Children’s Healthy and Unhealthy Food Intake Related to Parental Fear of the Covid-19, Family Communication Patterns, and Parental Controlling Feeding Practices

Background: The COVID-19 pandemic has caused abrupt changes in the daily lives of most families, including their food environments. Fear of COVID-19 and family communication patterns are hypothesized to inuence parental feeding practices and ultimately children’s intake of healthy as well as unhealthy foods. Based on a conceptual model of direct and indirect effects among these variables, we test these hypotheses in an observational cross-sectional design. Methods: 306 parents (51% fathers) with children in the age range 5 - 12 were recruited via a Facebook snowball sampling method. They completed questionnaires online to measure fear of COVID-19, conversation- and conformity-oriented family communication patterns, and parental controlling feeding practices. In addition, they reported on the child’s intake of food categories marking healthy (fruits and vegetables) and unhealthy (juice, soda, sweets, fast foods) diets. The conceptual model was analyzed with structural equations modeling, including a multi-group analysis to discern differences between mothers and fathers. Results: There were signicantly positive associations between parental fear of COVID-19 and both conversation and conformity family communication patterns, both of which in turn were positively associated with parental controlling feeding practices. Conversation communication pattern was associated with reduced unhealthy food intake in children. For the most part, these associations occurred for both mothers and fathers. However, whereas fathers’ communication patterns were not related to children’s food intake, mothers’ conversation pattern was negatively, and conformity pattern was positively, associated with children’s unhealthy food intake. Conclusion: COVID-19 has had a profound impact on families, including children’s dietary intake. These results underscore that general family patterns play an important role for children’s dietary intake. Therefore, it may be useful to help parents adopt general positive parenting approaches to inuence their children’s healthy development, including dietary intake.


Introduction
A well-balanced healthy diet with adequate nutrients is pivotal for children's mental and physical development [1]. Unhealthy food intake among young children therefore should be a critical public health concern, given that this not only inhibits overall healthy development but also becomes predictive of chronic diseases later into adulthood such as cardiovascular disease, obesity, and diabetes [2]. However, children's typical dietary intake is poorly aligned with national dietary guidelines in that their diets are often low in fruits and vegetables and high in discretionary food, which is often less healthy or unhealthy [3]. It is well known that parents and other aspects of the home environment are key in uences on children's food consumption [4]. Meanwhile, a striking shift has occurred recently that likely changed the home food environment for most families.
pandemic, at a time when many parents experienced heightened emotions including fear. Given the expectations that fathers on average became more engaged in parenting during this unique period due to spending more time at home, we will also examine if there were distinctive differences between mothers and fathers in shaping the feeding practices and dietary intake of their children.
Re ecting the discussion above, the conceptual model shown in Figure 1 identi es hypothesized relationships among parental fear of COVID-19, family communication patterns, parental controlling feeding practices, and child's dietary intake, which leads to three hypotheses we speci cally test here: H1. CONV communication is inversely and CONF communication is positively related to parental controlling feeding practices.
H2. Broader family factors such as parental fear of COVID-19 and family communication patterns are related more strongly to children's healthy and unhealthy food intake than the parental controlling feeding practices.
H3. Family communication and parental controlling feeding practices carry indirect effects between parental fear of COVID-19 and children's food intake.

Methods
Institutional Review Board from the University of California, Merced approved the study, which was conducted in compliance with ethical standards in the treatment of the participants between August 13, 2020 and August 21, 2020.

Participants
The study included 306 parents (51% fathers), satisfying common recommendations for sample size requirements [24], given 31 parameters and 8 variables in the structural equations modeling (SEM) of the proposed model. Eligibility requirements were participants being above 18 years of age and pro cient in English, residing in the US, and having at least one child between 5 and 12 years of age (Mean child age = 8.71, SD = 1.97). When a participant had more than one child, he or she was asked to select one child in the age range to complete the questionnaire. Demographic information is presented in Table 1. a Response to the question "when your child is at home, how often are you responsible for feeding him or her?"

Procedures
Participants were recruited using a Facebook snowball sampling method, which was selected because it provided easy access to the target population at a lower cost than alternatives [25]. Moreover, the number of cases detected by Facebook has found to be higher than the traditional snowball sampling method [26]. Participants saw threads on Facebook and clicked the link for the study, which led to the Google Survey form through which the study was administered.
To start, participants were presented with a description of the study and the informed consent. After indicating written consent, they answered questions online, using their smart phone or computer for approximately 20 -30 minutes. The rst 100 participants were compensated with a $10 Amazon e-gift card, and their remainder with a $5 card.

