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Mindful feeding and child dietary health
Eating Behaviors 24 (2017) 89–94
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Eating Behaviors
Mindful feeding and child dietary health Elizabeth A. Emley ⁎, Maija B. Taylor, Dara R. Musher-Eizenman Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, United States
a r t i c l e
i n f o
Article history: Received 28 August 2016 Received in revised form 15 December 2016 Accepted 19 December 2016 Available online 21 December 2016
a b s t r a c t Objective: This study examined the relationship between mindful feeding as a novel construct and parent-reported child dietary intake. Methods: Participants (N = 497) were parents of children ages 2.9 to 7.5 recruited through Amazon Mechanical Turk (MTurk). Parents were primarily non-Hispanic white (79%) and female (76%). Simple and hierarchical regression analyses were conducted to examine the associations between parental mindful feeding (i.e., parent mental and emotional presence while feeding a child) and their children's dietary intake. Results: Mindful feeding accounted for 5.1% of the unadjusted variance in child fruit and vegetable intake. Mindful feeding accounted for 4.2% of the unadjusted variance in child added sugar consumption after accounting for relevant covariates. Specifically, higher parental mindful feeding predicted higher fruit and vegetable intake and lower sugar intake among children. Conclusions: Mindful feeding was associated with almost all indicators of healthier child diet, indicating great potential for this approach to improve child health. If incorporated into general or health-focused interventions for parents, mindfulness could significantly improve child health outcomes. Further development and validation of the Mindful Feeding Questionnaire is also recommended, as it could become a useful survey tool to assess for this construct. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction 1.1. Mindfulness and health Mindfulness is the ability to bring one's attention to experiences in the present moment in a nonjudgmental way (Kabat-Zinn, 1990). Among adults, higher mindfulness is associated with greater cardiovascular health, which is mediated by the associations between higher mindfulness and nonsmoking, lower body mass index, lower fasting glucose, and higher physical activity (Loucks, Britton, Howe, Eaton, & Buka, 2015). Mindfulness has also been associated with reduced calorie consumption and healthier snack choices (Jordan, Wang, Donatoni, & Meier, 2014). In youth, mindfulness has also been found to be associated with eating behaviors. Higher mindfulness among adolescent (12–17 year-old) girls was associated with lower odds of binge eating and lower consumption of foods due to fatigue and boredom in the absence of hunger (Pivarunas et al., 2015). Recently, researchers have started investigating a school-based mindfulness intervention to promote healthy diet and physical activity in youth (Salmoirago-Blotcher et al., 2015) as well as a family-based mindful eating intervention for overweight youth ⁎ Corresponding author. E-mail addresses: [email protected] (E.A. Emley), [email protected] (M.B. Taylor), [email protected] (D.R. Musher-Eizenman).
http://dx.doi.org/10.1016/j.eatbeh.2016.12.002 1471-0153/© 2016 Elsevier Ltd. All rights reserved.
(Oregon Research Institute, 2016). Researchers have provided a compelling rationale for creating mindfulness-based health programs for youth which aim to improve health behaviors and positively impact health (Dalen, Brody, Staples, & Sedillo, 2015). However, the development of these programs is in its infancy.
1.2. Mindful feeding Mindful feeding is an understudied parenting variable that may be relevant to child health behavior and health outcomes. This concept has been operationalized by Meers as high mental and emotional presence while feeding a child (unpublished dissertation, 2013). In her research, Meers found that mindful feeding is related to higher general mindfulness among parents and higher mindful parenting. Specifically, mindful feeding was significantly positively associated with all factors of the Kentucky Inventory of Mindfulness Skills (i.e., non-reactivity, observation, description, acting with awareness, and nonjudgmental acceptance; Baer, Smith, & Allen, 2004; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). Furthermore, she found that mindful feeding was significantly positively associated with all factors of the Interpersonal Mindfulness in Parenting Scale (i.e., present-centered emotional awareness, present-centered awareness, nonjudgmental receptivity, and the ability to regulate reactivity; Duncan, 2007, unpublished dissertation). These results suggest that parents who are more mindful in general
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and exhibit more mindful parenting practices are also more mindful feeders. Regarding mindful feeding and other child feeding practices, Meers found that mindful feeding is associated with various feeding practices, as measured by the Comprehensive Feeding Practices Questionnaire (Musher-Eizenman & Holub, 2007). Specifically, higher mindful feeding is related to lower use of food to regulate children's emotions, lower use of food as a reward for children, higher encouragement of balance and variety in children's food intake, and having more healthy food available in the home. These results suggest that parents who are more mindful feeders may demonstrate a profile of feeding behaviors that promotes healthy diet in children. Research clearly demonstrates that parenting styles and various associated feeding practices are linked with child health behavior and physical and mental health outcomes (Berge, Wall, Loth, & Neumark-Sztainer, 2010; Collins, Duncanson, & Burrows, 2014; Kremers, Brug, de Vries, & Engels, 2003; Sleddens, Gerards, Thijs, de Vries, & Kremers, 2011; Zahra, Ford, & Jodrell, 2014). However, the relationship between mindful feeding as a parenting practice and child health behavior is largely unknown. 1.3. Child dietary intake and health Consuming a nutritious diet is critical for preventing negative chronic health conditions such as diabetes, heart disease, stroke, and some cancers (WHO, 2015). According to data from the National Health and Nutrition Examination Survey (NHANES), children and adolescents overall fail to meet the American Dietary Guidelines, typically consuming too many refined grains and empty calories (e.g., added sugars) and not enough fruits, vegetables, and whole grains (Banfield, Liu, Davis, Chang, & Frazier-Wood, 2016; Ervin, Kit, Carroll, & Ogden, 2012). Fruit and vegetable (FV) and sugar consumption are particularly important dietary components in regards to health outcomes. FV intake is associated with numerous positive health outcomes, including greater weight stability, lower waist circumference, and reduced risk of adiposity (Schwingshackl et al., 2015). It is also inversely associated with risk of all-cause mortality (Nguyen et al., 2016). Additionally, sugar intake is associated with numerous negative health outcomes, including greater prevalence of diabetes and cardiovascular disease, independent of body mass index (Basu, Yoffe, & Lustig, 2013; Weeratunga, Jayasinghe, Perera, Jayasena, & Jayasinghe, 2014; Yang et al., 2014). 1.4. Purpose of the present study The goal of the current study was to examine the relationship between mindful feeding (i.e., parent mental and emotional presence while feeding a child) and child dietary behaviors and BMI. Mindful feeding is a largely unexplored phenomenon that has the potential to critically improve child dietary and mental health. Thus, evidence from this study will contribute to our knowledge on this topic. It was hypothesized that greater mindful feeding would be associated with lower parent BMI and child BMI percentile levels; greater fruit and vegetable, whole grain, fiber, and calcium intake; and lower added sugar and sugar-sweetened beverage intake.
