BMJ Open · For peer review only Feeding styles, parenting styles and snacking behavior in school...

For peer review only

Feeding styles, parenting styles and snacking behavior in school age children: findings from a multi-ethnic population

Journal: BMJ Open

Manuscript ID bmjopen-2016-015495

Article Type: Research

Date Submitted by the Author: 20-Dec-2016

Complete List of Authors: Wang, Lu; Department of Public Health Van de Gaar, Vivian; Department of Public Health Jansen, Wilma; Gemeente Rotterdam Mieloo, Cathelijne; Gemeente Rotterdam van Grieken, Amy; Erasmus Medical Center, Public Health Raat, Hein; Erasmus Medical Center, Department of Public Health

<b>Primary Subject Heading</b>:

Public health

Secondary Subject Heading: Public health

Keywords: feeding style, parenting style, child snacking behavior, ethnicity

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Feeding styles, parenting styles and snacking behavior in 1

school age children: findings from a multi-ethnic population 2

L Wang1, VM van de Gaar

1, W Jansen

1,2, CL Mieloo

1,3, A van Grieken

1, H Raat

1* 3

4

1 Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands 5

2 Department of Social Development, City of Rotterdam, Rotterdam, the Netherlands 6

3 Municipal Public Health Service Rotterdam Rijnmond, Rotterdam, Netherlands 7

8

9

*Corresponding author: Hein Raat 10

Erasmus University Medical Center 11

Department of Public Health 12

PO Box 2040 13

3000 CA Rotterdam 14

The Netherlands 15

Telephone: +31615127884 16

E-mail: [email protected] 17

18

Shortened Title : 19

Parental feeding and child snacking 20

Word count: 3147 21

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Abstract 22

Objective: The aim of the present study was to investigate whether feeding styles and parenting 23

styles are associated with children’s unhealthy snacking behavior and whether the associations 24

differ according to children’s ethnic background. 25

Method: Cross-sectional data from the population-based ‘Water Campaign’ study were used. 26

Parents (n=644) of primary school children (6 to 13 years) completed a questionnaire covering 27

socio-demographic characteristics, feeding styles (‘control over eating’, ‘emotional feeding’, 28

‘encouragement’ and ‘instrumental feeding’), parenting styles (‘involvement’ and ‘strictness’), 29

and children’s unhealthy snack intake. Logistic regression analyses were performed to determine 30

whether feeding styles and parenting style were associated with children’s unhealthy snacking 31

behavior. 32

Result: Over all, children whose parents with a higher extent of ‘control over eating’ had a lower 33

odds of eating unhealthy snacks more than once per day (odds ratio [OR], 0.57; 95% CI: 0.42 to 34

0.76). Further stratified analysis shows that ‘control over eating’ was associated with less 35

unhealthy snack consumption only in children with a Dutch (OR, 0.37; 95% CI: 0.20 to 0.68), or 36

a Moroccan/Turkish (OR, 0.44; 95% CI: 0.25 to 0.77) ethnic background. ‘Encouragement’ was 37

associated with a lower odds of eating unhealthy snacks every day in children with a Dutch 38

ethnic background only (OR, 0.48; 95% CI: 0.25 to 0.90). ‘Instrumental feeding’ was associated 39

with a higher odds of eating unhealthy snacks more than once a day in children with a 40

Moroccan/Turkish ethnic background only (OR, 1.43; 95% CI: 1.01 to 2.04). 41

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Conclusion: Our results suggest that ‘control over eating’ may be associated with less unhealthy 42

snack consumption in children. The associations of feeding styles and parenting styles with 43

children’s unhealthy snacking behavior differ between children with different ethnic background. 44

Keywords: feeding styles, parenting styles, child snacking behavior, ethnic background. 45