Measures
Fear of COVID-19 Parent's controlling feeding practices The parental controlling feeding practices with the child were assessed, using the Child Feeding Questionnaire [30], which is designed to assess seven dimensions. From these, three dimensions addressing controlling feeding practices were selected, including (1) monitor (3 items, e.g., "How much do you keep track of the sweets that your child eats?"), (2) restriction (5 items, e.g., "I have to be sure that my child does not eat too much of his or her favorite foods"), and (3) pressure to eat (5 items, e.g., "My child should always eat all of the food on his or her plate"). Responses were made on 5point scales, with anchors from "never" to "always" for the monitoring items and from "disagree" to "agree" for the restriction and the pressure to eat items. Items were subjected to a con rmatory factor analysis (CFA) (see Results) to con rm the item structure of these three dimensions and that they could indicate a latent variable of controlling feeding practices. Internal consistency was α = .81.

Child's dietary intake
Using items from the California Health Interview Survey Diet Screener [31], parents were asked about the child's dietary intake of two food categories commonly used to mark healthy intake (fruits and vegetables) and four used to mark unhealthy intake (juice, soda, sweets, and fast-food consumption). These are food categories commonly used in survey research to mark healthy and unhealthy diet intake [32,33,34]. Questions ask about the number of servings the child consumed yesterday for each food category, with responses ranging from "0" to "more than 8 servings." The exception was for fast-food consumption, for which the period was last week. Servings were self-de ned by parent and considered to be child's regular portion of the food. Items were subjected to CFA to con rm using them to measure the latent variables of healthy intake and unhealthy intake, respectively. Internal consistency for healthy food was α = .60 and unhealthy food α = .80.

Race/ethnicity
Participants indicated which one or more of eight racial/ethnic categories described the child from the following: American Indian or Alaska Native, Asian, Black/African American, Caucasian/White, Hispanic/Latino, Middle Eastern, Mixed and Multi-racial, or other race and ethnicity. Using the Census classi cation approach, the child was classi ed as Asian or Latino if so indicted, regardless of other racial/ethnic indication.

Statistical Analysis
IBM SPSS Statistics 20 was used for descriptive statistics and Mplus for SEM analysis. To assess the construct validity of the measurement models of the controlling feeding practices and child's healthy and unhealthy dietary intake categories, a series of CFA were conducted to establish them as latent variables. After ensuring the adequate t of the measurement models, three items from restriction, one item from pressure to eat, and two items from monitoring were included in the nal model to measure the latent variable of controlling feeding practices.
A SEM path analysis was conducted rst for the total sample. Subsequently, a multi-group SEM analysis was used with the father and mother subsamples. Child's gender was entered as a control variable in the path analysis. Additionally, the structural models of indirect effects of family communication and parental controlling feeding practices between parental COVID-19 fear and children's healthy and unhealthy food intake were tested using maximum likelihood estimation and a bias corrected bootstrapping procedure with 1000 iterations. The bootstrapping method can correct bias and thus give more accurate estimations [35]. The indirect effect is considered statistically signi cant if zero is not contained in the 95% con dence interval. Multi-group path analysis was completed also to test for fathers and mothers group differences in structural parameters of the indirect effect model.
To examine goodness of t of the model, the comparative t index (CFI), Tucker-Lewis index (TLI), and root mean square error of approximation (RMSEA) were assessed. Adequate t for parsimonious SEM has been identi ed as CFI ≥ 0.90, TLI ≥ 0.90, and RMSEA ≤ 0. 10 [36]. A value of α = 0.05 was set for statistical signi cance. Missing data was implemented under maximum likelihood estimation [37].