range were maintained. This age range was chosen to examine eating patterns in pre-school to early elementary school children. Exclusion criteria included (1) parent age b 18 years old, (2) child's date of birth outside of our desired age range, and (3) non-U. S. residency. Responses were omitted from the final sample if (1) participants missed more than one quality control item, (2) the completion duration was b15 min, and/or (3) the IP address originated outside of the U.S. As a result of excluding these responses, a final sample of 497 participants were paid $0.50 for completing the 30–40-minute survey, a typical rate of payment on MTurk. Because all survey items were required, there was no missing data.
2.2. Measures 2.2.1. Mindful Feeding Questionnaire (MFQ) This questionnaire (Meers, 2013), comprises four items that measure parent mental presence while feeding a child. These items are, “I tend to feed my child while I am doing many other things (Reverse coded)” “When I feed my child, I am often distracted by other thoughts (Reverse coded),” “When I am feeding my child, I am completely focused on what I am doing,” and “I rush through meals with my child without really paying attention to them (Reverse coded).” A five-point response scale (1 = never, 5 = often) is used. In Meers' study, the internal consistency alpha coefficient of 0.73. In the current sample, the MFQ had an internal consistency alpha coefficient of 0.75. As mentioned above, Meers found that mindful feeding shows good convergent validity with general mindfulness among parents (i.e., nonreactivity, observation, description, acting with awareness, and nonjudgmental acceptance), mindful parenting (i.e., present-centered emotional awareness, present-centered awareness, nonjudgmental receptivity, and ability to regulate reactivity), and other child feeding practices (i.e., using food to regulate children's emotions, using food as a reward for children, encouraging balance and variety in children's food intake, and having more healthy food available in the home).
2.2.2. Diet Diet was measured using the Dietary Screener Questionnaire (DSQ; NCI, 2015). The DSQ was developed for use in the 2009–2010 National Health and Nutrition Examination Survey (NHANES). It features 26 items about the frequency of consumption of a variety of foods and drinks in the past month. This measure was modified to ask parents about their children's dietary behavior in the past month. Using an algorithm for scoring the DSQ (executed using SAS statistical software), estimations of daily fruit and vegetable (both with and without the inclusion of fried potatoes; cup equivalents), whole grains (ounce equivalents), added sugar (tsp equivalents), sugar sweetened beverages (tsp equivalents), fiber (g), and calcium (mg) consumption can be calculated. Most items were measured on a Likert scale, ranging from 0 (Never) to 9 (2 or more times per day). Modified sample items include, “During the past month, how often did your child eat green leafy or lettuce salad, with or without other vegetables?” and “During the past month, how often did your child eat cookies, cake, pie or brownies? (Do not include sugar-free kinds)?”
2. Methods 2.1. Participants A total of 535 adult parents were recruited from Amazon Mechanical Turk (MTurk), an online survey distributor that has been shown to provide socioeconomically and ethnically diverse samples as well as high quality data (Casler, Bickel, & Hackett, 2013). Participants were required to have at least one child between the ages of three and seven. To avoid excluding participants with a child whose age was slightly outside our criteria, children whose birthdays were within six months of this age
2.2.3. Child body mass index (BMI) percentile Child BMI was calculated from parent-reported child height and weight. Weight was reported in pounds and height was reported in inches. BMI was calculated using the formula: (weight in pounds) / (height in inches)2 × 703. Children's BMIs vary by age, so BMI scores were converted to BMI percentiles for age and gender (CDC, 2015). Parents who were unable to recall their child's height or weight were asked to report their child's height or weight percentile from their most recent doctor's visit if possible.
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2.2.4. Parent body mass index (BMI) Parent BMI was calculated from parent self-reported height and weight. Weight was reported in pounds and height was reported in inches. BMI was calculated using the aforementioned formula.
2.2.5. Demographic variables Parents reported on both their own and their child's gender, age, and race/ethnicity as well as their own educational attainment and their household income.
3. Results 3.1. Descriptive statistics All of the following analyses were conducted using SPSS (version 21, IBM Corp, Armonk, NY, 2012). See Table 1 for information on family socioeconomic status, race, and gender. Mean parent BMI (SD) was 27.01 (6.42) and ranged from 15.07 to 50.48. Approximately two-thirds of child BMI percentiles were unable to be computed due to missing or extreme data. Mean child BMI percentile (SD) of that which was available was 62.45 (6.5) and ranged from 0.00 to 99.90. Mean parent and child ages (SD) were 32.52 (6.62) and 4.65 (1.14), respectively. Parents ages ranged from 19 to 65, and child ages ranged from 2.86 to 7.51.
