The identification of factors associated with weight status can optimize early intervention strategies to prevent childhood obesity. Recent studies have reported that demographic characteristics, such as children’s age [28], family environment [29], caregivers’ feeding behavior [12, 13, 30-33], and children's eating behavior [10] are closely related to children’s weight status. Furthermore, parental feeding practices are partially responsible for the relationship between children’s eating behaviors and their BMI. On the other hand, children’s eating behaviors explain part of the association between parental feeding behaviors and children’s BMI [13]. Our multiple linear regression and binary logistic regression analyses consistently showed that children’s weight status was associated with family demographic characteristics, children’s eating behavior, and caregivers’ feeding behavior.
3.1 Association between family demographic characteristics and children's weight status
Nowicka et al. examined the psychometric properties of the Child Feeding Questionnaire (CFQ) [34] and explored the relationship between parenting practices and children’s weight status in Sweden [35]. The results showed that children’s BMI and parents’ foreign origin had a direct impact on restriction, and the pressure to eat was also affected by parental educational level. In 2014, Moreira et al.[29] confirmed the association between children’s gender, children’s age, child-caregiver relationship, family economic status, and children’s weight status by analyzing the data collected from the CFQ and the OCCS(Overt and Covert Control Scale) using linear regression analysis. They reported that family environment and maternal socioeconomic factors were associated with the pressure to eat and perceived monitoring, while maternal health behavioral characteristics were associated with restriction. Rodenburg et al. also found that sociodemographic variables, such as the child’s ethnicity and the primary caregivers’ educational level, were correlated with psychological control and the child’s BMI [36]. Using the Child Eating Behaviour Questionnaire (CEBQ), Alshammary et al. found that obesogenic-eating behaviors were associated with excess weight in both children and parents [19].
In this study, the linear regression model showed that a child’s gender, his or her age, his or her caregivers’ educational level, and monthly household income were the main factors associated with BMI in children. BMI was higher in boys than girls. Higher caregiver educational level was associated with lower BMI values in children. These findings indicate that Chinese caregivers with lower monthly household incomes and higher educational levels are more likely to be concerned about childhood obesity. Their feeding practices were not associated with high BMI, indicating that these behaviors may reduce the risk of childhood obesity.
3.2 The association between caregivers’ feeding behavior and children's weight status
Childhood overweight/obesity has become a common concern in recent years. However, Branch et al. found that concerns were rarely translated into healthier family meal characteristics or feeding behaviors. Maternal concerns alone may not be sufficient to motivate actions to reduce the risks of childhood obesity [21]. In 2010, Webber et al. used CFQ to confirm the impact of maternal perceptions and concerns on the weight status of their children [20]. Also, Ma et al.[37] developed a Young Child Feeding Questionnaire (YCSQ) for 18-month-old infants and young children. The results obtained with use of this questionnaire showed that parental concerns about infants’ weight status were positively correlated with BMI-for-age z-scores (β=0.293, P=0.029). Consistently, we found that caregivers’ concerns about children’s weight status during feeding led to increased BMI, suggesting that these feeding behaviors may increase risk for childhood obesity.
In 2012, Cheah et al. conducted a CFQ survey on Chinese and Korean caregivers of children (3–8 years of age) in the United States. The results demonstrated the impact of feeding responsibility on a child’s weight status [38]. The authors found that caregivers’ feeding responsibility correlated negatively with children’s weight status and the occurrence of overweight/obesity. The stronger the caregivers’ sense of responsibility, the higher the chance that he/she would have healthy feeding behaviors, which may decrease a child’s BMI and reduce the risk of obesity.
3.3 Associations among caregivers’ feeding behavior, children’s eating behavior, and children's weight status
To organize various potentially overlapping constructs in the literature, Rodgers et al. conducted a principal components analysis in a sample of 2-year-old children to clarify a set of core independent constructs representing maternal feeding styles [18]. The authors found that weight-based restriction, encouragement to eat, emotional feeding, and restriction were positively correlated with the development of children’s obesogenic eating behaviors, including food approach behaviors (such as good appetite and enjoyment of food), tendency to overeat, and emotional eating. Moreover, Sleddens et al. stated that the use of snacks as a reward may increase the number of external factors related to eating for the child, and may affect the child's eating behaviors by increasing exposure to unhealthy snacks, leading to overeating and obesity in children [39]. Therefore, the authors advised parents not to use food to regulate children’s behavior or mood, and to encourage children's interest and curiosity in tasting different kinds of food. In the current study, the linear regression model showed a negative correlation between External Eating and BMI in children. The binary logistic regression also showed that children's Emotional Eating was negatively correlated with the occurrence of overweight/obesity, indicating that stimulate children's interest in tasting and eating different foods may promote the development of healthy eating behaviors in children, thereby reducing children's weight and decreasing the risk of obesity.
