The Role of Responsive Feeding in Overweight During Infancy and Toddlerhood a Systematic Review
Responsive feeding values and practices among families across the Canadian Maritime provinces
Publication: Applied Physiology, Nutrition, and Metabolism
3 February 2022
Abstract
Children benefit from responsive feeding practices where their internal signals of hunger and satiety are valued and met with prompt, emotionally supportive, and developmentally appropriate responses. Using an online survey, this study describes responsive feeding values and practices among parents of young children (0–5 years) (n = 1039) across 3 Canadian Maritime provinces. Independent-samples t-tests and 1-way ANOVA were performed to determine the differences in survey questions related to the responsive feeding practices and values. First-time parents and parents with younger children report implementing more consistently some of the challenging responsive feeding practices, such as avoiding pressuring their children to eat, compared with parents with multiple children and parents with children ages 3–5 years. Parents often have well-intended reasons to encourage their children to eat; however, these can coincide with non-responsive practices with food such as pressuring, rewarding, and restriction. These coercive practices may be ineffective and counterproductive as they reinforce reasons to eat unrelated to appetite and self-regulation. Preschool and early feeding interventions that support parents in understanding normal child development, including typical eating behaviours and self-regulation, could help to equip them for challenging feeding experiences and encourage long-term responsive feeding practices.
Novelty:
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First-time parents and parents with younger children report more consistently avoiding pressuring their children to eat, compared with parents with multiple children and parents with children ages 3–5 years.
•
Parents often have well-intended reasons to encourage their children to eat; however, these can coincide with non-responsive practices such as pressuring, rewarding, and restriction.
Résumé
Les enfants bénéficient de pratiques d'alimentation réactives durant lesquelles leurs signaux internes de faim et de satiété sont évalués et satisfaits rapidement, accompagnés de réponses émotionnellement favorables et adaptées au développement. À l'aide d'un sondage en ligne, cette étude décrit les valeurs et les pratiques d'alimentation réactives chez les parents de jeunes enfants (n = 1039, 0–5 ans) dans 3 provinces maritimes canadiennes. Des tests t pour échantillons indépendants et une ANOVA à une voie ont été effectués pour déterminer les différences dans les questions de l'enquête liées aux pratiques et aux valeurs d'alimentation réactives. Les nouveaux parents et les parents d'enfants plus jeunes déclarent mettre en œuvre de manière plus cohérente certaines des pratiques d'alimentation réactives difficiles, comme éviter de faire pression sur leurs enfants pour qu'ils mangent par rapport aux parents de plusieurs enfants et aux parents d'enfants âgés de 3 à 5 ans. Les parents ont souvent des raisons bien intentionnées d'encourager leurs enfants à manger; cependant, celles-ci peuvent coïncider avec des pratiques non réactives avec la nourriture telles que la pression, la récompense et la restriction. Ces pratiques coercitives peuvent être inefficaces et contre-productives car elles renforcent les raisons de manger sans rapport avec l'appétit et l'autorégulation. Les interventions préscolaires et d'alimentation précoce qui aident les parents à comprendre le développement normal de l'enfant, y compris les comportements alimentaires typiques et l'autorégulation, pourraient contribuer à les équiper pour des expériences d'alimentation difficiles et encourager des pratiques d'alimentation réactives à long terme. [Traduit par la Rédaction]
Les nouveautés :
•
Les nouveaux parents et les parents d'enfants plus jeunes déclarent éviter plus systématiquement de faire pression sur leurs enfants pour qu'ils mangent par rapport aux parents de plusieurs enfants et aux parents d'enfants âgés de 3 à 5 ans.
•
Les parents ont souvent des raisons bien intentionnées d'encourager leurs enfants à manger; cependant, ces raisons peuvent coïncider avec des pratiques non réactives telles que la pression, la récompense et la restriction.