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3.2. Correlations To examine the relationships between mindful feeding and demographics and dietary outcomes, bivariate correlation analyses were conducted. Mindful feeding was associated with lower parent self-reported BMI (r = − 0.13, p = 0.01), lower parent educational attainment (r = − 0.11, p = 0.01), and greater healthy food availability in the home (r = 0.42, p b 0.001). Mindful feeding was not significantly associated with parent-reported child BMI percentile, parent age, child age, or household income. Mindful feeding was positively associated with parent-reported child fruit and vegetable intake (not including fried potatoes; r = 0.23, p b 0.001) and whole grain intake (r = 0.11, p = 0.02) and was negatively associated with parent-reported child added sugar intake (r = − 0.23, p b 0.001) and sugar-sweetened beverage intake (r = −0.16, p b 0.001). Mindful feeding was not related to parent-reported child fiber or calcium consumption. To explore possible covariates, correlations and univariate ANOVA analyses were conducted on demographic variables and all dietary outcomes. No significant relationships were found between parent age, parent income, or parent educational attainment and the outcome variables. Furthermore, the Caucasian and non-Caucasian parents did not differ on any of the outcome variables. The same was true for Caucasian and non-Caucasian children. Child age, parent gender, child gender, and parent BMI were related to the outcome variable of parent-reported child sugar intake, so they were controlled for in the relevant analysis. 3.3. Simple and hierarchical multiple regressions
Table 1 Demographic characteristics of parent and child. Variable
Frequency (N)
%
Household income b$20,000 $20,000–$50,000 $50,000–$80,000 N$80,000 Prefer not to answer
37 192 167 86 12
7.5 38.7 33.7 17.3 2.4
Parent educational attainment GED High school graduate Some college (did not graduate) Associate Bachelor's degree Some graduate school Master's degree Doctoral degree
10 44 137 77 148 16 55 8
2 8.9 27.6 15.5 29.8 3.2 11.1 1.6
Parent race White Black Asian American Indian or Hawaiian Pacific Hispanic Multiracial
393 41 11 4 19 26
79.2 8.3 2.2 0.8 3.8 5.2
Parent gender Female Male Other
376 119 2
75.7% 23.9% 0.4%
Child race White Black Asian American Indian or Hawaiian Pacific Hispanic Multiracial Other
364 58 15 8 41 7 2
73.4 11.7 3 1.6 8.3 1.4 0.4
Child gender Female Male Other
226 270 1
45.5% 54.3% 0.2%
Our primary hypothesis was that mindful feeding would be associated with healthier parent-reported child dietary outcomes. Due to the fact that mindful feeding was most highly correlated with child added sugar intake and fruit and vegetable intake, the relationships between mindful feeding and these two dietary outcomes were examined further in regression models. A hierarchical regression was used to predict parent-reported child added sugar intake after controlling for known covariates. In block one, child age, parent and child gender, and parent BMI were entered and accounted for 8.3% of the unadjusted variance in child added sugar intake. Specifically, higher child age and higher parent BMI were associated with greater child added sugar intake. Additionally, girls had lower child added sugar intake than boys and parent gender was no longer associated with child added sugar intake. In block two, mindful feeding accounted for an additional 4.2% of the unadjusted variance in child added sugar consumption. Higher mindful feeding predicted lower parent-reported child added sugar consumption. The full model explained 12.5% of the unadjusted variance in parent-reported child added sugar consumption. Refer to Table 2. A simple regression was used to predict parent-reported child fruit and vegetable intake, due to the fact that no demographic variables were related to this outcome variable. Mindful feeding explained 5.1% Table 2 Hierarchical multiple regression analysis predicting added sugar intake from mindful feeding. Variable
Step 1 β
Step 2 β
Child's age Parent gender Child gender Parent BMI Mindful feeding Unadjusted R2 Adjusted R2 F for change in R2
0.188⁎⁎⁎ −0.062 −0.174⁎⁎⁎ 0.113⁎
0.182⁎⁎⁎ −0.056 −0.163⁎⁎⁎
0.083⁎⁎⁎ 0.075⁎⁎⁎ 10.45⁎⁎⁎
0.089 −0.027⁎⁎⁎ 0.125⁎⁎⁎ 0.116⁎⁎⁎ 22.05⁎⁎⁎
Overall model
0.125⁎⁎⁎ 0.116⁎⁎⁎ 22.05⁎⁎⁎
Note. N = 465. Added sugar: daily added sugar consumption (tsp) of child based on parental reports. ⁎ p b 0.05. ⁎⁎⁎ p b 0.001.
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of the unadjusted variance in child fruit and vegetable consumption. Higher mindful feeding predicted greater parent-reported child fruit and vegetable intake. Refer to Table 3. 4. Discussion The current findings supported our hypotheses by showing that greater mindful feeding was associated with lower parent-reported child added sugar intake and greater parent-reported child fruit and vegetable intake for this sample of children ages two and a half to seven and a half. A few mechanisms of action may explain these relationships. Parents who are higher on mindful feeding may be more likely to remove electronics and other distracting stimuli from the mealtime environment, which would promote their child's mindful eating capabilities (e.g., ability to recognize their internal hunger and satiety cues, eat slowly, savor their food). Support for this hypothesis comes from research demonstrating that adolescents who watched television during family meals consumed fewer vegetables, fewer grains, and more sugar-sweetened beverages that those who did not (Feldman, Eisenberg, Neumark-Sztainer, & Story, 2007). Another possibility is that mindful feeding may help parents pay greater attention to behaviors exhibited by their children that demonstrate satiety (e.g., eating more slowly or showing decreased interest in food), and modify their feeding accordingly. Previous research has shown that higher maternal responsiveness to the satiety cues of infants is related to lower infant weight-for-length z-scores (Thompson et al., 2009), which lends support to the idea that parental satiety responsiveness may mediate the relationship between mindful feeding and positive child dietary outcomes uncovered in this study. Research has shown that parent general mindfulness and mindful parenting are positively associated with mindful feeding (Meers, 2013). This supports the hypothesis that more mindful parents feed their children more mindfully, which may in turn promote child mindful eating and healthier diet. Another possibility is that mindful feeding may help parents pay more attention to their health-oriented feeding goals and associated strategies, so that they choose to implement more positive and fewer negative feeding practices, which are in turn associated with better child dietary outcomes. This is supported by the findings that higher mindful feeding is related to greater encouragement of balance and variety in children's food intake, having more healthy food available in the home, lower use of food to regulate children's emotions, and lower use of food as a reward for children (Meers, 2013). Parental mindful eating may also play a large role in the current findings. Previous research has shown that mothers who were more mindful eaters were more likely to monitor their child's food intake (Tylka, Eneli, Kroon Van Diest, & Lumeng, 2013), which has been shown to be associated with healthier child eating and BMI development (Arredondo et al., 2006; Gubbels et al., 2011). This provides some support for the hypothesis that parents who eat mindfully themselves may be more likely to have and maintain a goal of keeping their child healthy via diet, which could in turn lead them to engage in more positive and fewer negative feeding practices. In addition, being mindful of Table 3 Hierarchical multiple regression analysis predicting fruit and vegetable intake from mindful feeding. Variable
Step 1 β
Overall model
Mindful feeding Unadjusted R2 Adjusted R2 F for change in R2
0.225⁎⁎⁎ 0.051⁎⁎⁎ 0.049⁎⁎⁎ 24.98⁎⁎⁎
0.051⁎⁎⁎ 0.049⁎⁎⁎ 24.98⁎⁎⁎
Note. Fruits and vegetables: daily cups of fruits and vegetables (not including fried potatoes) consumed by child based on parental reports. ⁎⁎⁎ p b 0.001.
