Parenting Advice School-Age Kids Offer to Parents to Promote Healthier Child Weight-Related Behaviors

ARTICLE IN PRESS Research Article Parenting Advice School-Age Kids Offer to Parents to Promote Healthier Child Weight-Related Behaviors Kaitlyn M. Eck, MS, RD1; Colleen L. Delaney, BS1; Karla P. Shelnutt, PhD, RD2; Melissa D. Olfert, DrPH, RD3; Carol Byrd-Bredbenner, PhD, RD, FAND1 ABSTRACT Objective: To explore parenting advice children would provide to help parents encourage positive healthrelated behaviors by children. Design: Focus group discussions were conducted, and children shared the advice they would provide parents to help them encourage healthy weight-related behaviors (ie, diet, physical activity, and sleep) for children. Setting: Focus groups (n = 65) were conducted in 3 states (Florida, New Jersey, and West Virginia). Participants: School-age children (n = 194) between the ages of 6 and 11 years old. Phenomenon of Interest: What parenting practices are recommended by children, and are they in line with best-practice guidelines? Analysis: Focus group data were analyzed to identify themes and trends. Results: Children’s recommendations were congruent with authoritative parenting styles (ie, high levels of warmth and control). Most of the advice shared by children aligned with recommended parent practices (ie, responsive feeding, facilitation, environmental restructuring, parent modeling, and encouragement). However, not all of the children’s advice aligned with best practices guidelines (ie, use of food rewards and deception). Conclusions And Implications: Future nutrition education programs may be strengthened by helping parents adopt best practices for promoting healthy child behaviors. Furthermore, teaching children about recommended child feeding parenting practices may help protect future generations by preparing children to care for younger siblings or raise their children using best parenting practices. Key Words: child, parenting, health, focus groups (J Nutr Educ Behav. 2019;000:1−9.) Accepted September 10, 2019.

INTRODUCTION One in 5 school-age children in the US is classified as obese, with rates continuing to increase over the years.1,2 There are numerous health consequences of childhood obesity, including early onset of weight-related diseases like diabetes and hypertension.3,4 Combating the problem of childhood obesity is particularly important as more than half of overweight children become overweight adults.5 Behaviors linked to healthy weights include regular breakfast consumption,6,7

frequent family meals,8−10 adequate fruit and vegetable intake,11−13 ageappropriate portion sizes,14,15 limited sugar-sweetened beverage intake,16−18 adequate physical activity,19 limited screen time,19,20 and adequate sleep duration.21 Although school-age children are beginning to gain their independence as they spend more time away from home each day, many of their health-related decisions continue to be influenced by parental behaviors.22,23 As gatekeepers in the home, parents are responsible for creating a

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Nutritional Sciences Department, Rutgers University, New Brunswick, NJ Department of Family, Youth, and Community Sciences, University of Florida, Gainesville, FL 3 Division of Animal and Nutritional Sciences, West Virginia University, Morgantown, WV Conflict of Interest Disclosure: The authors have not stated any conflicts of interest. Address for correspondence: Kaitlyn M. Eck, MS, RD, Nutritional Sciences Department, 26 Nichol Ave, Rutgers University, New Brunswick, NJ 08901; E-mail: [email protected] Ó 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jneb.2019.09.005 2

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lifestyle and environment that promotes healthy behaviors and makes it easy for children to make healthy decisions about physical activity, eating, and sleeping behaviors.24 Examples of parent choices that can affect children’s health decisions include purchasing and preparing only healthy foods and allowing children to decide how much to eat24 or ensuring that children have access to space and equipment to encourage physical activity.25−27 As suggested by the observational learning construct of Social Cognitive Theory,28−30 parental modeling of health-related behaviors influences child health-related decisions.31,32 Parental support and encouragement of healthy behaviors can form and improve child health behaviors.22,28,33,34 Conversely, some parenting practices have a detrimental effect on child health-related behaviors. For example, rewarding children for eating and pressuring or forcing children to eat are associated with the development of