1. Introduction
The early years of a child's life play an essential role in developing healthy diet and lifestyle habits. The home environment is a key determinant of a child's well-being, and parents have a strong influence on the development of healthy eating behaviours (Haines et al. 2019; Peters et al. 2014; Rylatt and Cartwright 2016; Walton et al. 2017). Adequate healthy food intake is essential for young children's growth and development; however, focusing on food consumption alone is not enough (Finnane et al. 2017; Health Canada 2012; Nishida et al. 2004; Uauy et al. 2008). Children benefit from positive food parenting (Daniels 2019; Haines et al. 2019; Sleddens et al. 2014; Vaughn et al. 2016), including responsive feeding practices where their internal signals of hunger and satiety are valued and met with prompt, emotionally supportive and developmentally appropriate responses (Black and Aboud 2011; Pérez-Escamilla et al. 2017). Responsive feeding refers to a reciprocal relationship between a child and their caregiver characterized by the child communicating feelings of hunger and satiety, followed by an appropriate response from the caregiver (Black and Aboud 2011; DiSantis et al. 2011; Health Canada, Canadian Paediatric Society, Dietitians of Canada, & Breastfeeding Committee for Canada 2015). Responsive feeding practices appear straightforward but using them consistently can be challenging for parents due to conflicting values and beliefs, parental confidence, family dynamics, economic pressures, time constraints, and child behaviours (Black and Aboud 2011; Galloway et al. 2006; Orrell-Valente et al. 2007).
Tensions and battles related to feeding young children are common and can impact the quality of family mealtimes, parent confidence, and broader family dynamics and well-being (Mitchell et al. 2013). Parents experience various challenges and barriers when feeding their children, including time constraints, conflicting parent views, and picky eating (De Lauzon-Guillain et al. 2012; Loth et al. 2018; Peters et al. 2014; Tucker et al. 2006). Children are born with the ability to recognize hunger and satiety and the capacity to self-regulate their intake of food (Birch et al. 1991; Ramsay et al. 2010). This capacity to self-regulate energy intake is supported when children are verbally cued to attend to their hunger and satiety (Bante et al. 2008; Sellers et al. 2005). Yet parents often unintentionally override young children's internal hunger and satiation cues by controlling food intake, restricting food, or using food to reward and encourage behaviour (Bante et al. 2008; Sellers et al. 2005). Responsive feeding practices are important because they reinforce reasons to eat that are related to appetite and self-regulation; factors that contribute to life-long healthy development and weight status (Black and Aboud 2011; Daniels 2019; DiSantis et al. 2011; Eneli et al. 2008; Frankel et al. 2014; Haines et al. 2019; Hurley et al. 2011; Shloim et al. 2015).
Currently, little is known about the extent to which responsive feeding is understood, valued, and practiced by families across the Canadian Maritime Provinces of Nova Scotia (NS), New Brunswick (NB), and Prince Edward Island (PEI). A recent cross-sectional study found many knowledge gaps around Canadian feeding recommendations for children aged 0–24 months among Nova Scotians (Chan and Whitfield 2020). Yet, paradoxically, participants were confident in their incorrect responses to these knowledge questions (Chan and Whitfield 2020). High rates of chronic disease and food insecurity have been reported in this region (Government of Canada, Statistics Canada 2018; Newell et al. 2014; Tarasuk and Mitchell 2020), and there is growing concern around infant food security (Frank 2020). The current study explored the responsive feeding values and practices of parents of children 0 to 5 years of age living in the Canadian Maritimes. Relationships between responsive feeding values and practices among the Maritime provinces, parity in the family (relationship to the number of other children in the family), and age of the child were also determined.