the food they eat may improve their own diet and, through the availability of healthy food in the home, improve their child's diet vicariously. Healthy food availability has been established as a correlate of greater FV consumption among preschool children, school-aged children, and adolescents (Ding et al., 2012; Wyse, Campbell, Nathan, & Wolfenden, 2011), and this construct has been supported as a mediator between maternal nutrition knowledge and healthy child diet (Campbell et al., 2013) and between a home environment intervention and child FV intake (Wyse, Wolfenden, & Bisquera, 2015). Mindful eaters have been found to consume smaller amounts of energy-dense foods (Beshara, Hutchinson, & Wilson, 2013), indicating that parents who are mindful eaters are less likely to consume these foods, most likely having less of them available in the home. These findings suggest that more healthy food availability may play a substantial role in child dietary quality, and that parental knowledge and mindful awareness of the importance of healthy foods may increase the amount of healthy foods they provide. Finally, it may be that mindful feeding promotes higher quality parent-child communication and social bonding, which may increase the likelihood that children will be receptive and responsive to parents' positive feeding strategies. For example, parental modeling of healthy food intake may be more effective at improving child dietary intake if it takes place in the context of an attentive, positive parent-child interaction. Furthermore, mindful feeding may be a key component of warm, positive family mealtimes. This full emotional and mental presence may allow parents to engage in the behaviors necessary to promote positive psychosocial development in their children, which may in turn improve children's health. While little research exists exploring family meal time with child health outcomes, one study found significant associations between positive interpersonal dynamics (e.g., warmth, parental positive regard) at meal time and reduced risk of childhood overweight as well as positive food-related dynamics (e.g., food communication, parental food positive reinforcement) and reduced risk of childhood obesity among 6–12 year olds (Berge et al., 2014). In addition, data from the Nation Survey of Children's Health (NSCH) found that greater frequency of family meals increased the odds of positive social skills and engagement in school and decreased the odds of problematic social behaviors among children 6 to 11 (Lora, Sisson, Degrace, & Morris, 2014). These studies highlight the importance of positive family interactions at and frequency of meal time in various child outcomes. The current study supported our hypothesis that greater mindful feeding would be associated with lower parent BMI but failed to support our hypothesis that mindful feeding would be associated with lower child BMI percentile. It may be that parents who have lower BMIs are more mindful when feeding their children because they are more conscious of how or what they eat themselves and place greater value on healthy eating. Mindful eating has been associated with lower BMI among adults (Moor, Scott, & McIntosh, 2013; Framson et al., 2009), providing some support for this hypothesis. Although mindful feeding was not related to BMI percentile in younger children, it is possible that a relationship may appear between these variables in older children when parental influence begins to substantially influence lifestyle behaviors and affect adiposity. No research has yet been conducted on the relationship between parental mindfulness and child weight outcomes, so future research may aim to answer this question. Mindful feeding had low but statistically significant relationships with all other child dietary variables measured and no significant relationship with child fiber or calcium consumption. Future researchers may want to explore the relationships between mindful feeding and these dietary variables. Findings about the link between mindful feeding and parent-reported child added sugar and fruit and vegetable intake suggest a potential for mindfulness-based interventions for parents and families. General parent mindfulness training as well as parent-directed or family-based mindful health behavior programs may create more mindful feeding habits in parents. In turn, this may help parents engage in undistracted feeding, which may shape child diet in positive ways. While the
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literature has yet to establish an effect of parent or family mindfulness interventions on child dietary intake, adding a mindfulness component to a standard family training program has provided evidence for the unique contribution of mindfulness activities in outcomes such as interpersonal mindfulness in parenting and youth behavior management (Coatsworth et al., 2015). 5. Limitations and future directions It is important to note that this research is in its infancy. The mindful feeding measure utilized in this study is the first to assess parental mindful feeding as opposed to parental or child mindfulness or mindful eating. As such, this measurement tool would benefit from further item development, including expanding its items and determining other important components of mindful feeding other than mental and emotional present-centered awareness. This study only surveyed parents of children between the ages of approximately three to seven, so our results may not generalize to parents of older children. This age range was selected to obtain a sample of children in pre-school and early grade school, as children in this age range are old enough to start making decisions regarding food intake and are not quite old enough to have established food independence. However, a narrower age range would have allowed for more specific conclusions, and future research may shed light on these findings as they compare across ages. Additionally, this sample of parents was primarily white and highly educated, so our results may not generalize to parents and children of other races or to parents with lower education levels. Future validation among various child age groups and diverse samples is warranted. Our measure of dietary outcomes was in the form of a dietary screener. These tools have been shown to provide useful rough estimates, but facilitating dietary recall at multiple time points would have provided a more accurate representation of child food consumption patterns. Another limitation of this study is its self-report, cross-sectional nature. Therefore, it is not possible to determine the causal directions of the uncovered relationships, and our results may have been impacted by self-report bias or recall errors. As such, it is suggested that future research use observational measurement of parent mindful feeding in both naturalistic and lab environments. This would be beneficial in validating the current measure as well as identifying other important components of mealtimes that may impact mindful feeding, such as the use of electronics and other distractions, positive or negative family interactions, and parents' modeling of mindful eating. Other than methodological improvements, future research in this field has enormous potential. Mindful feeding, if truly effective at improving child health, could become an innovative intervention strategy. As a component of a comprehensive parent or family mindfulness or mindful health intervention, mindful feeding would likely have a strong impact. Based on previous research, these types of programs influence child mental and emotional health rather directly. Adding a mindful feeding aspect may improve the impact of these programs on child physical health. Additionally, it could have a substantial effect on both child and parent outcomes at the individual and family level, broadening the benefits of mindfulness and mindful health training. Potential target populations are parents of children at risk for health behavior problems, such as obesity and type II diabetes, and children who struggle with emotional difficulties that may predispose them to emotional eating, eating disorders, and weight difficulties. Future research on the construct of mindful feeding is highly recommended. References Arredondo, E. M., Elder, J. P., Ayala, G. X., Campbell, N., Baquero, B., & Duerksen, S. (2006). Is parenting style related to children's healthy eating and physical activity in Latino