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undesirable eating behaviors, many of which are positively correlated with weight gain.15,35−38 Research suggests that parents should adopt an authoritative parenting style to promote the development of healthy behaviors that will last a lifetime.35,39 Authoritative parents offer high levels of warmth and control to children. This parenting style differs from an authoritarian parenting style which is characterized by low warmth coupled with high control, a permissive style wherein parents provide high warmth and low control, and an uninvolved parenting style which gives children both low warmth and low control.40 The authoritative style of parenting is associated with healthier child dietary behaviors and healthier child weights.35,39 In contrast, children of authoritarian parents have a higher risk of disordered eating behaviors and a greater risk of being overweight than children of authoritative, permissive, or uninvolved parents.41,42 Authoritative parents engage in more healthy feeding behaviors (eg, not promoting overeating, and not pressuring children to eat) than both authoritarian and permissive parents.43 The benefits of parenting practices that are in line with current bestpractice guidelines are numerous.44,45 The use of an authoritative parenting style and healthy parenting practices promote healthy childhood weights and healthy behavior choices,35,40,44,46,47 which offer lifetime benefits given the track into adulthood.5,48−50 In addition, the parenting practices children experience is likely to influence the parenting strategies they will use in the future when raising their children.51 However, little is known about children’s views on the type of parenting strategies they recommend parents use to persuade children to engage in healthy behaviors. Thus, the purpose of this study was to use focus groups to explore the parenting advice school-age children would provide parents to help parents encourage good health-related behaviors in their children. This study reported here was compelled by unexpected, aggregated observations from the original analysis of a series of focus groups with

Journal of Nutrition Education and Behavior  Volume 000, Number 000, 2019 children, wherein Social Cognitive Theory28−30 constructs (eg, barriers, facilitation, observational learning) about 1 or 2 of 9 distinct weightrelated behaviors were explored with each group children.52−59 Original analyses were aimed at gathering data to inform the development of nutrition education materials designed to help families make small, simple changes to their home environments and lifestyles and are reported elsewhere.52−59 When the focus group data were examined as an aggregate (across the 9 weightrelated behaviors, rather than 1 behavior at a time), the focus group data revealed strong threads of parenting strategies recommended by children that were not apparent during the initial analysis conducted by behavior in this secondary analysis.

METHODS This investigation was approved by the Institutional Review Boards at Rutgers University, University of Florida, and West Virginia University. Parents gave written informed consent for children to participate. Children gave verbal assent.

Sample School-age children between the ages of 6 and 11 from 3 states (Florida, New Jersey, and West Virginia) participated in focus group discussions. Printed and electronic notices distributed in community settings (eg, workplaces, schools) invited parents to sign up their children for a 30-minute discussion about small, easy changes families could make to their homes and lifestyles. Children were paid $15 for participating. The cognitive ability of children varies greatly between the ages of 6 and 11. Therefore, planned focus group assignment was based on age (ie, young children: aged 6−9 years; older children: aged 8−11 years). Children were asked the same questions regardless of age.

Instrument Focus groups were conducted by trained moderators using a semistructured moderator script, developed

according to standard guidelines to ensure uniformity and completeness of data collection.60,61 Each focus group discussion was limited to 1 or 2 topics (ie, family meals; breakfast and fruits/vegetables; beverages and physical activity; portion size and eating away from home; screen time and sleep). No child participated in more than 1 focus group. Each focus group was conducted by a moderator and a scribe who completed training and practice sessions. The moderator used a semistructured guide to ensure uniformity in data collection across sites. To explore the parenting advice children would give parents, children were asked, What advice would you give parents to help them help their family . . .make a healthy change related to the focus group topic [ie, eat meals together more often, eat healthy foods while away from home, eat breakfast more often, eat more fruits and vegetables, drink fewer sugary drinks, be more physically active, eat healthier portion sizes, decrease their screen time, and get enough sleep]. Focus group topics were assigned in a systematic order and continued until data saturation was reached. The scribe took comprehensive notes at each session, and afterward, reviewed notes for completeness and comprehension. Within 48 hours of focus group completion, the moderator reviewed the notes for completeness, accuracy, and clarity. The moderator and scribe discussed any discrepancies and reached full agreement on the notes before data analysis.