Strengths and limitations 46

• Our data were collected from an ethnically diverse study population. 47

• Validated questionnaires were used to measure feeding styles and parenting styles, which 48

allowed comparisons with other studies. 49

• We relied on parents’ self-reports for the child’s snack consumption, social desirability and 50

recall bias are possible. 51

• This study does not allow firm conclusions with regard to causality, due to the observational 52

nature of cross-sectional design. 53

Introduction 54

A high intake of unhealthy snack foods – i.e. snack foods high in fat, sugar and salt but low in 55

micronutrients – is known to have adverse health outcomes (e.g. obesity, metabolic syndrome 56

and dental caries).1-4

Among children, the consumption of unhealthy snack foods has increased 57

largely over the past four decades.5 According to the Netherlands’ national food consumption 58

survey 2007-2010, children aged 7 to 12 years ate an average of 3.3 energy-dense snack foods a 59

day, with 90% of children consuming more energy from unhealthy snack foods than is 60

recommended (837 to 1255 kJ per day).6 Given that snacking habits are established during 61

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childhood and often persist into adulthood 7, snacking of unhealthy food should be discouraged 62

at an early age. 63

Parents play an important role in shaping children’s eating behaviors, through food 64

provision,8 parental modeling,

9 as well as through feeding styles and parenting styles,

10 Parental 65

feeding styles, such as ‘control over eating’ (controlling the child’s food intake),11 12

and 66

‘encouragement’ (encouraging the child to eat a variety of foods)12 13

have been associated with a 67

lower unhealthy snacks intake. While ‘instrumental feeding’ (using food as a reward) and 68

‘emotional feeding’ (offering food to soothe the child’s negative emotions) have been associated 69

with a higher unhealthy snacks intake among children.11-13

Parenting style can be defined as a 70

constellation of attitudes and beliefs towards the children that create an emotional climate in 71

which parents’ behaviors are expressed.14

In general, authoritative parenting style characterized 72

by high involvement and high strictness is associated with healthier dietary behaviors for the 73

child,10 15-17

including lower unhealthy snack intake.18

74

To date, only limited researches have investigated the associations of feeding style and 75

parenting style with children’s unhealthy snacking behavior, and the majority of them have 76

focused on native European populations.11-13 18

According to previous researches and the 77

socioecological model of health behaviors, the adoption as well as the impact of parental feeding 78

practices and parenting styles may differ by ethnic groups.19-25

We therefore hypothesized that 79

the associations of feeding styles and parenting styles with children’s unhealthy snacking 80

behavior are different for children with different ethnic backgrounds. To our best knowledge, 81

few studies have investigated whether feeding styles and parenting styles have differential 82

impact on children’s unhealthy snacking behavior between ethnic groups. With regard to the 83

development of interventions in diverse populations, it is important to study the differential 84

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influence of feeding styles and parenting styles on children’s unhealthy snack consumption in 85

each ethnic sub-groups separately. 86

Therefore, the aim of the present study was to determine whether feeding styles and 87

parenting styles are associated with children’s unhealthy snacking behavior, and whether the 88

associations differ according to the child’s ethnic background. 89

Materials and Methods 90

Study population 91

Our cross-sectional study used data from the population-based ‘Water campaign’ study.26

This 92

controlled trial assessed the effects of a combined school and community-based intervention on 93

children’s sugar sweetened beverages consumption. Four primary schools located in multi-ethnic 94

neighborhoods in Rotterdam, the Netherlands, were included in the study; two schools were 95

included as intervention schools, two schools were included as control schools. Intervention and 96

control schools were matched on number of pupils, socio-economic status and overweight 97

prevalence. The included schools resulted from a convenience sample of schools participating in 98

a municipal overweight intervention program. Only schools in socially more deprived 99

neighborhoods were eligible for this intervention.26

100

At the participating schools, all children in grades 2 to 8 (1288 children, aged 6 to 13 101

years) were invited to participate. Parents (and children) were informed about the intervention 102

and study participation and were free to refuse participation without giving any explanation. 103

Measurements were performed at baseline and after one year, using questionnaires (child and 104

parental) and observations at school. For the present study, data from the baseline parental 105

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questionnaire (administered March/April 2011) was used. A study population of 644 children 106

was available for analyses. 107

Measures 108

Socio-demographic characteristics 109

The socio-demographic characteristics of the child were assessed using the parental 110

questionnaire. The child’s ethnic background was based on the country of birth of the parents, 111

according to definitions given by Statistics Netherlands.27

The child’s ethnic background was 112

Dutch only if both parents had been born in the Netherlands; if one of the parents had been born 113

in another country, then the ethnic background of the child was defined according to that country. 114