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Contents lists available at ScienceDirect
Eating Behaviors
Mindful feeding and child dietary health Elizabeth A. Emley ⁎, Maija B. Taylor, Dara R. Musher-Eizenman Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, United States
a r t i c l e
i n f o
Article history: Received 28 August 2016 Received in revised form 15 December 2016 Accepted 19 December 2016 Available online 21 December 2016
a b s t r a c t Objective: This study examined the relationship between mindful feeding as a novel construct and parent-reported child dietary intake. Methods: Participants (N = 497) were parents of children ages 2.9 to 7.5 recruited through Amazon Mechanical Turk (MTurk). Parents were primarily non-Hispanic white (79%) and female (76%). Simple and hierarchical regression analyses were conducted to examine the associations between parental mindful feeding (i.e., parent mental and emotional presence while feeding a child) and their children's dietary intake. Results: Mindful feeding accounted for 5.1% of the unadjusted variance in child fruit and vegetable intake. Mindful feeding accounted for 4.2% of the unadjusted variance in child added sugar consumption after accounting for relevant covariates. Specifically, higher parental mindful feeding predicted higher fruit and vegetable intake and lower sugar intake among children. Conclusions: Mindful feeding was associated with almost all indicators of healthier child diet, indicating great potential for this approach to improve child health. If incorporated into general or health-focused interventions for parents, mindfulness could significantly improve child health outcomes. Further development and validation of the Mindful Feeding Questionnaire is also recommended, as it could become a useful survey tool to assess for this construct. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction 1.1. Mindfulness and health Mindfulness is the ability to bring one's attention to experiences in the present moment in a nonjudgmental way (Kabat-Zinn, 1990). Among adults, higher mindfulness is associated with greater cardiovascular health, which is mediated by the associations between higher mindfulness and nonsmoking, lower body mass index, lower fasting glucose, and higher physical activity (Loucks, Britton, Howe, Eaton, & Buka, 2015). Mindfulness has also been associated with reduced calorie consumption and healthier snack choices (Jordan, Wang, Donatoni, & Meier, 2014). In youth, mindfulness has also been found to be associated with eating behaviors. Higher mindfulness among adolescent (12–17 year-old) girls was associated with lower odds of binge eating and lower consumption of foods due to fatigue and boredom in the absence of hunger (Pivarunas et al., 2015). Recently, researchers have started investigating a school-based mindfulness intervention to promote healthy diet and physical activity in youth (Salmoirago-Blotcher et al., 2015) as well as a family-based mindful eating intervention for overweight youth ⁎ Corresponding author. E-mail addresses: [email protected] (E.A. Emley), [email protected] (M.B. Taylor), [email protected] (D.R. Musher-Eizenman).
http://dx.doi.org/10.1016/j.eatbeh.2016.12.002 1471-0153/© 2016 Elsevier Ltd. All rights reserved.
(Oregon Research Institute, 2016). Researchers have provided a compelling rationale for creating mindfulness-based health programs for youth which aim to improve health behaviors and positively impact health (Dalen, Brody, Staples, & Sedillo, 2015). However, the development of these programs is in its infancy.
1.2. Mindful feeding Mindful feeding is an understudied parenting variable that may be relevant to child health behavior and health outcomes. This concept has been operationalized by Meers as high mental and emotional presence while feeding a child (unpublished dissertation, 2013). In her research, Meers found that mindful feeding is related to higher general mindfulness among parents and higher mindful parenting. Specifically, mindful feeding was significantly positively associated with all factors of the Kentucky Inventory of Mindfulness Skills (i.e., non-reactivity, observation, description, acting with awareness, and nonjudgmental acceptance; Baer, Smith, & Allen, 2004; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). Furthermore, she found that mindful feeding was significantly positively associated with all factors of the Interpersonal Mindfulness in Parenting Scale (i.e., present-centered emotional awareness, present-centered awareness, nonjudgmental receptivity, and the ability to regulate reactivity; Duncan, 2007, unpublished dissertation). These results suggest that parents who are more mindful in general
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and exhibit more mindful parenting practices are also more mindful feeders. Regarding mindful feeding and other child feeding practices, Meers found that mindful feeding is associated with various feeding practices, as measured by the Comprehensive Feeding Practices Questionnaire (Musher-Eizenman & Holub, 2007). Specifically, higher mindful feeding is related to lower use of food to regulate children's emotions, lower use of food as a reward for children, higher encouragement of balance and variety in children's food intake, and having more healthy food available in the home. These results suggest that parents who are more mindful feeders may demonstrate a profile of feeding behaviors that promotes healthy diet in children. Research clearly demonstrates that parenting styles and various associated feeding practices are linked with child health behavior and physical and mental health outcomes (Berge, Wall, Loth, & Neumark-Sztainer, 2010; Collins, Duncanson, & Burrows, 2014; Kremers, Brug, de Vries, & Engels, 2003; Sleddens, Gerards, Thijs, de Vries, & Kremers, 2011; Zahra, Ford, & Jodrell, 2014). However, the relationship between mindful feeding as a parenting practice and child health behavior is largely unknown. 1.3. Child dietary intake and health Consuming a nutritious diet is critical for preventing negative chronic health conditions such as diabetes, heart disease, stroke, and some cancers (WHO, 2015). According to data from the National Health and Nutrition Examination Survey (NHANES), children and adolescents overall fail to meet the American Dietary Guidelines, typically consuming too many refined grains and empty calories (e.g., added sugars) and not enough fruits, vegetables, and whole grains (Banfield, Liu, Davis, Chang, & Frazier-Wood, 2016; Ervin, Kit, Carroll, & Ogden, 2012). Fruit and vegetable (FV) and sugar consumption are particularly important dietary components in regards to health outcomes. FV intake is associated with numerous positive health outcomes, including greater weight stability, lower waist circumference, and reduced risk of adiposity (Schwingshackl et al., 2015). It is also inversely associated with risk of all-cause mortality (Nguyen et al., 2016). Additionally, sugar intake is associated with numerous negative health outcomes, including greater prevalence of diabetes and cardiovascular disease, independent of body mass index (Basu, Yoffe, & Lustig, 2013; Weeratunga, Jayasinghe, Perera, Jayasena, & Jayasinghe, 2014; Yang et al., 2014). 1.4. Purpose of the present study The goal of the current study was to examine the relationship between mindful feeding (i.e., parent mental and emotional presence while feeding a child) and child dietary behaviors and BMI. Mindful feeding is a largely unexplored phenomenon that has the potential to critically improve child dietary and mental health. Thus, evidence from this study will contribute to our knowledge on this topic. It was hypothesized that greater mindful feeding would be associated with lower parent BMI and child BMI percentile levels; greater fruit and vegetable, whole grain, fiber, and calcium intake; and lower added sugar and sugar-sweetened beverage intake.