Data Analysis Standard qualitative analysis procedures62,63 were employed by 3 trained researchers for the content analysis of focus group data. The researchers independently identified themes in the data, compared their results for congruence, then discussed differences in identified themes to reach consensus on all themes.62,64,65 Throughout the data collection period, the focus group data were continuously analyzed to identify the point of data saturation (ie, no new themes emerge, and the data become repetitive), at which point data collection was ended.64,66

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RESULTS A total of 194 children (47% female) participated in 1 of 65 focus group discussions. Children were fairly evenly distributed across discussion topics (family meals and after school activities [n = 37]; breakfast and fruits/vegetables [n = 41]; beverages and physical activity [n = 41; portions and eating away from home [n = 35]; screen time and sleep [n = 40]), age groups (younger children [n = 83; 26 groups]; older children [n = 105; 37 groups]; mixed ages [n = 6; 2 groups]), and states (Florida [n = 64], New Jersey [n = 63], West Virginia [n = 67]). Focus group size was intentionally kept small (≤5 per group) to allow for the full participation of all children. Eleven themes emerged from the content analysis of the focus group data: facilitation, advanced planning, environmental restructuring, encouraging children, respecting children, reminding children, parental decrees, incentives, and punishments, education, modeling, and deception. A comparison of findings by age group, sex, and region indicated themes were consistent, and thus were all combined for reporting.

Facilitation Many children believed that parents play a key role in facilitating healthy eating for their families. For example, to increase frequency and appeal of family meals, children thought parents could make family mealtime fun, serve “foods that children would like,” and offer options if children in the same family “don’t want [to eat] the same thing.” To promote children’s involvement in meal preparation, children advised parents to “show the kids” how to do a food preparation task and “give kids easy tasks to help out with during mealtime.” To facilitate healthy eating away from home, children suggested that parents “pack healthy snacks for them” or “contact [their friends’] parents ahead of time to make sure they have healthy foods at their home.” Children suggested that parents could facilitate fruit and vegetable intake by serving these foods in different ways, such as in “smoothies” and “pizza or pasta,” and by incorporating

them in foods that children like. Other suggestions to increase intake were cutting fruits and vegetables, so they are “ready and prepared for you” and serving them with toppings or dip. To facilitate active play, children recommended that parents provide toys and playmates. Children also suggested that parents take children to places where they can be active, like walking trails or parks. Children also gave facilitation strategies parents could use to help children feel safe and comfortable, so they could get adequate sleep. Children advised parents to soothe children by verbally reassuring them, providing “a pillow or stuffed animal,” “lay down with them,” “or let them read.”

Advanced Planning Children noted that busy schedules were a barrier to engaging in many healthy behaviors and that advanced planning was a potential solution. To increase family meal frequency, children suggested that parents “have a routine” and “plan” around family member schedules. Although children understood that parents were not able to always eat with them, they recommended that parents “come home from work as early as possible” to make it easier to have family meals. “Having a routine and knowing you have chores to do before dinner” was suggested as a method for getting children to help with meal preparation tasks. Children also felt that planning in advance could increase the likelihood of eating breakfast. Several suggestions focused on time management, such as having parents “go to sleep early,” “set an early alarm” so they have time to make breakfast and have it ready for children. Children also proposed planning ahead strategies parents could implement, such as “making breakfast the night before.” Busy schedules also were a barrier to physical activity. Children suggested that parents “schedule and plan activities” (eg, play dates, chores) to ensure children get to be physically active and limit screen time. Children also recommended that parents “make a special time for kids,” “play

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with kids to get them outside by doing things that the kids like,” or have “kids go outside” or have “a game night.” Children identified parents’ work schedules as a barrier to parent-child co-play and therefore suggested that parents could “take breaks from work” so they could play with children more often. To control sedentary screen time, children suggested that parents “have something kids can do after and . . . in between [screen time] like chores or playing with friends.”