2. Materials and methods
2.1. Data collection
Parents/guardians with at least 1 child aged 0- to 5-years-old living in NS, NB, and PEI were invited to participate in an online family survey from January–February 2020. The survey link, an information sheet, and a flyer were sent through email to all family resource centres, regulated childcare facilities, approved family home daycares, and other school-based early childhood programs across the 3 provinces. The survey was also promoted through social media accounts and other key online communities. This research was part of a larger study investigating responsive feeding both in home and child care settings. Here we report on findings from the family survey, which included 28 closed- and open-ended questions about demographic information and the participant's responsive feeding/healthy eating values and practices they engage in at home. Specific survey items were inspired by the validated Nutrition and Physical Activity Self-Assessment for Child Care (NAPSACC) assessment tool (Ward et al. 2014), modified to reflect the home environment, with the intent of investigating whether responsive feeding practices were understood and valued. This tool allowed for an exploration of certain aspects of responsive feeding across the 2 settings. The elements of responsive feeding explored in this work were 'eating together', 'eating the same food', 'social conversations during meals' and 'avoiding pressure to eat'. These are consistent with key healthy eating practices outlined in Canada's Food Guide (Health Canada 2019), including being mindful, enjoying food and eating together. There has been little research that has explored family values and practices corresponding with responsive feeding elements highlighted in the national healthy eating guidelines. The survey was available for completion through a secure, Canada-based online platform. Participants gave informed consent before taking part and ethics approval was received from Mount Saint Vincent University and the University of Prince Edward Island Research Ethics Boards.
2.2. Data analysis
Once the survey was closed, data were reviewed to identify incomplete responses and recode data as needed for consistency and statistical analyses. For example, participants who selected 'Other (please specify)' for a multiple-choice and specified a response that matches one of the other multiple-choice options were recoded as such. To enable further analysis, all target variable data were treated as Likert-type data by converting ordinal scales to numeric values ranging from 1 (Not important/Never or rarely) to 4 (Very Important/Always). Respondents who did not answer a question or indicated 'Prefer not to answer' were not included in the analysis of that question. Response frequencies were gathered for demographic questions. Independent-samples t-tests (parity) and 1-way ANOVA (with a Tukey's or Games–Howell post-hoc test) (province, child age) were performed to assess differences on survey questions related to the responsive feeding practices and values. Spearman correlations were performed to compare participants' responses to feeding/healthy eating questions focused on values and questions focused on practices (parity, province, child age).
3. Results
One thousand and thirty-nine families participated in the family survey (Table 1). The majority of family survey participants identified as a mother (92%) of a child 3 to 5 years old (65%). Most families were from NS (58%), followed by NB and PEI (24% and 18%, respectively). Families reported high levels of education and income, with most participants indicating having an undergraduate or graduate/advanced university degree (30% and 38%, respectively) and a household income of $81 000–$100 000 or more than $100 000 (15% and 40%, respectively).
Table 1.
Table 2 outlines the items reflective of participant's values and practices for specific responsive feeding related routines. Responses are categorized by parity and age of the child. Responses are not categorized by province as no significant differences were found between provinces. Table 3 highlights the correlations between participants reported responsive feeding values and practices.
Table 2.
Table 3.
3.1. Eating together (Value/Practice 1)
The majority of participants reported that eating together as a family was 'very important' to them (75%; data not shown). First-time parents appeared to sit with their child during snack/mealtimes more consistently compared with parents with multiple children (t(776.438)= −3.779, p < 0.001). Parents with children <3 years reported sitting with their child more consistently during snack/mealtimes compared with parents with older children (3–5 years) (F(2, 911) = 13.267, p < 0.001). Table 3 highlights a weak but statistically significant correlation between participants' reported value and practice of eating together as a family (rho = 0.261; p < 0.001).
3.2. Eating the same food (Value/Practice 2)
The majority of participants felt that it was important (30%) or very important (64%) for children to see parents eat the same food as them. While 15% of parents in this study reported 'sometimes' eating the same foods and beverages as their children, most participants either did so 'often' or 'always'. Parents with a 3–5-year-old indicated eating the same food and drink as their child more often than parents with a 0–17-month-old (p = 0.002) and parents with an 18–35-month-old (p = 0.020). There was a statistically significant moderate, positive correlation between the reported value and practice of eating the same food, but only for parents of children aged 18–35 months (rho= 0.415, p < 0.001). All other results indicated statistically significant weak correlations.
