested in information about age-appropriate portion sizes and who should determine children’s portion sizes.
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DISCUSSION Many of the goals and concerns about child feeding identified by our focus groups of mothers were in accordance with the Dietary Guidelines for Americans and the Food Guide Pyramid (20). However, several of their strategies for accomplishing these goals diverged from those currently recommended to promote healthful eating and to prevent overweight and parent child-feeding conflicts. These well-intended, but potentially counterproductive, strategies included accommodating specific requests for alternative choices at meals; using foods (especially sweets) as bribes, rewards, and pacifiers to encourage eating or another desired behavior; allowing children to watch television during meals; determining portion sizes for their children; pressuring their children to eat enough (especially Hispanics); and not believing their children when they say they are full. Use of these strategies becomes an important issue considering that research findings suggest parental control of child feeding may interfere with children’s ability to self-regulate energy intake and lead to the development of overweight (12,13). We need to learn more about how, when, and why mothers use these strategies to effectively encourage mothers to change their approach and use recommended strategies. Satter (21) and Dietz and Stern (22) advocate the division of responsibility for child feeding where parents serve as gatekeepers for foods served and children decide whether and how much to eat. Use of this principle helps to avoid parent– child conflicts over eating by giving both the parents and children some control, and its use could help mothers adopt recommended strategies. Results of a recent pilot study suggest that children’s diets could be improved by reducing parental control. Researchers found that reducing parental control coupled with enhancing children’s knowledge about fruits resulted in an increase in fruit intake (23). Another area in need of intervention is helping mothers accept their child’s response when appropriate. The common beliefs that children are prevaricating when they say they are full, that mothers should determine the portion sizes for their children, and that children should eat enough, could all result in overfeeding. The use of social marketing methods to understand mother’s incentives and barriers to changing behavior and underlying beliefs might help resolve this challenge (24). Our finding that low-income mothers are concerned about underweight is consistent with the focus group findings reported by Baughcum and colleagues (25). Additionally, our mothers’ different perceptions of overweight are also of interest. About 20% of low-income African-American and middle-income white mothers selected the schematic drawing with the highest number as their cutpoint for defining overweight, suggesting their acceptance as normal weight what public health officials describe as overweight. Our findings are consistent with those reported by others (26,27). These perceptions appear culturally bound and will require different approaches to convey to mothers the health concerns associated with the level of weight they perceive as normal. Again, a social marketing focus might help identify approaches that could influence mothers’ perceptions of pediatric overweight and the need to prevent and treat it. The lack of consistent findings among our focus groups on topics not in the focus group guide requires further study. One group would raise and discuss an issue, yet
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others did not; for example, the Hispanic-American groups stressed the importance of including culturally specific foods in their children’s diets. Consequently, we don’t know whether this issue was not important to the other groups or whether the topic did not arise spontaneously. Our small number of focus groups within each racial/ethnic and income category limits our ability to generalize any differences. Many of the feeding practices identified in our focus groups need to be examined further, preferably in a longitudinal study, to determine whether they are etiologically associated with the development of childhood overweight. In addition, we identified several areas that need more careful examination with quantitative research methods to further our understanding of maternal attitudes, practices, and concerns about child feeding. Examples of topics needing further study include the importance and use of culturally specific foods; the use of food as bribes, rewards, or pacifiers; procedures used to introduce new foods; fathers’ participation in encouraging or restricting food consumption at mealtime; and the time frame used to assess whether a child has eaten enough. In addition to developing appropriate strategies for effective interventions to prevent child overweight, more qualitative research is needed to better understand issues such as how to help mothers accept children’s reported lack of hunger and why mothers respond to children’s specific alternative food requests at meal times. CONCLUSIONS Focus group themes identified that may be useful to dietetics professionals for tailoring interventions to promote healthful child weight include: ●
●
●
●
Build on mothers’ feeding goals to provide good nutrition to their children by enhancing their knowledge of the Dietary Guidelines for Americans and appropriate child portion sizes, and providing culturally appropriate suggestions for balancing convenience, variety, and food costs. Providing education on meal planning, quick-to-prepare healthful meals, and budgeting may be helpful. Help mothers overcome the stress and chaos of mealtimes. One approach to help mothers reduce parent– child feeding conflicts is to advocate use of the division of responsibility principle for child feeding to empower mothers to plan and serve one meal to the family, not to “short order” cook for individual children who refuse to eat, and to serve as the gatekeepers to prevent excess intake of sweets and other foods they want to limit. Help mothers believe their children when they say are “full” and discourage mothers from encouraging their children to eat after they say they are full. Recognize that there are differences in cultural perceptions of child overweight and provide culturally appropriate information for increasing mothers’ knowledge about healthful child weight and the health consequences associated with overweight during childhood.