If both of the parents had been born in other countries, the ethnic background of the child was 115

defined according to the mother’s country of birth.27

The ethnic background of the child was 116

categorized as Dutch, Surinamese/Antillean, Moroccan/Turkish, or other.26

117

Respondents were either the father or the mother of the child, and parental gender was 118

based on this item (male/female). Parental age (years) and educational level were also reported. 119

According to the standard Dutch cut-off points, the educational level of the responding parents 120

was categorized as ‘low’ (no education; primary school; ≤ 3 years of general secondary school); 121

‘mid-low’ (>3 years of general secondary school); ‘mid-high’ (higher vocational training; 122

undergraduate programs); or ‘high’ (higher academic education).28

123

Weight status of the child 124

The child’s height and weight were measured in light clothing without shoes by trained 125

personnel and according to the Youth Health Care protocol.29

The child’s body mass index (BMI) 126

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was calculated as weight/(height).2 Children’s weight status were categorized as being ‘non-127

overweight’, ‘overweight’ or ‘obese’ based on the BMI cut-off points published by the 128

International Obesity Task Force.30

129

Feeding style 130

The validated Dutch version of the Parental Feeding Style Questionnaire (PFSQ)31

was used to 131

assess the four feeding style dimensions: ‘control over eating’ (10 items), ‘emotional feeding’ (4 132

items), ‘instrumental feeding’ (5 items) and ‘encouragement’ (8 items). Parents were asked to 133

respond on a five-point Likert scale ranging from ‘never’ (1 point) to ‘always’ (5 points). 134

Average scores on each scale were calculated when less than half of the items in that scale were 135

missing. For each dimension, less than 2% of the scores were missing (Table 2). A higher score 136

indicated a greater tendency for parents to apply a specific feeding style. In the present study, the 137

Cronbach’s α was 0.78 for the ‘control over eating’ scale, 0.87 for ‘emotional feeding’, 0.79 for 138

‘instrumental feeding’ and 0.77 for the ‘encouragement’ scale. 139

Parenting style 140

The validated Dutch version of the Steinberg parenting style instrument32-34

was used to measure 141

the two parenting styles dimensions: ‘involvement’ and ‘strictness’. The ‘involvement’ scale 142

contains nine items that assess indicators of parental loving, responsiveness, and involvement. 143

The ‘strictness’ scale contains six items that asses parental monitoring and supervision of the 144

child. Parents were asked to respond to each item on a five-point Likert scale ranging from 145

‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). Average scores on each scale were 146

calculated when less than half of the items in that scale were missing. For each dimension, less 147

than 2% of the scores were missing (Table 2). Based on the median split of both scales,33

four 148

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parenting styles were further defined: authoritative (high involvement and high strictness), 149

authoritarian (low involvement and high strictness), indulgent (high involvement and low 150

strictness), and neglectful (low involvement and low strictness). 151

Snacking behavior of the child 152

Two items in the parental questionnaire were used to assess the unhealthy snacking behavior of 153

the children. Unhealthy snacks were defined as energy-dense nutrient-poor foods eaten between 154

the three main meals in the present study. Parents were provided with the following examples of 155

unhealthy snacks: crisps, nuts, chocolate, mars bars, pastry, iced cake, ice cream, pizza, 156

meatballs, and burgers. The first question asked the parents to indicate how many days in a 157

normal week the child ate unhealthy snacks (answer categories: ‘every day’ and ‘not every day’). 158

The parent was also asked to report the frequency of eating unhealthy snacks for the child on 159

such a day. The response categories ranged from ‘none’, ‘1 per day’ to ‘5 or more per day’, 160

which were dichotomized into ‘≤1 snack per day’ and ‘>1 snack per day’ in the statistical 161

analysis. 162

Statistical analysis 163

Descriptive statistics were used to present the demographic characteristics of the children and the 164

responding parents. Differences in demographic characteristics between subgroups according to 165

the child’s ethnic background were compared using ANOVA or Kruskal-Wallis test for 166

continuous variables and Chi-square test for categorical variables. 167

Logistic regression analyses were used to investigate whether feeding styles and 168

parenting styles were associated with the child’s unhealthy snacking behavior. Unhealthy 169

