Healthcare providers can help: first, by identifying children that may be at risk because of key family environmental characteristics, and second, by encouraging parents to provide a healthy balance of good foods accompanied by the freedom of choice.
Eating Behavior Shaped by Parents
Researchers have long acknowledged the role of the family environment in shaping the development of problems with energy balance in children.1,2 Children exist as part of a parent-child, or caregiver-child relationship; parents are embedded in families, which are, in turn, embedded in communities, neighborhoods and social networks—all of which are influenced by broader societal and cultural norms.3 Thus, a number of proximal and distal sources of influence exist, and often work together to shape children's behavior.
The feeding relationship between caretaker and child is described as involving a series of shifts in the balance of power as the child develops.4 Infants rely solely on their caregivers for nourishment, and maintain a certain degree of control over the size and timing of meals. During the early childhood years, there is some reciprocity and shared control in feeding between the child and the caretaker. Children are able to voice their opinions about meal contents, as well as express feelings of hunger and fullness. This is also a time when children learn how to exercise autonomy over their food intake. Excess parental control may negatively affect children's development of self-regulatory behaviors.
What is Self-Regulation?
Self-regulation is the process of overriding an impulse, preventing it from taking its usual course.5 For example, self-regulation is in operation when a child sees a jar of cookies on the table, desires the cookies, but controls the urge to take one because she's not really hungry, or because she knows that she can have one after dinner.
Self-regulation is evident across several domains of development. Specific to the eating domain, self-regulation, or the control of food intake, contributes to the size and timing of meals. There is limited evidence that infants can regulate energy intake. Most infants can respond, however, to internal cues that signal hunger and satiety, subsequently signaling their caregiver to initiate or terminate the meal.6 What is unclear is the process by which some children move from being efficient energy intake regulators to poor regulators who no longer have primary control over the size and timing of their meals.
Three Ways Parents Influence Child Eating Behaviors
Parents attempt to socialize their children by acting as: 1) interactive partners, 2) direct instructors, and 3) providers of opportunities.7 (See sidebar, "Parental Roles Affecting Child Self-Regulation.") All three parental roles are interrelated and work together to affect children's socialization in the eating domain. Socialization is driven by the interplay of parental cognitions, genetics, context, culture, parent-child characteristics, parents' responses to children, and children's responses to parents.8
Parents as Interactive Partners
As interactive partners, parents communicate with children through direct contact, transmitting ideals and values through shared activities. In the context of child feeding, a parent may act as an interactive partner by conveying messages (either verbally or through modeling behaviors) about foods that are healthy, and foods that are considered "junk" foods.
Although several authors have speculated, the process by which children learn to make associations between weight and eating issues is yet to be understood. Findings reported by Thelen and Cormier (1995) show that prepubertal girls who reported higher levels of dieting perceived higher levels of pressure from their mothers (but not fathers) to lose weight.9 Girls' dieting behaviors included reports of being preoccupied with food and body weight concern. Parental pressure to lose weight took the form of talking about the child's weight, or encouraging the child to eat differently or exercise to lose weight. These verbal messages, which may be in tandem with controls over children's eating behavior, may promote the development of unhealthy eating behaviors. To the extent that parental messages about restricting children's intake are linked to messages about weight status, children may be receiving direct instruction about the links between eating and weight status.
Parents as Direct Instructors
As direct instructors, parents coach, oversee activities, manage activities and provide advice and support for children's activities and decisions. Parents may act as direct instructors by showing children how to maintain a healthy diet, pointing out healthier choices in the supermarket, and reinforcing children for making healthy food choices.
Several studies have documented parental influences on children's development of weight and eating-related issues. Cutting, Fisher, Grimm-Thomas and Birch (1999) examined relationships between the overeating styles of five-year-old girls and those of their mothers.10 Mothers reported the degree to which they themselves had a tendency to exhibit out of control eating. Girls were fed a standard meal, and after they indicated they were no longer hungry, they were given access to a large amount of snack foods for a 10-minute period; this procedure provided a measure of out-of-control eating. The results showed that mothers who reported overeating behaviors had daughters who exhibited similar eating styles. That is, mothers who were out-of-control eaters had daughters who ate more of the snack foods during the 10-minute period.