The authors thank Marco Pardi, MS, for conducting the focus groups. This research was supported in part by Centers for Disease Control and Prevention contract No. 200-95-0957, Task Order No. 0957-029 to LL Birch through Penn State Geisinger, via American Association of Health Plans.
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Attitudes, Practices, and Concerns about Child Feeding and Child Weight Status among Socioeconomically Diverse White, Hispanic, and African-American Mothers BETTYLOU SHERRY, PhD, RD; JUDITH MCDIVITT, PhD; LEANN LIPPS BIRCH, PhD; FRANCES HANKS COOK, MA, RD; SUSAN SANDERS, MPH, RD; JENNIFER LYNN PRISH, MS, RD; LORI ANN FRANCIS, PhD; KELLEY SEAN SCANLON, PhD, RD
ABSTRACT Parents play an important role in the development of their children’s eating behaviors. We conducted 12 focus groups (three white, three African-American, and three HispanicAmerican low-income groups; three white middle-income groups) of mothers (N⫽101) of 2- to less than 5-year-old children to explore maternal attitudes, concerns, and practices related to child feeding and perceptions about child weight. We identified the following major themes from responses to our standardized focus group guide: 12 groups wanted to provide good nutrition, and most wanted children to avoid eating too many sweets and processed foods; 12 groups prepared foods their children liked, accommodated specific requests, and used bribes and rewards to accomplish their feeding goals (sweets were commonly used as bribes, rewards, or pacifiers); and 11 of 12 groups believed their children were prevaricating when they said they were full and mothers encouraged them to eat more. The common use of strategies that may not promote healthful weight suggests work is needed to develop culturally and socioeconomically effective overweight prevention programs. Further study is needed to verify racial/ethnic or income differences in attitudes, practices, and concerns about child feeding and perceptions of child weight. J Am Diet Assoc. 2004;104:215-221. B. Sherry, J. McDivitt, and K. S. Scanlon are with the Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and Physical Activity, Atlanta, GA. L. L. Birch and L. A. Francis are with the Pennsylvania State University, Department of Human Development and Family Studies, University Park, PA. F. H. Cook and S. Sanders are with The Georgia Division of Public Health, Nutrition Section, Atlanta, GA. J. L. Prish is with the University of Southern Illinois, Carbondale, IL. Address correspondence to: Bettylou Sherry, PhD, RD, Maternal and Child Nutrition Branch, Division of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K-25, 4770 Buford Hwy, NE, Atlanta, GA 30341-3717. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10402-0007$30.00/0 doi: 10.1016/j.jada.2003.11.012
© 2004 by the American Dietetic Association
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he increasing trend in prevalence of pediatric overweight is a major public health problem (1-3) because of the tracking of overweight (4-5) and its association with elevated health risks (6-9). Parents play an important role in the development of their children’s eating behaviors, food preferences, and energy intake (10). They commonly attempt to restrict children’s access to sweets, snack food, and other foods they believe are unhealthful, and attempt to encourage or pressure children to eat healthful foods at mealtimes (11). There is some evidence that parental child-feeding practices may actually contribute to the development of pediatric overweight (12). A cross-sectional study of white, middleincome families showed that parents who control their children’s food intake may potentiate children’s preferences for high-fat, energy-dense foods, limit their acceptance of a variety of foods, and disrupt their natural ability to self-regulate energy intake by altering their responsiveness to internal hunger and satiety cues (12). Although not yet conclusive, there is a growing body of evidence of an association between parental control of child feeding and the development of child overweight, particularly in regard to food restriction. Studies have revealed that parental restriction of certain high-preference snack foods was positively associated with children’s preference for these foods (13), a higher intake of these foods (13,14), higher child weight status (13,15), and daughters’ inability to regulate energy intake (14). A 2-year follow-up study of 5-year-old girls showed that parental restriction of intake was associated with a high snack intake in the absence of hunger at 7 years of age, and that eating in the absence of hunger at 5 and 7 years was associated with overweight (16). In contrast, a large population-based study did not find a significant association between parental restriction of feeding and body mass index in boys or girls (17). Associations between parental encouragement during feeding and child energy intake or weight are less clear (18,19). The goal of our study was to engage mothers of preschool children from culturally and economically different backgrounds in focus group discussions to explore maternal attitudes, concerns, and practices related to child feeding and to examine maternal perceptions and concerns regarding child weight. These findings can be used to develop appropriate questionnaires for further assessing associations between parental control of child feeding