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snacking behavior of the child was assessed using two variables: eating unhealthy snack every 170

day (yes/no), and snacking frequency per day (≤1 or >1 per day). Separate logistic regression 171

models were built for each dimensions of feeding style and parenting style, adjusted for potential 172

confounders. In order to select potential confounders, we used logistic regression to examine the 173

associations of the child’s unhealthy snacking behavior, and general linear regression to examine 174

the associations of feeding styles and parenting styles. Factors were considered as potential 175

confounders if they were associated with both the child’s unhealthy snacking behavior and any 176

of the dimensions of feeding styles and parenting styles. 177

To examine whether the associations between feeding styles, parenting styles and the 178

child’s unhealthy snacking behavior differed according to the child’s ethnic background, an 179

interaction term of the independent variable with the child’s ethnic background was added to the 180

models. The interaction term was considered significant at a level of p<0.10.35

In Table 3, the 181

significant interaction terms are shown, 3 out of 12 interaction terms were significant (p<0.10). 182

The previous logistic regression models were then repeated for subgroups of children with a 183

Dutch, Surinamese/Antillean, Moroccan/Turkish, and other ethnic background respectively. 184

Assuming a random missing pattern of our data, complete–subject analysis were chosen to 185

handle the missing values.36

All analyses were conducted using the statistical software SAS 186

(version 9.3, SAS Institute Inc, Cary, NC, 2010). 187

Results 188

Characteristics of the study population 189

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The characteristics of the children and parents are shown in Table 1, which presents data from 190

the overall sample as well as for each ethnic background. The mean age of the children in our 191

study was 9.4 (SD 1.8) years; 45.9% of them were boys and 30.3% had a Dutch ethnic 192

background. Based on the parents’ report, 14.6% of the children ate unhealthy snacks on a daily 193

basis, and 29.7% ate unhealthy snacks more than once a day. The mean age of the responding 194

parents was 37.9 (SD 7.4), 87.4% of them were mothers, and 18.5% indicated having completed 195

a high level of education. 196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

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Table 1. Characteristics of children and parents in the overall sample and according to the ethnic 216

background of the child (n=644) 217

Overall

sample

(n=644)

Dutch

(n=195)

Surinamese/

Antillean

(n=142)

Moroccan/

Turkish

(n=186)

Other ethnic

background

(n=121)

p-

value*

Child characteristics

Age, mean (SD) (missing, n=6) 9.4 (1.8) 8.7 (1.8) 9.4 (1.8) 9.6 (1.5) 10.4 (1.6) <0.001

Gender, Girl, n (%) (missing

n=12)

342 (54.1) 107 (55.2) 76 (53.9) 89 (50.0) 70 (58.8) 0.50

Overweight or obese†, n (%)

(missing n=45)

138 (23.0) 25 (13.8) 35 (26.1) 54 (31.8) 24 (21.1) 0.002

Unhealthy snacks every day, n

(%) (missing n=12)

92 (14.6) 32 (16.8) 20 (14.2) 21 (11.4) 19 (16.2) 0.45

Unhealthy snacks per day, n (%) (missing n=17) 0.37

>1 time per day 186 (29.7) 55 (28.8) 37 (26.1) 56 (30.4) 38 (32.8)

Parental characteristics

Gender, Female, n (%) (missing

n=47)

522 (87.4) 166 (88.8) 127 (94.8) 140 (82.4) 89 (84.0) 0.007

Age, mean (SD) (missing, n=6) 37.0 (8.9) 37.3 (8.6) 36.7 (7.7) 36.4 (9.4) 37.6 (10.0) 0.66

Education level of the parent (missing n=21) <0.001

Low 137 (22.0) 20 (10.6) 16 (11.4) 75 (41.2) 26 (23.2)

Mid-low 156 (25.0) 58 (30.7) 33 (23.6) 46 (25.3) 19 (17.0)

Mid-high 215 (34.5) 61 (32.3) 66 (47.1) 45 (24.7) 43 (38.4)

High 115 (18.5) 50 (26.5) 25 (17.9) 16 (8.8) 24 (21.4)

* p-value derived from Chi-square test (categorical variables) or ANOVA (continuous variables). 218