Results
Descriptive information about the participants is presented in Table 1 and for the study variables in Table 2. About the same proportion of fathers (69%) and mothers (66%) reported that they are responsible for feeding their child "about half the time" or more (Table 1). Independent samples t-tests indicated there was no signi cant differences between fathers and mothers reporting use of the family communication or controlling feeding practices patterns ( Table 2). Children were reported to consume approximately three servings a day for both fruits and vegetables. They were also reported to consume between two and three servings each of sweets, juice, and soda per day and three servings of fast-food per week. Correlations among variables as well as factor loadings for latent variable are presented in Table 3. All observed variables loaded signi cantly onto their respective latent factors of parental controlling feeding, child's healthy intake, and child's unhealthy intake based on the CFA (Table 3) and the resulting measurement models showed a close t. a Composite score of 7 items each ranged from "strongly disagree (1)" to "strongly agree (5)"; b Scores ranged from "strongly disagree (1)" to "strongly agree (5)" ; c Scores ranged from "disagree (1)" to "agree (5)"; d Scores ranged from "never (1)" to "always (5)"; e Scores ranged from "0/yesterday (0)" to "more than 8 servings/yesterday (8)"; f Scores ranged from "0/last week (0)" to "more than 8 servings/last week (8)"; *p < .05. Results from the path analysis tested with SEM on the total sample are shown in Figure 2. This resulted in a satisfactory t with the data (CFI = 0.92, TLI = 0.90, RMSEA = 0.07). Parental fear of COVID-19 was positively associated with both CONV and CONF family communication patterns but did not show association with either children's healthy or unhealthy food intake. Both CONV and CONF family communications were positively related to parental controlling feeding practices. While CONV communication was inversely related to children's unhealthy food consumption, CONF was positively associated with children's unhealthy dietary intake. Parental controlling feeding practices did not have associations with children's dietary intake. Table 4, both CONV and CONF family communications had signi cant indirect effects on children's unhealthy dietary intake. Speci cally, CONV family communication mediated between parental COVID-19 fear and children's unhealthy food intake in the negative direction whereas CONF family communication did in the positive direction. Note. CI = Con dence Interval.

Structural Model for Fathers and Mothers
The multi-group testing resulted in slightly reduced t (CFI = 0.89, TLI = 0.87, RMSEA = 0.08), which is typically due to the smaller sample size when sub-samples are tested. However, based on the satisfactory t from the total sample and RMSEA at 0.08, the multi-group model ts the data su ciently well that it should be informative to examine differences between fathers and mothers.
In the rst iteration of implementing the multi-group model, analysis of the mothers produced a non-signi cant negative residual variance for one observed variable (child's salad intake). This situation is common in SEM when there is little-to-no variation across individuals, and a solution is to x this variation to zero and remove the negative variance from the model [38]. With this adjustment, the model properly estimated all parameters. This multi-group analysis examined whether parameters differed signi cantly from zero and enabled us to explore differences in signi cant patterns between fathers and mothers.
As shown in Figure 2, both fathers and mother had the similar associations that their fear of COVID-19 is positively related to communication patterns, and communication patterns are also positively related to their controlling feeding practices. The notable difference was witnessed that only mothers' CONV communication pattern was negatively and mothers' CONF communication was positively linked to children's unhealthy eating. Also, as shown in Table 4, only mothers' CONV and CONF communication carried an indirect effect between COVID-19 fear and children's unhealthy food intake.