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and overweight and to explore appropriate intervention strategies to improve child-feeding practices. METHODS We conducted 12 focus groups among mothers of children 2 to less than 5 years old. Nine groups (three white [total n⫽22], three African American [total n⫽24], and three Hispanic American [total n⫽27]) were recruited from low-income families participating in the Georgia Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The Georgia Division of Public Health staff identified and obtained Health District permission to recruit from three Atlanta metropolitan area WIC clinics that had good representation of the racial/ ethnic groups of interest. Two to three weeks before the focus group sessions, for a few hours on several days, state Division of Public Health staff members approached all mothers with 2- to less than 5-year-old children seated in WIC clinic waiting rooms about participation in the focus groups. Interested mothers were screened for eligibility. Eligible mothers participated in WIC, indicating a family income ⱕ185% poverty level; did not work in the health field; were between ages 20 and 35 years; could communicate in English or Spanish; lived in an urban or suburban area; identified themselves as white, African American, or Hispanic American; had at least one child between 2 and less than 5 years old who lived with them and did not have a health condition that would affect his or her diet; and had the primary responsibility for feeding their child. An attempt was also made to balance child gender. Fifteen mothers were contacted by telephone and scheduled for each group to ensure a target attendance of nine mothers. We included three additional middle-income white focus groups (total n⫽28) to better understand our topics of interest in the socioeconomic and cultural group that had been used for previous studies on the association between child-feeding practices and child overweight (12,13). These groups, with the exception of one mother, were white and were recruited from a listing of mothers in the State College, PA, local area. This listing was generated by the Department of Human Development and Family Studies at The Pennsylvania State University from local area birth records and included only parents who indicated that they might be interested in participating in additional research projects on child development. Mothers of 2- to less than 5-year-olds were contacted two to three weeks before the focus group sessions by telephone, and if interested in participating, were screened for eligibility (criteria same as Georgia groups except that income was ⬎185% poverty level). Twelve mothers were recruited for each focus group to ensure a target attendance of nine mothers. Limited funding did not permit inclusion of additional groups. One moderator, an anthropologist, facilitated all focus group sessions, which were held between April and July 1999. The moderator was fluent in English and Spanish, and experienced in focus-group work among whites, African Americans, and Hispanics. Despite over–recruiting, we did not always have nine attendees for each focus group session (range⫽5 to 10 per group; mean⫽8.4 per group); however, all of those who came to their session participated and completed it. Each mother participated in only one session. All of the low-income focus groups