Environmental Restructuring Some children suggested that parents could promote healthy eating behaviors by altering the home environment. For instance, children believed parents could improve the frequency of breakfast consumption by stocking up on foods that are “easy to take on the go,” “breakfast foods kids like,” or foods that are fun to eat, “like [making] faces with fruit on pancakes.” Children also recommended that parents give “kids choices about what to eat.” Children felt that by “buying healthy foods” and serving “fruits and vegetables as sides instead of unhealthy foods,” parents could improve family fruit and vegetable intake. Children also indicated that parents could control sugary drink intake by “only buying it for parties,” storing it in hard to access places, and providing healthier beverage choices. To increase physical activity and reduce screen time, children suggested providing supports, such as bikes and balls. To help their families get more sleep, children recommended that parents “get rid of the distractions” for example, taking away children’s phones.

Encouraging Children Children recommended that parents encourage them to engage in healthy behaviors. Children indicated that parents could increase the frequency of family meals in their homes by reminding their children that family meals are “a special time where you are having some personal time with specific members of the family.” Simple encouragement in the form of

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“asking [children] to help make meals” was reported by many children to be an effective way to get children involved in mealtime activities. To help children overcome their food neophobia, several children recommended that parents “tell them that it tastes good” and “tell them to take a bite.” Similar advice was particularly prevalent for fruits and vegetables. Children advised parents to promote fruit and vegetable intake by telling children these foods are healthy and good to eat. Children also recommended encouragement for increasing physical activity. To help their children be physically active, children suggested that parents “encourage kids to play” or, tell children, “it is beautiful out.”

Respecting Children Children also reported wanting parents to show children respect and to recognize their wants. For example, when asking children to help around the house, children specified that parents should “ask nicely” and “be polite about asking kids to help them make meals.” To promote fruit and vegetable consumption, children reported that parents should be responsive to children’s food preferences and requests. Similarly, children suggested that rather than forcing the children to try new food, “parents should ask first. . . kids will try it if they are asked.”

Reminding Children Children were aware that eating well, being active, and getting enough sleep was important to their health, but they acknowledged the need for occasional reminders from their parents. Children thought that parents could remind children about the importance of breakfast — “tell them it starts their day, it’s healthy.” When eating out children suggested that parents share reminders of healthy options on the menu, “Sometimes when I say I want something like a cheeseburger, my mom says get meat or something, and then I say OK I didn’t know it was on the menu.” To encourage children to be physically active, children recommended that parents “remind kids to play outside.”

Journal of Nutrition Education and Behavior  Volume 000, Number 000, 2019 Children also noted that reminders of the benefits of healthy behaviors could also be beneficial. For example, to help children get enough sleep, children felt that parents should help children think about how too little sleep affects how they feel and perform in school.

Parental Decrees Children recommended that parents help children make healthy choices by “making rules and being strict.” For example, children recommended that parents establish a “no electronics at the table” policy to facilitate distraction-free family meals. To get children to help with meal preparation, children suggested that parents “not let kids get on their electronics until they help wash the dishes or set the table.” To encourage breakfast consumption, children suggested that parents “make kids sit at the table” in the morning and “just tell them to eat breakfast.” Similarly, they felt that parents could force children to try new foods, set rules, or tell children “to eat at least one fruit or vegetable” at each meal. Children advised parents to help their families have fewer sugary drinks by “having rules requiring you to drink water or milk,” and “limiting the amount of soda and juice” children can drink. Some thought that parents should monitor “how much foods kids are serving” themselves and should “limit their [child’s] intake by telling them how much they should eat.” When eating away from home, children felt that “parents shouldn’t let kids decide what to eat because they will be impulsive.” To promote adequate physical activity, children said that parents should “tell kids how much time to play,” send children “out to play,” and “just tell them to play more” or “go play sports.” To help them get less screen time, children recommended that parents “set limits.” To some children, setting limits meant “only letting them watch TV on certain days.” For most children, setting limits meant using the timer on the tablet, TV, phone, or computer that the child is using to remind the child when it is time to engage in a different activity. Furthermore, children