Discussion
The current study aimed to understand how parental fear of COVID-19, family communication patterns, parental controlling feeding practices, and children's dietary intake are associated according to a conceptual model among American families with young school-age children during the rst few months of the COVID-19 pandemic. We found signi cantly positive associations between parental fear of COVID-19 and both CONV and CONF family communication patterns. Both communication patterns in turn were positively associated with parental controlling feeding practices. Finally, CONV communication pattern was associated with reduced unhealthy food intake in children, while CONF communication was related to increased unhealthy food consumption. For the most part, these associations occurred for both mothers and fathers. But they differed in that fathers' communication patterns were not related to children's food intake, whereas mothers' CONV pattern was negatively and CONF pattern was positively associated with children's unhealthy food intake. Moreover, we found that COVID-19 fear among mothers was indirectly associated with children's unhealthy diet through a link with CONV and CONF communications, where speci cally more CONV communication and less CONF communication were associated with reduced food intake in children.
The consistently positive association between parental fear of COVID-19 and both types of family communication patterns revealed that when parents fear COVID-19 more, they are more likely to actively engage in communicating with their children in various ways. Past research identi ed families that are high in both CONV and CONF orientation as "consensual," which is characterized by a focus on each other's needs and wants [39]. In these families, while open discussion of a wide variety of topics is highly encouraged, each family member's feelings about those topics are ultimately aligned to be congruent with family beliefs and values [40]. Under the pandemic situations, we could argue that parents are very interested in their children's feelings and thoughts to ensure children adapt to the changing conditions. At the same time, parents have the nal say on the decisions and expect their children to follow their direction as a team to stay healthy and safe.
The nding that both CONV and CONF family communications were related to increased parental use of controlling feeding tactics was contrary to our Hypothesis 1, as we expected that CONV would inversely relate to parental controlling feeding. Although the COVID-19 has added a toll on families, it also had silver linings in that families spent more time together at home, providing opportunities to increase family bonds [41]. Some parents sought to provide structure in the meal environment as they shared meals more frequently with children [42]. It could be that parental controlling feeding practices of monitoring and restricting the discretionary food items and pressuring child to eat enough were of high value during the rst phase of the pandemic, at a time when parents may have felt the need to ensure their children's healthy development under abnormal, even threatening, circumstances.
Parents' controlling feeding practices are considered to hinder children developing their own food preferences and selfcontrol, resulting in children's worse diet quality [43,44,45]. Also, a recent meta-analysis concluded that pressure to eat overall had a signi cantly negative association with children's healthy intake while restriction had a negative association with unhealthy food intake [46]. However, our study did not nd signi cant direct or indirect effects involving parental controlling feeding practices on children's neither healthy nor unhealthy dietary intake. One potential explanation is that there are many other important factors in uencing child eating, depending on types of meals and snacks, family demographics such as number of siblings, cultural differences, and child food preferences that cannot be in uenced by speci c food-related practices.
While we did not nd signi cant effects involving parental controlling feeding practices, we found associations indicating two indirect effects through CONV and CONF communication. Speci cally, CONV communication negatively mediated whereas CONF communication positively mediated the relationship between parental COVID-19 fear and children's unhealthy food intake. The positive indirect effect through CONF communication to children's unhealthy food intake suggests that this type of rigid communication of expecting children to follow parents' direction may interfere with children's diet quality. Similarly, increased CONV communication, which emphasizes open and honest communication among family members, signi cantly correlated with children's decreased unhealthy food intake, suggesting that bi-directional communication and a positive interaction climate in the family and similar parenting behaviors may affect children's food intake [16]. Thus, this study suggests that broader family factors exert more in uence on children's diets than speci c foodfocused feeding practices, which was consistent with our Hypothesis 2.
Furthermore, we found no associations with children's healthy food intake, which could suggest that the in uences of parental and family factors are more salient on health-risk behaviors, such as unhealthy eating than on health-promoting behaviors, such as healthy eating [16]. Alternatively, families adopted more distinctive eating patterns around unhealthy food in general during the pandemic. Indeed, studies have reported that families were more likely to reach for snacks or comfort foods due to the increased availability when spending more time at home or in response to stress or boredom during this time [47,48].
The COVID-19 has opened the opportunity for fathers to become more involved in caretaking, and the majority of the current sample of fathers indicated that they were involved in the feeding of their child. Nonetheless, the multi-group analysis revealed that mother's communication patterns were more prominent correlates of children's unhealthy food intake. The father's COVID-19 fear was linked to CONV and CONF communication, which were also related to their controlling feeding practices, but neither was connected with children's eating behaviors. This pattern of ndings suggest that fathers contribute to the family emotional climate, but mothers are more likely to in uence children's diets through their communication pattern, as primarily mothers make decisions of grocery shopping, food preparation, or meal plan [49].

Limitations
Among limitations of this study is that the sample volunteered to participate in response to a Facebook thread. Given the focus of the study, many parents presumably volunteered because of interest in what the study addressed, possibly creating a biased sample that may not represent all parents. Our sample furthermore was over-represented with educated parents who had access to the internet, likely also limiting generalization. Moreover, the experience of the COVID-19 pandemic may differ depending on the infection rate and the government response in the location of the participants, which have varied considerably even within the United States. We were unable to examine such regional variations here. Finally, the causal relationships among the variables cannot be determined due to the observational study design. Notwithstanding these limitations, this is the rst study we are aware of that illuminates the potential mechanism how family dynamics may in uence children's dietary intake during the rst few months of the COVID-19 pandemic.

Conclusions
The COVID-19 pandemic has changed our lives deeply, and it will certainly linger in children's and parents' lives. Parents both knowingly and unknowingly share the family context in the household during stressful time. Therefore, we need to recognize that the burden of COVID-19 has on the multiple family dynamics including dietary intake. This argues for providing practical help to strengthen family coherence and resilience and promoting family well-being, which should create numerous positive cascades in family lives, including the food environment. Broad approaches to support parents to practice advanced parenting skills should be identi ed. More research, especially longitudinal studies, will help us better understand what constitutes optimal family food environments for children's health and well-being.

Declarations
Ethics approval and consent to participate: Institutional Review Board from the University of California, Merced approved the study, which was conducted in compliance with ethical standards in the treatment of the participants. Informed consent was obtained from all individual participants included in the study.