A study by Stice and colleagues (1999) investigated the risk of having a parent with a history of overweight and other eating and weight-related issues on the emergence of dieting in young children.11 Children were followed from infancy through age five. Results showed that parents who reported having high weight and eating related issues—including body dissatisfaction and an overeating style—reported their children practicing secretive eating behaviors by age five.
To determine why some parents are overly concerned about their children's weight, Francis, Hofer and Birch12 examined whether mothers who were more focused on their own weight and eating would be more controlling over their daughters' weight and eating. The results revealed that mothers who had weight and eating issues of their own were, indeed, more controlling over their daughters' intake. Thus, children who live in households where mothers are overly focused on weight and eating may be at risk for developing similar issues over time.
Parents as Providers of Opportunities
As providers of opportunities, parents either grant or restrict access to situations and opportunities for children's socialization and learning. A parent who limits a child's intake of certain foods, restricts a child's access to energy-dense snack foods, or provides healthier food choices in the home is acting as a provider of opportunities.
Conflicts between Children's Food Preferences and Dietary Guidelines. Parents are responsible for providing and choosing the foods that are brought into the home. It is likely that parents' food choices are based on their own and their children's food preferences. Thus, children who are exposed to these feeding environments are likely to learn to prefer those foods provided in the home.
Children have a natural preference for sugar, salt and fat, and tend to reject bitter tastes.13-15 Thus, children's preferences are often at odds with dietary guidelines, which recommend that children eat a variety of foods, and that children have a limited intake of sugars and fats.16 This poses a problem for parents, who are responsible for making sure that children meet dietary guidelines. Parents may often respond with controlling feeding strategies in attempts to bring children's diets into correspondence with dietary guidelines.
Controlling Child-Feeding Practices. In the child-feeding domain, parents are responsible for providing children with healthy food choices and opportunities to learn to respond to cues that affect energy balance and energy-intake regulation. However, controlling child feeding practices—in which parents either restrict a child's access to foods or pressure the child to eat more food—have been shown to hamper the child's development of healthy eating behaviors and to influence the development of eating styles that are disordered and promote overweight.17, 18
Negative and coercive feeding practices have been found to be related to problematic eating in young children.19, 20 In an experiment designed to investigate the effects of restrictive feeding practices on three-to-five-year-old children's consumption in an unrestricted setting, parents were asked to report the extent to which they limited their three-to-five-year-old child's access to 10 snack foods, including potato chips, pretzels, chocolate chip cookies and ice cream.21 Examples of limiting access included keeping the foods out of children's reach, offering the foods for special occasions only or never buying the foods at all. In addition, children were asked to report their perceptions of parents' attempts to limit their access to the 10 snack foods.
The findings showed that when children were given permission to eat as much of the snack foods as they wanted, children ate more of the "forbidden" snack foods when 1. parents reported restricting their child's access to these snack foods, and 2. when children reported their parents limiting their access to these foods. These results were only true for girls, however, not for boys. The authors concluded that even though parents did not report differences in their use of restriction based on the gender of their child, it is possible that girls respond differently to restriction than boys. In addition, although boys and girls may receive the same level of parental restriction, it is possible that the type of restriction that parents use (e.g. keeping food out of the home vs. having food present, but unavailable) may impact boys and girls in different ways.
In a related study, scientists measured children's eating in response to restricted access to a preferred food.22 Children were allowed to self-serve themselves two snack foods (wheat crackers and fish-shaped cheese crackers) during a 15-minute period. On some days, children had unlimited access to both crackers. On other days children had unlimited access to the wheat cracker and access to the fish-shaped cracker for only five of the 15 minutes. The "restricted" fish-shaped crackers were placed in clear containers in the middle of the table, where children could "look but not touch."