indicated that parents could help their children get enough sleep each night by having children manage their time better, such as scheduling homework and chores early enough to not run into bedtime, encouraging children to play actively enough to feel physically tired and ready to sleep, and establishing bedtimes and bedtime routines.

Incentives and Punishments The use of rewards, such as offering favorite snack foods, was named repeatedly by children as a way parents could motivate children to engage in healthy behaviors like eating fruits and vegetables, helping prepare meals, playing actively, eating breakfast, getting to bed on time, or trying new foods. Children also suggested using rewards as a way to discourage unhealthy behaviors. Other children suggested punishment as another strategy for parents to use. Most of the punishments suggested by children were about not limiting their screen time. To help children watch less TV, a few children suggested that children balance time watching TV with other activities, such as playing actively. One child said that parents should tell their children that “for every hour they watch TV, they [children] have to pay you $5.” Interestingly, many of the potential rewards suggested by children were also suggested as potential punishments. For example, some children viewed screen time as a potential reward, “if you go out and play, you can have computer time” and others as a punishment, “do it [play actively] or no video games.” Favorite foods also were identified as both a reward and punishment, “make them try the new food before they can have their favorite food” or give treats for eating vegetables. Most children suggested candy or “treats” as rewards, but one older girl specifically mentioned that parents should “reward them with something other than candy.”

Education Children commonly suggested that parents educate children, so they understand why healthy behaviors

ARTICLE IN PRESS Journal of Nutrition Education and Behavior  Volume 000, Number 000, 2019 were preferred. Children advised parents to tell them why vegetables or breakfast is good for them. They also suggested that parents tell children “what sugary drinks are made of and why they are not healthy” and what “can happen to your body” if you drink them. Some children expressed the idea that parents could help them understand why healthier drinks are a better choice, and they could “explain it’s good for sports” and that “water is healthy.” Children recommended that parents tell children that eating healthy foods is important to help children make healthy choices when away from home. They also supported the idea of parents promoting the benefits of healthy foods, such as “eating healthy makes you strong, healthy, and gives you more energy” and “telling their kids they want them to feel good while playing with their friends” or describing the negatives of unhealthy food, such as “it’s not good for their teeth.” Learning from the experience was another method of education that children suggested concerning sleep. They suggested that if children put up a fight at bedtime, parents should “let them stay up late and see how bad they feel after, and they won’t do it again.” To discourage children, children recommended that parents provide disinformation. For example, to reduced screen time, they suggested that parents tell children that “unhealthy food is disgusting” or that electronic devices can cause physical harm, such as brain damage.

Modeling Parent modeling of healthy behaviors was another method suggested by children. Modeling fruit and vegetable consumption and having children and parents “try new foods together” was suggested. Most modeling suggestions were related to promoting healthy drink consumption. Children noted that parents should “not to drink a lot of soda” because when children see parents enjoying sugary beverages, children want to drink them, too. Instead, children suggested that parents should “drink a lot of

water, so it makes me want to drink water.”

Deception Many children suggested that parents use trickery to get children to engage in good health-related behaviors. Several children suggested that parents “sneak” fruits and vegetables into other foods or mixing healthy foods with other ingredients, so children are not aware they are eating healthy foods. To decrease sugary drink consumption, an older girl suggested that parents deceive children by mixing water with dye to appear to be juice.