† Weight status of the child was categorized according to the BMI cut-off points published by the International Obesity Task 219

Force. 220

Over all, the scores for all the feeding style dimensions and parenting style dimensions 221

were different between the ethnic groups (p<0.05) (Table 2). Parents of children with a Dutch 222

ethnic background reported using the highest levels of “control over eating”, and 223

“encouragement”, but the lowest levels of “instrumental feeding” and “emotional feeding”(post 224

hoc analysis, p<0.05). Parents of children with a “Surinamese/Antillean” background had similar 225

levels of “encouragement”, “ instrumental feeding”, and “emotional feeding” with parents of 226

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children with a Dutch ethnic background, but a lower level of “control over eating” (post hoc 227

analysis, p<0.05). While parents of children with a “ Moroccan/Turkish” ethnic background 228

reported using the highest levels of “instrumental feeding” and “emotional feeding” (post hoc 229

analysis, p<0.05). 230

Table 2 Average scores on feeding style dimensions and parenting style dimensions according to children’s 231

ethnic background (n=644) 232

Dutch

(n=195)

Surinamese/Antillean

(n=142)

Moroccan/Turkish

(n=186)

Other ethnic

background

(n=121)

P-

value*

n mean(SD) n mean(SD) n mean(SD) n mean(SD)

Feeding style dimensions

Control over

eating

192 4.03(0.55) 142 3.72(0.63) 183 3.76(0.58) 116 3.56(0.72) <0.001

Emotional

feeding

191 1.58(0.66) 142 1.58(0.60) 184 2.02(0.87) 116 2.03(0.94) <0.001

Encouragement 192 3.86(0.62) 141 3.80(0.69) 184 3.74(0.66) 116 3.72(0.67) 0.03

Instrumental

feeding

191 1.93(0.78) 142 1.90(0.77) 183 2.56(0.91) 116 2.28(0.93) <0.001

Parenting style dimensions

Involvement 190 4.58(0.33) 142 4.65(0.36) 180 4.55(0.42) 115 4.48(0.51) 0.02

Strictness 186 4.58(0.58) 139 4.52(0.63) 180 4.50(0.57) 115 4.41(0.71) 0.03

*The difference in the level of scores on each feeding style and parenting style dimension between ethnic groups, 233

was compared using Kruskal-Wallis test. 234

Associations between feeding styles, parenting styles and snacking 235

behavior of children 236

Table 3 presents the associations between feeding styles, parenting styles and parent-reported 237

unhealthy snacking behavior of the children. With regard to feeding styles, children whose 238

parents with a higher score on ‘control over eating’ had a lower odds of eating unhealthy snacks 239

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every day (OR 0.63; 95% CI :0.44 to 0.91), and of eating unhealthy snacks more than once per 240

day (OR 0.57; 95% CI :0.42 to 0.76). With regard to parenting styles, no significant association 241

was observed for neither the ‘involvement’ nor the ‘strictness’ dimension with children’s 242

unhealthy snacking behavior in the overall population. Children of parents with an ‘indulgent’ 243

parenting style were less likely to eat unhealthy snacks every day (OR 0.25; 95% CI :0.09 to 244

0.73), compared to children with authoritative parents. 245

Table 3. Results of the logistic regression analyses for the associations of the feeding styles and parenting 246

styles with children’s unhealthy snacking behavior (n=644) 247

Eating unhealthy snacks every day

(Yes vs No)

Unhealthy Snacks frequency per day

(>1 vs ≤1)

Variables Unadjusted *

Adjusted † Unadjusted *

Adjusted

†

OR (95% Cl) OR (95% Cl) OR (95% Cl) OR (95% Cl)


Control over eating

0.63(0.45, 0.88) 0.63(0.44, 0.91) 0.54(0.41, 0.71) 0.57(0.42, 0.76)

Emotional feeding 0.92(0.69, 1.23) 0.95(0.69, 1.30) 1.24(1.01, 1.53) 1.18(0.93, 1.48)

Encouragement 0.80(0.57, 1.11) 0.73(0.52, 1.04) 0.87(0.67, 1.13) 0.97(0.73, 1.28)

Instrumental feeding 0.92(0.71, 1.19) 0.92(0.69, 1.22) 1.10(0.90, 1.33) 0.99(0.80, 1.23)