range were maintained. This age range was chosen to examine eating patterns in pre-school to early elementary school children. Exclusion criteria included (1) parent age b 18 years old, (2) child's date of birth outside of our desired age range, and (3) non-U. S. residency. Responses were omitted from the final sample if (1) participants missed more than one quality control item, (2) the completion duration was b15 min, and/or (3) the IP address originated outside of the U.S. As a result of excluding these responses, a final sample of 497 participants were paid $0.50 for completing the 30–40-minute survey, a typical rate of payment on MTurk. Because all survey items were required, there was no missing data.
2.2. Measures 2.2.1. Mindful Feeding Questionnaire (MFQ) This questionnaire (Meers, 2013), comprises four items that measure parent mental presence while feeding a child. These items are, “I tend to feed my child while I am doing many other things (Reverse coded)” “When I feed my child, I am often distracted by other thoughts (Reverse coded),” “When I am feeding my child, I am completely focused on what I am doing,” and “I rush through meals with my child without really paying attention to them (Reverse coded).” A five-point response scale (1 = never, 5 = often) is used. In Meers' study, the internal consistency alpha coefficient of 0.73. In the current sample, the MFQ had an internal consistency alpha coefficient of 0.75. As mentioned above, Meers found that mindful feeding shows good convergent validity with general mindfulness among parents (i.e., nonreactivity, observation, description, acting with awareness, and nonjudgmental acceptance), mindful parenting (i.e., present-centered emotional awareness, present-centered awareness, nonjudgmental receptivity, and ability to regulate reactivity), and other child feeding practices (i.e., using food to regulate children's emotions, using food as a reward for children, encouraging balance and variety in children's food intake, and having more healthy food available in the home).
2.2.2. Diet Diet was measured using the Dietary Screener Questionnaire (DSQ; NCI, 2015). The DSQ was developed for use in the 2009–2010 National Health and Nutrition Examination Survey (NHANES). It features 26 items about the frequency of consumption of a variety of foods and drinks in the past month. This measure was modified to ask parents about their children's dietary behavior in the past month. Using an algorithm for scoring the DSQ (executed using SAS statistical software), estimations of daily fruit and vegetable (both with and without the inclusion of fried potatoes; cup equivalents), whole grains (ounce equivalents), added sugar (tsp equivalents), sugar sweetened beverages (tsp equivalents), fiber (g), and calcium (mg) consumption can be calculated. Most items were measured on a Likert scale, ranging from 0 (Never) to 9 (2 or more times per day). Modified sample items include, “During the past month, how often did your child eat green leafy or lettuce salad, with or without other vegetables?” and “During the past month, how often did your child eat cookies, cake, pie or brownies? (Do not include sugar-free kinds)?”
2. Methods 2.1. Participants A total of 535 adult parents were recruited from Amazon Mechanical Turk (MTurk), an online survey distributor that has been shown to provide socioeconomically and ethnically diverse samples as well as high quality data (Casler, Bickel, & Hackett, 2013). Participants were required to have at least one child between the ages of three and seven. To avoid excluding participants with a child whose age was slightly outside our criteria, children whose birthdays were within six months of this age
2.2.3. Child body mass index (BMI) percentile Child BMI was calculated from parent-reported child height and weight. Weight was reported in pounds and height was reported in inches. BMI was calculated using the formula: (weight in pounds) / (height in inches)2 × 703. Children's BMIs vary by age, so BMI scores were converted to BMI percentiles for age and gender (CDC, 2015). Parents who were unable to recall their child's height or weight were asked to report their child's height or weight percentile from their most recent doctor's visit if possible.
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2.2.4. Parent body mass index (BMI) Parent BMI was calculated from parent self-reported height and weight. Weight was reported in pounds and height was reported in inches. BMI was calculated using the aforementioned formula.
2.2.5. Demographic variables Parents reported on both their own and their child's gender, age, and race/ethnicity as well as their own educational attainment and their household income.
3. Results 3.1. Descriptive statistics All of the following analyses were conducted using SPSS (version 21, IBM Corp, Armonk, NY, 2012). See Table 1 for information on family socioeconomic status, race, and gender. Mean parent BMI (SD) was 27.01 (6.42) and ranged from 15.07 to 50.48. Approximately two-thirds of child BMI percentiles were unable to be computed due to missing or extreme data. Mean child BMI percentile (SD) of that which was available was 62.45 (6.5) and ranged from 0.00 to 99.90. Mean parent and child ages (SD) were 32.52 (6.62) and 4.65 (1.14), respectively. Parents ages ranged from 19 to 65, and child ages ranged from 2.86 to 7.51.