3.3. Social conversation during meals (Value/Practice 3)
The majority of participants reported that having conversation during meals was 'very important' to them (70%). Parents self-reported tendency to engage their child in a social conversation during meals differed by child's age, with caregivers of 3- to 5-year-olds indicating they engaged their child in conversation during snack/mealtimes more than parents with a 0- to 17-month-old (p = 0.007). Spearman's correlation results indicated a statistically significant but weak correlation between participants' reported value and practice of social conversation with their child during meals (rho = 0.309; p < 0.001).
3.4. Avoiding pressure to eat (Value/Practice 4)
The majority of participants reported that avoiding pressure to eat all the food provided was 'important' (37%) or 'very important' (53%) to them. Both parity and child age were found to impact parent's tendency to value and practice pressuring children to eat. There was higher indicated valuing of not pressuring children to eat among first time parents and parents of children younger than 3 years old (Table 2; p < 0.05). Parent's self-reported values and practices aligned on this topic: valuing avoiding pressuring children to eat was inversely correlated with their practice of encouraging children to finish their food (rho = −0.393, p < 0.001). The self-reported practice of encouraging children to finish the food on their plate was highest for parents with more than 1 child and parents with a 3–5-year-old (p < 0.001). It was also found that parents with an 18–35-month-old indicated encouraging their child to finish their food more than parents with a 0–17-month-old (p < 0.001).
4. Discussion
Healthy eating practices develop at an early age, foster a healthy relationship with food and provide the foundation for lifelong health (DiSantis et al. 2011; Health Canada 2012). This study examined some aspects of responsive feeding practices among families across the 3 Maritime Provinces in Canada, where a current gap in the literature exists. Most parents in this study described valuing responsive feeding practices, such as eating together as a family and avoiding pressuring children to eat; however, maintaining these best practices from infancy to preschooler age appeared to be more challenging.
The relationship between family meals and healthier eating patterns in young children has been documented (Caldwell et al. 2018; Haines et al. 2019; Verhage et al. 2018; Wedde et al. 2020). A meta-analysis found that children and adolescents who shared at least 3 family meals per week were 20% less likely to consume unhealthy foods and 24% more likely to have healthy dietary habits compared with those who shared fewer than 3 family meals weekly (Hammons and Fiese 2011). More recently, Verhage et al. (2018) reported that the frequency of family meals was positively associated with more nutrient-dense food and a more balanced diet, but also emphasized that having structured mealtimes and family meals were associated with more food enjoyment and less fussy and emotional eating (Verhage et al. 2018). Most parents in the present study valued eating together with their children at any age. Interestingly, parents reported sitting down more consistently with younger children (0–17 months) than older children (3–5 years). This conflicts with findings from national surveys conducted in France (Le Heuzey and Turberg-Romain 2015; Le Heuzey et al. 2007) that report eating together as a family regularly increased as children got older. At 8–12 months, 26% of the mothers reported that they ate together regularly with their child, which increased to 64% at 13 to 18 months and 91% by 3 years old (Le Heuzey et al. 2007); similar results were also found 5 years later (Le Heuzey and Turberg-Romain 2015). Cultural differences may contribute to the variances between food consumption and eating together in Canada compared with France. Rozin (2005) describes the French traditions of enjoying the quality of the food consumed and the opportunity of eating together as a valued experience (Rozin 2005). It is also possible that children in the preschool age range may find it challenging to sit for a more extended period, get distracted, or lose interest in sitting for a family meal (Marks 2015). Parental distraction during mealtime may also be a factor (Gramm et al. 2020). Lack of time has also been reported as a challenge for many families and can impact the structure and frequency of family meals, as it can be difficult for parents to find time to prepare meals at home while balancing work, school, and evening activities (Chircop et al. 2015; Peters et al. 2014; Tucker et al. 2006).