DISCUSSION This study aimed to identify, through secondary analysis of focus group notes, the parenting strategy recommendations that children believed parents should use to persuade children to engage in healthy behaviors. Many children suggested that parents use both overt and covert methods of control. Suggestions made by children commonly included covert methods of control such as preparing healthy foods and making them easy for children to access, providing toys and playmates to encourage physical activity, planning ahead to have breakfast ready for children when they wake up and keeping unhealthy foods like sugary drinks out of the house. Children also suggested methods of overt control. The suggestions for overt control spanned discussion topics, including having rules about eating breakfast, specifying the number of fruits and vegetables to eat each day, setting screen time limits, establishing physical activity time goals. These data suggest that children want parents to exert control and are not requesting parents to use parenting styles associated with low control (ie, permissive or uninvolved parenting style). Instead they are asking for either authoritative or authoritarian parenting, both of which use high levels of control.40 The difference between these parenting styles is the presence of warmth, with authoritative parents demonstrating high levels of warmth compared with the low levels offered by authoritarian parents.

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The focus group data also indicated that children want parents to display warmth. Children repeatedly suggested that parents could demonstrate warm feelings were related to how children wanted parents to communicate with them. Children wanted parents to show respect to children (eg, acknowledge children’s preferences, politely communicate with children), verbally reassure children, encouraging children to engage in a variety of healthy behaviors, remind children to make healthy choices, and teach children to promote healthy behaviors. Other parenting strategies that suggested a request for warmth included suggestions that parents made special time for children and lay down with children to comfort them before bed. Encouraging children to make healthy choices and making it easy for children to make healthy choices (facilitation) are other ways parents can promote healthy behaviors without force.67 The desire expressed for warmth suggests that children prefer either authoritative or permissive parents, but when the desire for control is taken into account, the data indicate a preference for an authoritative parenting style.39,40,68 The advice children provide to parents generally was in line with best-practice parent feeding guidelines, including the suggested use of an authoritative parenting style.40 For instance, children recommended that parents be responsive to child food preferences and allow children some control over their food intake while simultaneously encouraging healthy food intake. This feeding style has many benefits over the rigid control of children’s eating. When parents overly control children’s intake of less nutrient-dense foods (eg, sweets, salty snacks) preference for these foods can increase.69,70 Children whose parents restrict their food intake have a higher body mass index compared with children of parents who do not restrict.71 Facilitating healthy behavior change by altering the home environment was another strategy suggested by children that is also recommended by experts.72−75 To promote healthy eating, children advised parents to keep healthy foods

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stocked at home and pack healthy snacks for times children are on the go. These are examples of methods of covert control, which has been associated with higher diet quality.76,77 Ensuring children have access to space and supports for physical activity near home and providing a safe and comfortable sleep environment were other strategies suggested by children. The restructuring of the home environment to promote healthy behaviors that children suggested is in line with the core concept of Social Cognitive Theory, namely reciprocal determinism.30,78 Reciprocal determinism posits that an individual’s behaviors can simultaneously be influenced by their environment while also influencing their environment.30,78 Children’s proposals of environmental changes (eg, keeping healthy foods on hand and easy for children to access, not buying unhealthy foods, and providing toys that encourage physical activity) to support improved health-related behaviors are congruent with research showing that having more healthy foods and fewer unhealthy foods (like sugary drinks) at home is associated with greater fruit and vegetable intake and decreased sugary sweetened soft drink consumption.72,73 Moreover, access to safe play spaces and equipment is positively associated with child activity levels.27,74 Parent modeling of healthy behaviors was another suggestion of children that is in line with current parenting guidelines.75,79−81 Social Cognitive Theory supports the concept of observational learning, which is the idea that behaviors are learned through observing the modeled behavior of others, often those held in high regard, such as parents.30,78 Children commonly suggested that parents model healthy eating behaviors for their children to encourage improved fruit and vegetable intake and decreased sugary beverage intake. Parent modeling of healthy behaviors is particularly important for the development of healthy child behaviors.82−84 Children recommended that parents encourage their children to make healthy choices by reminding them of the importance of family meals, telling them that healthy food