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were held in conference rooms at the health department clinics and each mother received $35 remuneration to help cover transportation and babysitting costs. The three Pennsylvania sessions were held in a classroom on The Pennsylvania State University campus; these mothers were not reimbursed for their participation. A structured focus-group guide (Figure 1) was used to query the mothers. The guide included a series of questions, adapted from the Child Feeding Questionnaire, which focused on parental child-feeding strategies regarding responsibility for feeding, pressure to eat, restriction of feeding, and the use of food as a reward or bribe (11). Questions that examined maternal concerns about their children’s weight and maternal perceptions of weight were also part of the guide. Mothers were also asked to look at two sets (boys and girls separate) of seven sequentially numbered schematic drawings of children whose weight status ranged from very thin to very overweight and to select the drawing number that defined the cutoff to identify as child as overweight. The 90-minute focus-group sessions were audiotaped and transcribed later by professional transcriptionists. The focus-group facilitator reviewed the transcripts and produced an edited transcript that included only the mothers’ responses to each question. One coauthor verified the accuracy and completeness of the initial transcriptions and the edited transcript of the mothers’ responses. To identify key themes in the responses to each question, four coauthors independently read the edited versions of the transcripts. Two coauthors read and coded each focus group. The coauthors typed these themes into a master table for comparisons within and among racial/ ethnic and income categories. Themes within a group were defined as issues raised or agreed on by several members of a group. Themes among groups were themes that arose in two or more groups within a racial/ethnic or income category. Key findings were defined as themes that arose in all three groups within a racial/ethnic or income category or across the majority of all groups. The coauthors met several times to review findings and reach consensus on the major group themes. To define maternal perceptions of overweight in each group, we calculated the proportion of mothers who selected each schematic drawing number as the cut point for overweight. RESULTS The six topic areas with their key findings are summarized in Figure 2. Additional themes, findings, and comments for each topic are described. Maternal Feeding Goals and Beliefs about What Constitutes Good and Bad Nutrition In addition to the findings in Figure 2, we found that having a child clean his or her plate was not a theme among any of the groups of mothers; and, most white mothers controlled children’s intake of or access to “foods they did not want children to eat excessively.” Key Perceived Determinants of Foods Available in the Home Only one Hispanic-American group specifically mentioned cost, the key determinant for all other groups; two
Question Are there things about feeding your child that you find fun or easy? Are there things about feeding your child that you find difficult or hard to deal with? What goals do you have when you are feeding your child? Think about the typical meal time you share with your child. What happens?
Probe
What strategies do you use to reach these goals? Who is there? What is the mood? Is there any interaction between you and your child? How often do you eat with your child?
Think about the times it has been difficult to feed your child. What was happening?
Were there other important things going on in the house?
What do you think your child is telling you when he/she says he/she is full?
When he/she is hungry? Or still hungry at the end of a meal? What do you do when your child eats nothing or not very much at a meal?
How do you feel about food left on your child’s plate?
When your child leaves food on his/her plate, what do you do? If your child says he/she is full, are there particular foods on the plate that you would prefer to see them finish? When serving a meal, who determines the portion size for the child?
Are there foods that you don’t want your child to eat too much of?
If yes, what are they? Why are you concerned about these foods? Do you try to keep your child from eating too much of these foods? If yes, how? Reward or bribe for good behavior? Reward or bribe for eating foods that you want them to eat? Are special snacks or treats given to your child to help him/her feel better, to keep them quiet, when bored, to stop crying? What are the special snacks or treats in your house?
When are special snacks or treats given to your child?
Did you have disagreements with your child?
What sorts of things affect the foods you have at home? Looking at these schematic drawings of girls and boys, how would you describe them in terms of their weight status? Circle those that are overweight.
For example, money, transportation, available at grocery, other?
Thinking about your child’s growth and weight, do you have any concerns?
What concerns, if any, do your have about your daughter’s/son’s growth? How do you feel about your daughter/son becoming overweight? How do you feel about your daughter/son becoming underweight?
Closing thoughts? Figure 1. Questions and probes for focus group sessions.