Role modelling healthy eating behaviours have been positively correlated to children's diet and preference for fruits and vegetables (Draxten et al. 2014). Parents in the current study felt that it was very important for children to see parents eat the same food as them. In a qualitative study investigating factors that affect family meals, mothers also reported the importance of social time and the opportunity to model healthy behaviours (Spence et al. 2016). Parents in this study with an older child indicated eating the same food and drink as their child more often than parents with a younger infant or toddler. Canadian guidelines outlined in Nutrition for Healthy Term Infants (Health Canada, Canadian Paediatric Society, Dietitians of Canada, & Breastfeeding Committee for Canada 2015) recommend modified family foods from 1 year onwards; thus, it is encouraging that children aged 3–5 eat the same foods as their parents. We also found that parents in this study highly valued social interaction while feeding and reported engaging in social conversation with their children, particularly older children, during meals. Although this social interaction is valuable for social-emotional and cognitive development (Snow and Beals 2006), it may not necessarily impact eating behaviours. Addessi et al. (2005) found that children are more likely to eat a new food if others eat the same type of food than when others are simply present or eating another kind of food. This suggests the presence of an adult during mealtime is notable, but that adult eating the same food as the child has a substantial impact on the likelihood of the child also consuming that same food (Addessi et al. 2005).
Children are born with an innate ability to self-regulate their food intake (Daniels 2019). Self-regulation encourages healthy development and healthy weight status long-term (Black and Aboud 2011; DiSantis et al. 2011; Eneli et al. 2008; Frankel et al. 2014; Hurley et al. 2011; Shloim et al. 2015). Parent responses to children's expressions of their hunger and satiety can either support or weaken this capacity for children to regulate their own energy intake. By using pressure to encourage children to finish their food, parents may be inadvertently encouraging their children to diminish this ability to self-regulate their appetite (Orrell-Valente et al. 2007). Li et al. (2014) reported a potential long-lasting impact of such pressuring, showing that children who were encouraged to finish their bottles as infants were more likely to clean their plates at 6 years (Li et al. 2014). First-time parents and parents of younger children in this study reported placing more value on not pressuring children to eat all the food provided. This could be due to fewer distractions or fewer commitments with only 1 child, or perhaps parents with children in the youngest category are not experiencing neophobia that often emerges by the age of 3–5 years (Birch 1998; Schwartz et al. 2011). In this study, parents with older children (ages 3–5 years) encouraged them to finish their food more than younger children (<3 years old). Parents may be overestimating how much food children need to eat or may have less trust in a child's ability to self-regulate their food intake. Parents may also encourage food consumption more as children get older because they feel confident that children better understand verbal recommendations as their language skills begin to develop. This belief or value of parents to not pressure children to eat appeared to decrease in parent respondents of older children. As children age and move into a stage where picky eating typically intensifies (Birch 1998; Cooke 2007), parents may feel that pressuring children to eat is important or needed. Byrne et al. report findings that parents want their child to be a "good eater" and praise them for eating all that is offered. At a time when the child's autonomy is thriving, the rejection of new foods or picky eating is reported by 10–50% of parents and can be a source of concern and conflict in families (Birch 1998; Chan et al. 2011; Dovey et al. 2008; Taylor et al. 2015; Vaughn et al. 2016; Walton et al. 2017). Fussy or picky eating is a normal developmental phase for young children but is also characterized when parents have the perception that their child does not eat as much as the parent thinks they should (Daniels 2019). Parent stress and concern about their child's diet can influence the feeding environment resulting in non-responsive feeding practices that can reinforce picky eating, fuel a cycle of child refusal and parental pressure to eat (Cooke 2007; Galloway et al. 2006; Peters et al. 2014; Walton et al. 2017).