Results showed that when children were given access to the fish-shaped crackers after the period of restriction, they responded with more positive comments, requests for more and attempts to obtain the fish-crackers. These responses were much more favorable than the responses to the same food during unlimited access. These findings support the notion that attempts to strictly control children's energy intake may have adverse effects on children's development of healthy eating behaviors.
Birch and colleagues describe two major aspects of controlling child-feeding practices as 1. restriction of intake, and 2. pressure to eat.23 Restriction refers to the extent to which parents restrict their child's access to "unhealthy" foods, particularly the type and amount of energy-dense snack foods. Pressure to eat refers to parents' attempts to increase their child's intake by pressuring the child to eat more food, typically at mealtimes.
As in other domains of development, excessive control of children's eating may affect children's developing self-regulation. In an early experiment, Birch, McPhee, Shoba, Steinberg, and Krehbiel (1987) investigated the effects of external cues on eating in a group of two-to-five-year-old preschool children.24 Children participated in a series of snack trials, with the focus placed on either internal or external cues to control food intake. In the internal trials, children were encouraged to focus on their intrinsic cues to hunger and satiety, such as how their tummies felt. Children in the external trials were pressured to focus on external cues, such as the amount of food on their plates, or the rewards they could earn for cleaning their plates. Children were given either a high- or low-calorie drink, followed by a period of unlimited access to snack foods. One would expect that children with strong self-regulatory capacities would eat more snacks after drinking the low-calorie drink than they would after drinking the high-calorie drink.
Results revealed that children in the internal trials were better able to regulate energy intake by eating fewer snacks after drinking the high-calorie drink and more snacks after the low-calorie condition. In contrast, children in the external trials were driven by the rewards they could earn for cleaning their plates; these children increased their snack food intake regardless of whether they drank a low- or high-calorie drink.
This illustrates that while children can be responsive to internal cues that signal hunger and fullness, at least under some circumstances, child-feeding practices that focus on external, environmental features can shift this focus. Children's ability to self-regulate energy intake may be compromised when they are continually forced to pay attention to external, as opposed to their natural, internal cues to satiety. As a consequence, self-regulation failure in the eating domain may translate into problems with energy balance and overweight and the negative psychosocial outcomes associated with these problems.
Portion Size. Birch and Fisher suggest that the natural ability to compensate begins to diminish once children are continually exposed to large portion sizes.25 This change is most evident in a study conducted by Rolls, Engell, and Birch, who measured three-to-five-year-old children's intake of macaroni and cheese in two experimental conditions.26
Children were given three different portion sizes that were either the same as, smaller than or larger than the USDA-recommended serving size. Intriguingly, the younger children's consumption did not change while the older children's increased significantly when served the larger portions. Compared to the small portion, older children's caloric intake increased by about 1/3 when served the medium portion, and about 2/3 when served the large portion. These findings suggest that while younger children (ages two and three) have the ability to regulate their energy intake based on their physiological needs, children approaching the ages of four and five may have a compromised ability to self-regulate, which may be due to learning or conditioning over time.
In a similar study, Fisher and colleagues27 investigated the effects of repeated exposure to a large portion of macaroni and cheese on three-to-five-year-old children's intake. Results revealed that children ate approximately 25% more calories when served the large portion, compared to the age-appropriate serving size. (See sidebar, "Increased Intake with Large Portions.") What is notable, however, is that when children in this study were allowed to self-serve their entrée, intake was comparable to intake in the age-appropriate portion size condition. The authors concluded that by giving children the opportunity to choose how much they eat, while parents maintain control of what children are eating, children may be better able to self-regulate their energy intake.
Eating During Television Viewing. Parents also provide opportunities for their children to watch television, and to eat while watching television. A recent study suggests the possibility that children who are given opportunities to eat while watching television may become less sensitive to internal cues that signal hunger and fullness (Francis & Birch, in press). Preschool children ages three-to-five were served lunch under two different conditions: while talking freely over lunch, as they would normally do in their regular classrooms, and while watching a 22-minute cartoon video.