Hispanic-American groups were concerned about transportation and time to shop. Household Mealtime Environment and What Makes Feeding Young Children Easy or Difficult The middle-income mothers did not accommodate children’s mealtime requests for specific foods; however, among the other groups of mothers who did accommodate, it difficult for them to sit with their children for the entire meal. Two each of the low-income and middleincome white groups reported that it was fun when the children were involved in meal preparation. Several feeding challenge themes specific to the racial/ ethnic groups were reported. The middle-income white mothers reported the following challenges: tiredness of adults or children, the influence of older siblings, and keeping children on a breakfast time schedule that allows
mothers and children to get to work and school on time. All groups of African-American mothers noted difficulties with external factors such as company, playing outside with other children, limited food supply, and with children who are sick or picky eaters or those who drink fluids before meals. Additionally, the African American groups reported other feeding challenges, including dealing with conflicts about eating the food served at mealtime, attaining a balanced diet, and finding foods that are easy to prepare and that their children can eat without making a mess, but these did not emerge as major themes. Three groups (two African American and one Hispanic American) found this question difficult to answer and provided little information beyond the general themes. Several working mothers in both low-income and middle-income groups mentioned lack of time for meal preparation as a challenge, especially at dinner when
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Category Maternal feeding goals and beliefs about what constitutes good nutrition
Themes ● Primary feeding goals for all groups were “good nutrition” and getting their children to eat. Hispanics valued traditional foods. ● All groups did not want children to eat too many sweets; Hispanics were concerned about “processed foods”; middle-income whites were concerned about high-fat foods. ● Strategies for controlling intake of foods they did not want children to eat excessively included not purchasing, hiding, controlling portions, or giving an approved form of food (eg, fruit-flavored gelatin vs candy). ● Mixed responses were given about foods to finish at each meal, but low-income white and African-American mothers were concerned about vegetables and protein; Hispanics valued eating “enough”
Key perceived determinants of foods available in the home
● Cost was the key determinant in six of nine low-income groups and all middle-income groups. Key strategies used were purchasing sale items and using coupons. ● Hispanics concerned about having “what they needed” (eg, nutritious, liked by their children, easy and quick to prepare).
Household mealtime environment and what makes feeding young children easy or difficult
● All groups reported food conflicts and chaos and stress during usual, structured family dinners, yet they wanted meal preparation and meal times to be easy. ● Feeding was considered fun and easy when the child liked the food and preparation was easy. ● Feeding was considered difficult when their children would not eat or did not like the food served. ● Reasons cited for difficult feedings were changing likes and dislikes (seven groups, including six white and one African American recognized this as part of normal development), growth spurts (low-income white), and introducing new foods (low-income whites and African Americans), breaking routines, and illness (only Hispanic groups). Six low-income groups cited watching television during meals as competition for their children’s attention to food and eating. ● Hispanics prepared traditional foods and focused on persuading their children to eat enough ● Middle-income whites were challenged to get their children to eat a balanced diet and enough, but not too much food ● Mothers determined portion sizes and reported that they knew how much their children would or needed to eat; however, several mothers requested advice on appropriate portion sizes.
Maternal strategies used to persuade their children to eat
● All groups reported considering children’s likes and dislikes in planning meals, and they commonly prepared foods their children liked. ● All groups encouraged their children to eat. ● Six low-income groups of mothers (two in each of the racial/ethnic groups) accommodated requests for specific foods during meals. ● Food and non-food bribes and rewards, or games were commonly used to attain desired behaviors, such as finishing a meal. ● Special snacks or treats were used as rewards, bribes, and as pacifiers. Common foods used included ice cream, fruit-flavored gelatin, popcorn, cookies, and fruit (Hispanics only).
Maternal reactions to their children’s assessment of being full or hungry
● Eleven groups said “full” usually meant wanting to do something else; one middle-income group believed their children were full. ● Mothers who did not believe their children were “full” encouraged or pressured them to eat. ● “Hungry” usually meant hungry, but could mean bored or to divert attention from undesired activity. ● Hispanic groups were concerned that “not hungry” meant ill.