Responsive feeding has been identified as a positive element in early childhood growth (Frankel et al. 2014; Heller and Mobley 2019). Having the capacity to identify and accurately assess responsive parental feeding would inform responsive feeding interventions and health promotion programs in the early years. A recent systematic review highlighted the need for instruments to consider parental responsive feeding in young children reporting that frequently assessed feeding practices included pressure to eat, parental control, and food rewards (Heller and Mobley 2019). The Feeding Practices and Structure Questionnaire (FPSQ) has been commonly used to measure maternal responsiveness while feeding toddlers (2 years+) and has recently been adapted for use in infants (Feeding Practices and Structure Questionnaire – Milk Feeding FPSQ-M) (Jansen et al. 2021). As well, maternal symptoms of anxiety have been linked to some non-responsive feeding behaviours such as pressure to eat and using food to regulate emotions (Haycraft 2020). Interventions to reduce controlling child feeding practices and maternal anxiety are important to support caregivers in navigating the challenges of feeding young children (Haycraft et al. 2020). In their digital health intervention to help parents/caregivers with feeding children and establishing children's healthy eating behaviours, Haycraft et al. (2020) saw significant decreases in maternal anxiety and maternal use of controlling feeding practices, such as pressure to eat. While researchers acknowledge additional work is needed to include a more diverse sample, these findings demonstrate that behaviour change can help to promote healthy eating behaviours in young children (Haycraft et al. 2020).
This study addresses a gap in characterizing several responsive feeding practices in family homes across the Maritime Provinces. The size and multi-province nature of the sample are strengths of this study. Compared with the median household income in Nova Scotia (Government of Nova Scotia: Finance and Treasury Board 2019), participants in this study had higher levels of education and family income status, which has implications for the generalizability of the findings. While this study assesses some aspects of responsive feeding, it is important to note that this was not an exhaustive investigation and there are other aspects such as structured meal timing or covert restriction that are not captured that might be specific to the home environment. This study was part of a larger project that also considered childcare settings. Future research should consider collecting additional information on family structure and food security and use tools more specific to the home environment. The self-report nature of the data and potential social desirability bias are limitations of this work. It is important to also note that the NAPSACC tool was developed for a childcare setting. Using this measure with a parent population is a limitation of the work.
5. Conclusion
Parents value responsive feeding practices across the Maritime Provinces. First-time parents and parents with younger children report implementing more consistently some of the challenging responsive feeding practices, such as avoiding pressuring their children to eat, compared with parents with multiple children and parents with children ages 3–5 years. Parents often have well-intended reasons to encourage their children to eat; however, these can coincide with non-responsive practices with food such as pressuring, rewarding, and restriction. These coercive practices may be ineffective and counterproductive as they reinforce reasons to eat that are not related to appetite and self-regulation (Frankel et al. 2014). Preschool and early feeding interventions that support parents and caregivers in understanding normal child development, including typical eating behaviour and self-regulation, could help to equip them for challenging feeding experiences and encourage responsive feeding practices long term.
Competing interests statement
The authors declare there are no competing interests.
Authors' contributions
All authors have contributed to and approved the final article.
Data availability statement
Data will be made available via a request to the authors and through a formal data sharing agreement.
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Applied Physiology, Nutrition, and Metabolism
Volume 47 • Number 5 • May 2022
History
Received: 8 October 2021
Accepted: 6 January 2022
Published online: 3 February 2022
Copyright
© 2022 The Author(s). This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
Key Words
- responsive feeding
- family feeding practices
- healthy eating practices
Mots-clés
- alimentation réactive
- pratiques alimentaires familiales
- pratiques alimentaires saines
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Funding Information
The research was supported by Research Nova Scotia (Award # 2062) and was also undertaken, in part, thanks to funding from the Canada Research Chairs program.
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Melissa D. Rossiter, Brenna Richard, Kyly C. Whitfield, Linda Mann, and Jessie-Lee D. McIsaac. Responsive feeding values and practices among families across the Canadian Maritime provinces. Applied Physiology, Nutrition, and Metabolism. 47(5): 495-501. https://doi.org/10.1139/apnm-2021-0692
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Source: https://cdnsciencepub.com/doi/abs/10.1139/apnm-2021-0692
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