Stunkard et al.[40] used a three-factor dietary behavior scale (TFEQ) as a measurement tool and found that food response had a strong positive correlation with children’s BMI. Wu et al. used the Dutch version of the Adult Dietary Behavior Scale (DEBQ) in 1171 middle school students and reached the same conclusion [41]. Jansen et al. performed a cross-sectional study using the CEBQ and CFQ, and found that higher levels of parental restriction, children’s food responsiveness and enjoyment of food were associated with higher BMI values, independent of measured confounders [13]. Consistent with their findings, our results showed that children’s responsiveness to food was positively correlated with excessive dietary intake, which may lead to an increase in BMI and a higher risk of obesity.
Viana et al.[42] and Sleddens et al. [43] used CEBQ to evaluate the dietary behavior of a pediatric population (3–13 years of age) in Portugal and another pediatric population (6–7 years of age) in the Netherlands. The results obtained showed a strong negative correlation between children’s satiety response and their BMI. Jansen et al. also confirmed that children’s fussiness, children’s satiety responsiveness, and parents’ pressure to eat were negatively correlated with children’s BMI [13]. Our linear regression model did not incorporate Satiety Responsiveness. However, the binary logistic regression showed that children’s Satiety Responsiveness had a significant negative correlation with overweight/obesity, indicating that children with greater satiety responsiveness had better capacity to regulate food consumption, which may prevent an excessive increase in BMI and reduce the incidence of overweight/obesity.
Previous evidence has shown that not only insufficient parental control [44] but also parental over-control [45] contribute to children’s overweight/obesity status, as children are likely tempted to overeat in the obesogenic environment. Poor parental restriction [46-48] and monitoring [46] of children’s food intake were positively correlated with higher BMI values. Birch et al. stated that caregivers’ restriction of feeding may lead to unhealthy eating behaviors in children (Birch, 2008). Elford et al. used an adapted version of the CFQ to explore the impact of other key care providers on the weight and eating habits of children [49]. The results showed that a controlling maternal child-feeding style (e.g. restriction of certain food, the use of pressure to eat) was associated with fussy eating, overconsumption, and abnormal weight. Conversely, a responsive child-feeding style, whereby children were encouraged to eat different kinds of food, encouraged to try new tastes, and allowed to regulate their food intake, was associated with healthy eating styles and normal weight. Our results were not consistent with theirs. In the binary logistic regression model, Restriction Feeding was negatively correlated with the occurrence of overweight/obesity, indicating that a child showed healthy eating behaviors when a caregiver restricted his/her food consumption, and thus the risk of overweight/obesity was decreased.
We did not identify a relationship among caregiver feeding behaviors (e.g., Content-Restricted Feeding, Forced Feeding, Supervised Eating), children’s eating behaviors (e.g., Eating Habits, Initiative Eating), and children's BMI or overweight/obesity status. The influencing factors are complex, as dietary culture and feeding habits vary among regions, ethnicities, and family social environments. Another source of complexity is the diversity of caregivers’ feeding practices and children’s eating behaviors.
3.4 Limitations
This study had some limitations. First, the study participants may not have been representative of the entire population of preschool children in China, as we only recruited subjects from Jinan and Xi’an City. Secondly, the sample size was small. Thirdly, the current study was limited by its cross-sectional design. Longitudinal studies are necessary to determine the direction of causality. Also, the information pertaining to children’s eating behaviors was collected based on the subjective opinions of caregivers, which may have been confounded by reporting bias. Future investigations on other potential confounding factors will be needed.
3.5 Conclusions
In summary, this study comprehensively evaluates the relationships among demographic characteristics, caregivers’ feeding behavior, children’s eating behavior, and children’s weight status using regression analyses. Our results show that caregivers’ feeding behaviors and children’s eating behaviors are associated with children’s weight status and the occurrence of overweight/obesity in China, suggesting that the prevention of unhealthy overweight/obesity status among children may require behavioral changes on the parts of children as well as their caregivers. These findings provide reference information for the development of healthy feeding habits and the optimization of prevention and intervention strategies for the management of childhood obesity.