Maternal concerns about children’s weight and general beliefs about child weight
● All low-income groups cited underweight as a concern. All white groups and one African-American group cited overweight as well. ● Hispanics believed that good health and what their children ate was more important than weight, yet they did not want their children to be either underweight or overweight. ● Middle-income white groups also concerned about eating disorders and the development of good eating habits early in life. ● African-American groups generally believed children would outgrow their overweight, or that having a high weight in childhood was healthy. ● Seven groups (3 low-income and 3 middle-income white, 1 African American), believed genetics and environment determined weight status; 2 African-American groups cited genetics as the key determinant; and 2 Hispanic groups reported environment as the key determinant. One Hispanic group did not comment.
Figure 2. Key findings from focus group discussions.
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Percent of mothers selecting cut point for overweight Racial/ethnic and income category Low-income whites Low-income African Americans Low-income Hispanic Americans Middle-income whites
Sample (N)
Child #5
Child #6
Child #7
22 24 27 28
32 4 33 15
59 75 59 67
9 21 7 18
Figure 3. Percentage of focus group mothers selecting specific child numbers from schematic drawingsa to define cut points for “overweight.” (aSource: Collins ME. Body figure perceptions and preferences among pre-adolescent children. Int J Eating Disord. 1991;10:199-208. Copyright 姝1991 by John Wiley & Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.) their children were hungry and tired, although this was not common enough to be a theme. Maternal Strategies Used to Persuade Children to Eat Two groups (low-income white and African American) mentioned withholding drinks at mealtimes until the required amount of food was eaten. All Hispanic-American groups mentioned using fruit as a special treat, in contrast with only one or two groups in each of the other racial/ethnic categories. African-American mothers reported that they did not offer snacks or special treats when their children were bored. Middle-income white groups cited using food as a pacifier in the car or when shopping, and they used sweets or salty treats as special treats or snack foods. Other specific strategies reported that were not common enough to emerge as themes were negotiation, using themselves or sibling as role models, involving children in meal preparation, or making mealtimes special by, for example, having a picnic. Maternal Reactions to Their Children’s Assessment of Being Full or Hungry In addition to the common themes listed in Figure 2, the low-income and middle-income white groups also re-
ported that they tried to understand what children meant when they said they were “full” or “hungry.” Maternal Concerns about Children’s Weight and General Beliefs about Child Weight There were racial/ethnic and income differences in mother’s perceptions of overweight, as shown by the schematic drawing number they chose to define overweight (Figure 3). The most commonly selected cutoff was the sixth category. About one-third of the mothers in each of the lowincome white and Hispanic-American groups (32% and 33%, respectively) defined the cutoff at the fifth category. In contrast, about one-fifth of the African-American groups (21%) and the middle-income white (18%) groups selected the highest category to define overweight. Thus, several mothers in these latter two categories defined overweight at a higher apparent weight than did lowincome white and Hispanic mothers. In addition to the specific topics addressed in our focus groups, several mothers asked for guidance on strategies for persuading their children to eat and about balancing convenience, variety, and food cost. They were also interested in information about age-appropriate portion sizes and who should determine children’s portion sizes.