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3.2. Correlations To examine the relationships between mindful feeding and demographics and dietary outcomes, bivariate correlation analyses were conducted. Mindful feeding was associated with lower parent self-reported BMI (r = − 0.13, p = 0.01), lower parent educational attainment (r = − 0.11, p = 0.01), and greater healthy food availability in the home (r = 0.42, p b 0.001). Mindful feeding was not significantly associated with parent-reported child BMI percentile, parent age, child age, or household income. Mindful feeding was positively associated with parent-reported child fruit and vegetable intake (not including fried potatoes; r = 0.23, p b 0.001) and whole grain intake (r = 0.11, p = 0.02) and was negatively associated with parent-reported child added sugar intake (r = − 0.23, p b 0.001) and sugar-sweetened beverage intake (r = −0.16, p b 0.001). Mindful feeding was not related to parent-reported child fiber or calcium consumption. To explore possible covariates, correlations and univariate ANOVA analyses were conducted on demographic variables and all dietary outcomes. No significant relationships were found between parent age, parent income, or parent educational attainment and the outcome variables. Furthermore, the Caucasian and non-Caucasian parents did not differ on any of the outcome variables. The same was true for Caucasian and non-Caucasian children. Child age, parent gender, child gender, and parent BMI were related to the outcome variable of parent-reported child sugar intake, so they were controlled for in the relevant analysis. 3.3. Simple and hierarchical multiple regressions
Table 1 Demographic characteristics of parent and child. Variable
Frequency (N)
%
Household income b$20,000 $20,000–$50,000 $50,000–$80,000 N$80,000 Prefer not to answer
37 192 167 86 12
7.5 38.7 33.7 17.3 2.4
Parent educational attainment GED High school graduate Some college (did not graduate) Associate Bachelor's degree Some graduate school Master's degree Doctoral degree
10 44 137 77 148 16 55 8
2 8.9 27.6 15.5 29.8 3.2 11.1 1.6
Parent race White Black Asian American Indian or Hawaiian Pacific Hispanic Multiracial
393 41 11 4 19 26
79.2 8.3 2.2 0.8 3.8 5.2
Parent gender Female Male Other
376 119 2
75.7% 23.9% 0.4%
Child race White Black Asian American Indian or Hawaiian Pacific Hispanic Multiracial Other
364 58 15 8 41 7 2
73.4 11.7 3 1.6 8.3 1.4 0.4
Child gender Female Male Other
226 270 1
45.5% 54.3% 0.2%
Our primary hypothesis was that mindful feeding would be associated with healthier parent-reported child dietary outcomes. Due to the fact that mindful feeding was most highly correlated with child added sugar intake and fruit and vegetable intake, the relationships between mindful feeding and these two dietary outcomes were examined further in regression models. A hierarchical regression was used to predict parent-reported child added sugar intake after controlling for known covariates. In block one, child age, parent and child gender, and parent BMI were entered and accounted for 8.3% of the unadjusted variance in child added sugar intake. Specifically, higher child age and higher parent BMI were associated with greater child added sugar intake. Additionally, girls had lower child added sugar intake than boys and parent gender was no longer associated with child added sugar intake. In block two, mindful feeding accounted for an additional 4.2% of the unadjusted variance in child added sugar consumption. Higher mindful feeding predicted lower parent-reported child added sugar consumption. The full model explained 12.5% of the unadjusted variance in parent-reported child added sugar consumption. Refer to Table 2. A simple regression was used to predict parent-reported child fruit and vegetable intake, due to the fact that no demographic variables were related to this outcome variable. Mindful feeding explained 5.1% Table 2 Hierarchical multiple regression analysis predicting added sugar intake from mindful feeding. Variable
Step 1 β
Step 2 β
Child's age Parent gender Child gender Parent BMI Mindful feeding Unadjusted R2 Adjusted R2 F for change in R2
0.188⁎⁎⁎ −0.062 −0.174⁎⁎⁎ 0.113⁎
0.182⁎⁎⁎ −0.056 −0.163⁎⁎⁎
0.083⁎⁎⁎ 0.075⁎⁎⁎ 10.45⁎⁎⁎
0.089 −0.027⁎⁎⁎ 0.125⁎⁎⁎ 0.116⁎⁎⁎ 22.05⁎⁎⁎
Overall model
0.125⁎⁎⁎ 0.116⁎⁎⁎ 22.05⁎⁎⁎
Note. N = 465. Added sugar: daily added sugar consumption (tsp) of child based on parental reports. ⁎ p b 0.05. ⁎⁎⁎ p b 0.001.
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of the unadjusted variance in child fruit and vegetable consumption. Higher mindful feeding predicted greater parent-reported child fruit and vegetable intake. Refer to Table 3. 4. Discussion The current findings supported our hypotheses by showing that greater mindful feeding was associated with lower parent-reported child added sugar intake and greater parent-reported child fruit and vegetable intake for this sample of children ages two and a half to seven and a half. A few mechanisms of action may explain these relationships. Parents who are higher on mindful feeding may be more likely to remove electronics and other distracting stimuli from the mealtime environment, which would promote their child's mindful eating capabilities (e.g., ability to recognize their internal hunger and satiety cues, eat slowly, savor their food). Support for this hypothesis comes from research demonstrating that adolescents who watched television during family meals consumed fewer vegetables, fewer grains, and more sugar-sweetened beverages that those who did not (Feldman, Eisenberg, Neumark-Sztainer, & Story, 2007). Another possibility is that mindful feeding may help parents pay greater attention to behaviors exhibited by their children that demonstrate satiety (e.g., eating more slowly or showing decreased interest in food), and modify their feeding accordingly. Previous research has shown that higher maternal responsiveness to the satiety cues of infants is related to lower infant weight-for-length z-scores (Thompson et al., 2009), which lends support to the idea that parental satiety responsiveness may mediate the relationship between mindful feeding and positive child dietary outcomes uncovered in this study. Research has shown that parent general mindfulness and mindful parenting are positively associated with mindful feeding (Meers, 2013). This supports the hypothesis that more mindful parents feed their children more mindfully, which may in turn promote child mindful eating and healthier diet. Another possibility is that mindful feeding may help parents pay more attention to their health-oriented feeding goals and associated strategies, so that they choose to implement more positive and fewer negative feeding practices, which are in turn associated with better child dietary outcomes. This is supported by the findings that higher mindful feeding is related to greater encouragement of balance and variety in children's food intake, having more healthy food available in the home, lower use of food to regulate children's emotions, and lower use of food as a reward for children (Meers, 2013). Parental mindful eating may also play a large role in the current findings. Previous research has shown that mothers who were more mindful eaters were more likely to monitor their child's food intake (Tylka, Eneli, Kroon Van Diest, & Lumeng, 2013), which has been shown to be associated with healthier child eating and BMI development (Arredondo et al., 2006; Gubbels et al., 2011). This provides some support for the hypothesis that parents who eat mindfully themselves may be more likely to have and maintain a goal of keeping their child healthy via diet, which could in turn lead them to engage in more positive and fewer negative feeding practices. In addition, being mindful of Table 3 Hierarchical multiple regression analysis predicting fruit and vegetable intake from mindful feeding. Variable
Step 1 β
Overall model
Mindful feeding Unadjusted R2 Adjusted R2 F for change in R2
0.225⁎⁎⁎ 0.051⁎⁎⁎ 0.049⁎⁎⁎ 24.98⁎⁎⁎
0.051⁎⁎⁎ 0.049⁎⁎⁎ 24.98⁎⁎⁎
Note. Fruits and vegetables: daily cups of fruits and vegetables (not including fried potatoes) consumed by child based on parental reports. ⁎⁎⁎ p b 0.001.