Involvement 0.56(0.33, 0.93) 0.60(0.35, 1.04) 0.68(0.45, 1.04) 0.78(0.50, 1.21)

Strictness 1.23(0.83, 1.82) 1.43(0.92, 2.21) 0.80(0.61, 1.05) 0.89(0.66, 1.20)

Parenting style categories

Authoritative ref ref ref ref

Authoritarian 1.14(0.57, 2.27) 1.10(0.53, 2.28) 1.20(0.68, 2.11) 1.31(0.72, 2.38)

Indulgent 0.26(0.09, 0.76) 0.25(0.09, 0.73) 0.90(0.51, 1.60) 0.87(0.48, 1.56)

Neglectful 0.94(0.57, 1.57) 0.84(0.48, 1.46) 1.33(0.89, 1.98) 1.21(0.78, 1.87)

* Results from separate logistic regression models for each independent variable, without adjusting for potential 248

confounders. 249

† Results from separate logistic regression models for each independent variable, adjusted for the child’s age, weight 250

status, ethnic background, and the responding parent’s education level. 251

Note: numbers printed in bold represent a significant association at p<0.05 between the independent variable and 252

daily snack consumption. 253

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Analyses according to ethnic background of the child 254

Table 4 shows the associations of feeding styles and parenting styles with children’s unhealthy 255

snacking behavior according to ethnic background of the children. With regard to feeding styles, 256

a higher score on the ‘control over eating’ was associated with a lower possibility of eating 257

unhealthy snacks every day in children with a Dutch ethnic background (OR 0.41; 95% CI: 0.21 258

to 0.79), and children with a Moroccan/Turkish ethnic background (OR 0.40; 95% CI: 0.19 to 259

0.88). A higher score on the ‘encouragement’ was also associated with lower possibility of eating 260

unhealthy snacks every day in children with Dutch ethnic background only (OR 0.48; 95% CI: 261

0.25 to 0.90). In addition, a higher score on the ‘control over eating’ was associated with a lower 262

possibility of eating unhealthy snacks more than once per day in children with a Dutch ethnic 263

background (OR 0.37; 95% CI: 0.20 to 0.68), a Moroccan/Turkish ethnic background (OR 0.44; 264

95% CI: 0.25 to 0.77). Finally, ‘instrumental feeding’ was associated with a higher possibility of 265

eating unhealthy snacks more than once per day in children with a Moroccan/Turkish ethnic 266

background only (OR 1.43; 95% CI: 1.01 to 2.04). 267

With regard to parenting styles, a higher score on the parental ‘involvement’ was 268

associated with a lower possibility of eating unhealthy snacks every day in children with an 269

‘other’ ethnic background (OR 0.21; 95% CI: 0.08 to 0.59). Children with an ‘other’ ethnic 270

background whose parents with an ‘neglectful’ parenting style were more likely to eat unhealthy 271

more than once a day (OR 2.78; 95% CI :1.05 to 7.33) compared to children with authoritative 272

parents. 273

Table 4. Results of the logistic regression analyses for the associations of feeding styles and parenting styles 274

with children’s unhealthy snacking behavior, stratified by child ethnic background 275

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Dutch

n=195

Surinamese/ Antillean

n=142

Moroccan/ Turkish

n=186

Other ethnic

background

n=121

OR (95% CI) †

OR (95% CI) †

OR (95% CI) †

OR (95% CI) †

Eating unhealthy snacks every day


Control over eating

0.41(0.21, 0.79) 1.17(0.52, 2.64) 0.40(0.19, 0.88) 0.66(0.33, 1.31)


Encouragement 0.48(0.25, 0.90) 1.17(0.56, 2.47) 1.05(0.52, 2.11) 0.71(0.35, 1.45)



Involvement* 1.00(0.32, 3.17) 1.74(0.39, 7.86) 0.51(0.18, 1.41) 0.25(0.09, 0.67)

Strictness* 2.04(0.86, 4.85) 2.60(0.84, 8.09) 0.92(0.41, 2.06) 0.67(0.35, 1.29)