Results revealed that children ate less food while watching television than they ate in the situation in which the television was not present. In the TV- viewing condition, children were fixated on the television screen almost 95% of the time. However, children who were accustomed to eating while watching television at home, ate more when watching television in the laboratory, compared to the condition in which television viewing was not present. Because many children are eating a large proportion of their meals in front of the television, many opportunities arise for children's self-regulation of food intake to be compromised.28, 29
What is a Parent to Do?
Most parents endeavor to provide their children with the optimal environment for healthy growth
and development. They have the difficult task of providing the best nutrition for their children while offering opportunities for children to develop healthy eating behaviors, including the ability to respond to internal cues that signal hunger and fullness. Whether as a result of feeding practices used to alter children's eating behaviors, dietary patterns and food preferences that directly influence the types of foods children are eating and are exposed to, or eating styles that influence how children respond to the presence of foods, it is clear that parents can influence children's eating behavior.
Parents should be encouraged to provide healthy mealtimes for children: they should decide when and what to eat, while children decide how much and whether to eat. This division of responsibility provides parents with the level of control needed to provide the right foods to children and develop a meal, while ensuring that children have opportunities to develop their ability to self-regulate food intake.
In addition, parents should limit opportunities for children to eat while watching television. The American Academy of Pediatrics (AAP) recommends that children age two and under do not watch any television, and that children two years and over be limited to only two hours of television each day.30 Data from the National Longitudinal Survey of Youth show that infants and toddlers in the U.S. exceed the recommendations.31 Any activity that may distract children during eating may present a risk for poor self-regulation of energy intake, including under or overeating.
Parents' attempts to control their children's eating may be a way of coping with a toxic food environment in which energy-dense foods are abundant and highly accessible. Parents, however, should not bring children's attention to associations between food and weight. Rather, they should make connections between food and health to avoid the possibility that children may develop problematic weight-focused eating behaviors with age. They should respond to children's preferences by providing healthy alternatives to energy-dense foods, and by making these foods accessible. For example, cutting up fruit and providing healthy choices at each meal will increase the likelihood that children's diets measure up to dietary recommendations.
Finally, food should not be used as reward for good behavior or for eating healthier foods. Eating may be driven by the reward rather than children's hunger and fullness levels.
Conclusions and Implications
The good news is that children can relearn to self-regulate their energy intake, and can be trained to focus on internal cues to hunger and satiety. Over a six-week period, Johnson32 trained children at various self-regulatory capacities to respond to internal cues that signal hunger and fullness. Children were trained to focus on their feelings of hunger and fullness using dolls with detachable stomachs. The stomachs were three sizes to correspond to an empty, in-between and full stomach. Before and after snack times, children were encouraged to focus on how their stomachs felt, and were allowed to play with the dolls and to attach the stomach that felt like their own. Both over- and under-eaters responded to the training by improving their ability to self-regulate food intake. This holds promise for clinicians working with children who exhibit a diminished capacity to self-regulate food intake.
Taken together, scientific studies reveal that attempts to focus children's attention on external cues or parental prompts to eat may be counterproductive; children may develop problems responding to internal cues that signal hunger and fullness. Children in need of intervention may be identified through several family environmental characteristics, including parents' use of controlling feeding strategies, eating during television viewing, and parents' own problematic eating styles. Healthcare providers can help by encouraging parents to provide many opportunities for children to develop healthy eating behaviors. However, learning must begin early.
Lori Francis is a developmental scientist with expertise in early childhood influences on problematic eating behaviors and overweight. Her research has focused on factors within the immediate family environment that affect parental child-feeding strategies, children's self-regulation of energy intake and excessive weight gain throughout middle childhood. In addition, Dr. Francis has examined various links between parental overweight status and family food and activity environments.