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DISCUSSION Many of the goals and concerns about child feeding identified by our focus groups of mothers were in accordance with the Dietary Guidelines for Americans and the Food Guide Pyramid (20). However, several of their strategies for accomplishing these goals diverged from those currently recommended to promote healthful eating and to prevent overweight and parent child-feeding conflicts. These well-intended, but potentially counterproductive, strategies included accommodating specific requests for alternative choices at meals; using foods (especially sweets) as bribes, rewards, and pacifiers to encourage eating or another desired behavior; allowing children to watch television during meals; determining portion sizes for their children; pressuring their children to eat enough (especially Hispanics); and not believing their children when they say they are full. Use of these strategies becomes an important issue considering that research findings suggest parental control of child feeding may interfere with children’s ability to self-regulate energy intake and lead to the development of overweight (12,13). We need to learn more about how, when, and why mothers use these strategies to effectively encourage mothers to change their approach and use recommended strategies. Satter (21) and Dietz and Stern (22) advocate the division of responsibility for child feeding where parents serve as gatekeepers for foods served and children decide whether and how much to eat. Use of this principle helps to avoid parent– child conflicts over eating by giving both the parents and children some control, and its use could help mothers adopt recommended strategies. Results of a recent pilot study suggest that children’s diets could be improved by reducing parental control. Researchers found that reducing parental control coupled with enhancing children’s knowledge about fruits resulted in an increase in fruit intake (23). Another area in need of intervention is helping mothers accept their child’s response when appropriate. The common beliefs that children are prevaricating when they say they are full, that mothers should determine the portion sizes for their children, and that children should eat enough, could all result in overfeeding. The use of social marketing methods to understand mother’s incentives and barriers to changing behavior and underlying beliefs might help resolve this challenge (24). Our finding that low-income mothers are concerned about underweight is consistent with the focus group findings reported by Baughcum and colleagues (25). Additionally, our mothers’ different perceptions of overweight are also of interest. About 20% of low-income African-American and middle-income white mothers selected the schematic drawing with the highest number as their cutpoint for defining overweight, suggesting their acceptance as normal weight what public health officials describe as overweight. Our findings are consistent with those reported by others (26,27). These perceptions appear culturally bound and will require different approaches to convey to mothers the health concerns associated with the level of weight they perceive as normal. Again, a social marketing focus might help identify approaches that could influence mothers’ perceptions of pediatric overweight and the need to prevent and treat it. The lack of consistent findings among our focus groups on topics not in the focus group guide requires further study. One group would raise and discuss an issue, yet
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others did not; for example, the Hispanic-American groups stressed the importance of including culturally specific foods in their children’s diets. Consequently, we don’t know whether this issue was not important to the other groups or whether the topic did not arise spontaneously. Our small number of focus groups within each racial/ethnic and income category limits our ability to generalize any differences. Many of the feeding practices identified in our focus groups need to be examined further, preferably in a longitudinal study, to determine whether they are etiologically associated with the development of childhood overweight. In addition, we identified several areas that need more careful examination with quantitative research methods to further our understanding of maternal attitudes, practices, and concerns about child feeding. Examples of topics needing further study include the importance and use of culturally specific foods; the use of food as bribes, rewards, or pacifiers; procedures used to introduce new foods; fathers’ participation in encouraging or restricting food consumption at mealtime; and the time frame used to assess whether a child has eaten enough. In addition to developing appropriate strategies for effective interventions to prevent child overweight, more qualitative research is needed to better understand issues such as how to help mothers accept children’s reported lack of hunger and why mothers respond to children’s specific alternative food requests at meal times. CONCLUSIONS Focus group themes identified that may be useful to dietetics professionals for tailoring interventions to promote healthful child weight include: ●
●
●
●
Build on mothers’ feeding goals to provide good nutrition to their children by enhancing their knowledge of the Dietary Guidelines for Americans and appropriate child portion sizes, and providing culturally appropriate suggestions for balancing convenience, variety, and food costs. Providing education on meal planning, quick-to-prepare healthful meals, and budgeting may be helpful. Help mothers overcome the stress and chaos of mealtimes. One approach to help mothers reduce parent– child feeding conflicts is to advocate use of the division of responsibility principle for child feeding to empower mothers to plan and serve one meal to the family, not to “short order” cook for individual children who refuse to eat, and to serve as the gatekeepers to prevent excess intake of sweets and other foods they want to limit. Help mothers believe their children when they say are “full” and discourage mothers from encouraging their children to eat after they say they are full. Recognize that there are differences in cultural perceptions of child overweight and provide culturally appropriate information for increasing mothers’ knowledge about healthful child weight and the health consequences associated with overweight during childhood.
The authors thank Marco Pardi, MS, for conducting the focus groups. This research was supported in part by Centers for Disease Control and Prevention contract No. 200-95-0957, Task Order No. 0957-029 to LL Birch through Penn State Geisinger, via American Association of Health Plans.
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