Journal of Nutrition Education and Behavior  Volume 000, Number 000, 2019 is delicious or suggesting that they go outside to play on a beautiful day. Parental encouragement is a strong determinant of healthy behaviors in children.22,34,85,86 Children often suggested that parents use foods like candy and other sweets as rewards to encourage positive behavior, such as eating healthy foods—a suggestion not in line with recommended child feeding practices15 or congruent with authoritative parenting style.87 When less nutrientdense foods are offered as a reward for eating healthier foods (eg, eat your peas, and you can have dessert), the preference for the healthier foods drops while the preference for the less nutrient-dense food rises.15 Using less nutrient-dense foods to reward positive behaviors also may lead to overeating.69,70 Authoritative parenting styles are negatively correlated using food rewards, further supporting the benefit of this style of parenting.87 Some children suggested the use of nonfood rewards such as money, or extra screen time as potential motivators for children. These types of rewards, when used judiciously, have been shown to improve child acceptance of new foods without producing the same negative effects seen when food rewards are used.88−90 Authoritative parenting is negatively correlated using food rewards to incentivize consumption of healthy foods and positive behaviors while both authoritarian and permissive parenting styles were correlated using food rewards.87 Children also suggested that parents trick them into eating vegetables by hiding them in foods. When parents hide vegetables children are not able to develop their taste for these healthy foods.91 Furthermore, when parents choose to hide vegetables from children it restricts their ability to involve children in meal preparation,91 which is an effective method of promoting child fruit and vegetable intake.92 Children likely suggested these negative and positive strategies because of being exposed to these parenting behaviors. Parenting practices are passed through generations, and grown-children tend to use their life experiences and raise their children similarly to how they were raised.51 This suggests that incorporating guidelines related to healthy

parenting practices into health interventions aimed at children may improve child health behaviors now and their parenting practices in the future. The findings of the current analysis revealed that children recommended parenting behaviors congruent with the high control, high warmth that defines an authoritative parenting style. A limitation of this study was that parenting styles, and practices were not measured to allow a comparison of whether children’s advice was influenced by the parenting styles they received. However, given the sample size and collection of data across 3 diverse geographic regions, it is unlikely that all children received an authoritative parenting style and were merely reporting on daily experiences. Another potential limitation is that although the focus groups were initially planned to explore parenting advice school-age children would provide parents, this secondary analysis of data across aggregated focus groups exploring distinctly different weightrelated behaviors was not planned a priori. Demographic characteristics were also limited to age, sex, and region. These findings also indicate that most of the advice children have for parents aligns with best parenting practices, such as responsive feeding practices, facilitation, environmental restructuring, parent modeling, and encouragement. However, not all the children’s advice for parents was in line with best practices. For example, children suggested the use of food rewards and recommended that parents hide vegetables in dishes to deceive children. Although data were not collected to determine the type of feeding practices children’s parents used, actual or observed experiences likely informed these parenting suggestions.

IMPLICATIONS FOR RESEARCH AND PRACTICE The results of this study indicate an opportunity for nutrition education programs to help current parents adopt best practices for promoting healthy child behaviors. Helping parents understand that these are the practices that children themselves

ARTICLE IN PRESS Journal of Nutrition Education and Behavior  Volume 000, Number 000, 2019 recommend could help parents realize the benefits of the practice can extend to improved parent-child relationships and bonding. In addition, teaching children about recommended child feeding parenting practices now may help protect future generations by preparing children to care for their children in the future or for their younger siblings currently using best parenting practices to promote healthy choices. Future research could consider the potential relationship between parenting style experienced by a child and their suggested health-related parenting practices.

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ACKNOWLEDGMENT 11. This project was supported by a grant from the US Department of Agriculture, National Institute of Food and Agriculture (Grant Number 2017680001-26351). 12.

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