the food they eat may improve their own diet and, through the availability of healthy food in the home, improve their child's diet vicariously. Healthy food availability has been established as a correlate of greater FV consumption among preschool children, school-aged children, and adolescents (Ding et al., 2012; Wyse, Campbell, Nathan, & Wolfenden, 2011), and this construct has been supported as a mediator between maternal nutrition knowledge and healthy child diet (Campbell et al., 2013) and between a home environment intervention and child FV intake (Wyse, Wolfenden, & Bisquera, 2015). Mindful eaters have been found to consume smaller amounts of energy-dense foods (Beshara, Hutchinson, & Wilson, 2013), indicating that parents who are mindful eaters are less likely to consume these foods, most likely having less of them available in the home. These findings suggest that more healthy food availability may play a substantial role in child dietary quality, and that parental knowledge and mindful awareness of the importance of healthy foods may increase the amount of healthy foods they provide. Finally, it may be that mindful feeding promotes higher quality parent-child communication and social bonding, which may increase the likelihood that children will be receptive and responsive to parents' positive feeding strategies. For example, parental modeling of healthy food intake may be more effective at improving child dietary intake if it takes place in the context of an attentive, positive parent-child interaction. Furthermore, mindful feeding may be a key component of warm, positive family mealtimes. This full emotional and mental presence may allow parents to engage in the behaviors necessary to promote positive psychosocial development in their children, which may in turn improve children's health. While little research exists exploring family meal time with child health outcomes, one study found significant associations between positive interpersonal dynamics (e.g., warmth, parental positive regard) at meal time and reduced risk of childhood overweight as well as positive food-related dynamics (e.g., food communication, parental food positive reinforcement) and reduced risk of childhood obesity among 6–12 year olds (Berge et al., 2014). In addition, data from the Nation Survey of Children's Health (NSCH) found that greater frequency of family meals increased the odds of positive social skills and engagement in school and decreased the odds of problematic social behaviors among children 6 to 11 (Lora, Sisson, Degrace, & Morris, 2014). These studies highlight the importance of positive family interactions at and frequency of meal time in various child outcomes. The current study supported our hypothesis that greater mindful feeding would be associated with lower parent BMI but failed to support our hypothesis that mindful feeding would be associated with lower child BMI percentile. It may be that parents who have lower BMIs are more mindful when feeding their children because they are more conscious of how or what they eat themselves and place greater value on healthy eating. Mindful eating has been associated with lower BMI among adults (Moor, Scott, & McIntosh, 2013; Framson et al., 2009), providing some support for this hypothesis. Although mindful feeding was not related to BMI percentile in younger children, it is possible that a relationship may appear between these variables in older children when parental influence begins to substantially influence lifestyle behaviors and affect adiposity. No research has yet been conducted on the relationship between parental mindfulness and child weight outcomes, so future research may aim to answer this question. Mindful feeding had low but statistically significant relationships with all other child dietary variables measured and no significant relationship with child fiber or calcium consumption. Future researchers may want to explore the relationships between mindful feeding and these dietary variables. Findings about the link between mindful feeding and parent-reported child added sugar and fruit and vegetable intake suggest a potential for mindfulness-based interventions for parents and families. General parent mindfulness training as well as parent-directed or family-based mindful health behavior programs may create more mindful feeding habits in parents. In turn, this may help parents engage in undistracted feeding, which may shape child diet in positive ways. While the
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literature has yet to establish an effect of parent or family mindfulness interventions on child dietary intake, adding a mindfulness component to a standard family training program has provided evidence for the unique contribution of mindfulness activities in outcomes such as interpersonal mindfulness in parenting and youth behavior management (Coatsworth et al., 2015). 5. Limitations and future directions It is important to note that this research is in its infancy. The mindful feeding measure utilized in this study is the first to assess parental mindful feeding as opposed to parental or child mindfulness or mindful eating. As such, this measurement tool would benefit from further item development, including expanding its items and determining other important components of mindful feeding other than mental and emotional present-centered awareness. This study only surveyed parents of children between the ages of approximately three to seven, so our results may not generalize to parents of older children. This age range was selected to obtain a sample of children in pre-school and early grade school, as children in this age range are old enough to start making decisions regarding food intake and are not quite old enough to have established food independence. However, a narrower age range would have allowed for more specific conclusions, and future research may shed light on these findings as they compare across ages. Additionally, this sample of parents was primarily white and highly educated, so our results may not generalize to parents and children of other races or to parents with lower education levels. Future validation among various child age groups and diverse samples is warranted. Our measure of dietary outcomes was in the form of a dietary screener. These tools have been shown to provide useful rough estimates, but facilitating dietary recall at multiple time points would have provided a more accurate representation of child food consumption patterns. Another limitation of this study is its self-report, cross-sectional nature. Therefore, it is not possible to determine the causal directions of the uncovered relationships, and our results may have been impacted by self-report bias or recall errors. As such, it is suggested that future research use observational measurement of parent mindful feeding in both naturalistic and lab environments. This would be beneficial in validating the current measure as well as identifying other important components of mealtimes that may impact mindful feeding, such as the use of electronics and other distractions, positive or negative family interactions, and parents' modeling of mindful eating. Other than methodological improvements, future research in this field has enormous potential. Mindful feeding, if truly effective at improving child health, could become an innovative intervention strategy. As a component of a comprehensive parent or family mindfulness or mindful health intervention, mindful feeding would likely have a strong impact. Based on previous research, these types of programs influence child mental and emotional health rather directly. Adding a mindful feeding aspect may improve the impact of these programs on child physical health. Additionally, it could have a substantial effect on both child and parent outcomes at the individual and family level, broadening the benefits of mindfulness and mindful health training. Potential target populations are parents of children at risk for health behavior problems, such as obesity and type II diabetes, and children who struggle with emotional difficulties that may predispose them to emotional eating, eating disorders, and weight difficulties. Future research on the construct of mindful feeding is highly recommended. References Arredondo, E. M., Elder, J. P., Ayala, G. X., Campbell, N., Baquero, B., & Duerksen, S. (2006). Is parenting style related to children's healthy eating and physical activity in Latino
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