Parenting style category*

Authoritative Ref Ref Ref Ref

Authoritarian 1.25(0.48, 3.22) 0.58(0.07, 5.16) 1.77(0.31, 10.09) 0.49(0.05, 4.54)

Indulgent -‡ 0.20(0.03, 1.66) 1.55(0.34, 6.99) -

‡

Neglectful 0.53(0.20, 1.40) 0.31(0.08, 1.18) 2.01(0.68, 6.51) 2.33(0.74, 7.33)

Unhealthy snacks >1 times per day


Control over eating 0.37(0.20, 0.68) 1.02(0.56, 1.85) 0.44(0.25, 0.77) 0.44(0.24, 0.79)


Encouragement 0.64(0.38, 1.02) 0.97(0.56, 1.67) 1.20(0.73, 1.96) 0.74(0.41, 1.32)



Involvement* 1.26(0.48, 3.29) 0.88(0.31, 2.49) 0.65(0.31, 1.37) 0.45(0.20, 1.02)

Strictness* 1.13(0.64, 2.00) 0.77(0.43, 1.38) 0.83(0.48, 1.44) 0.58(0.33, 1.00)

Parenting style category*


Authoritarian 1.79(0.77, 4.14) -2

1.15(0.35, 3.75) 0.94(0.21, 4.14)

Indulgent 0.97(0.35, 2.68) 0.83(0.27, 2.61) 0.46(0.14, 1.51) 2.68(0.67, 10.73)

Neglectful 0.64(0.28, 1.48) 1.03(0.44, 2.44) 1.62(0.79, 3.33) 2.78(1.05, 7.33)

*Interaction term between ethnic background of the child and the noted independent variable was significant (p<0.10) 276

† Results from separate logistic regression model adjusted for the child’s age and weight status, and the parent’s 277

education level. 278

‡ Not available due to low sample size in these groups (see supplemental Table S1.) 279

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Note: numbers printed in bold represent a significant association between the independent variable and unhealthy 280

snacking behavior of the child. 281

Discussion 282

In this study, we investigated the associations of feeding styles and parenting styles with 283

unhealthy snack consumption in school-aged children from a multi-ethnic population. Our results 284

suggest that ‘control over eating’ was associated with lower unhealthy snack consumption of the 285

child, and that the associations of feeding styles and parenting styles with children’s unhealthy 286

snack consumption differed according to the ethnic background of children. 287

In line with previous studies, the present study found that children whose parents with a 288

higher level of ‘control over eating’ had a lower unhealthy snack consumption.11-13

Further 289

stratified analysis showed that ‘control over eating’ was associated with lower unhealthy snack 290

consumption in most of the ethnic groups, excepted for the group of children with a 291

Surinamese/Antillean ethnic background. Our results in line with previous studies suggest that 292

parental control may play an important role to facilitate healthy snacking behavior of children. 293

The lack of association in the Surinamese population might be due to the relatively lower level of 294

“control over eating”, and a more traditional dietary pattern which contains lower unhealthy 295

snack food in this population.37

296

In the present study, ‘encouragement’ was associated with a lower unhealthy snack 297

consumption only in the group of children with a Dutch ethnic background. It is possible that the 298

association between ‘encouragement’ and lower unhealthy snack consumption only exist when 299

parents provide the child with more healthy food instead of unhealthy snack food. Further studies 300

examining the association between parental encouragement to eat and children’s unhealthy snack 301

consumption should consider the potential influence of food provision into account. 302

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Previous researches suggested that ‘emotional feeding’ and ‘instrumental feeding’ were 303

positively associated with children’s unhealthy snack intake.11-13

While in our study, the 304

associations of ‘instrumental feeding’ and ‘emotional feeding’ with children’s unhealthy snack 305

intake only existed in children with a “ Moroccan/ Turkish” background and children with an 306

“other” background. In addition, our study suggest that parents of children with a 307

“Moroccan/Turkish” background were more likely to apply “instrumental feeding” and 308

“emotional feeding”. It has been indicated that parents mainly offer unhealthy snack food in the 309

context of emotional and instrumental feeding practices.38

Moreover, using snacks as a reward 310

may increase children’s preference for the rewarding snack.39

Higher exposure together with 311

increased preference for the unhealthy snack food may contribute to an increased risk of high 312

unhealthy snack intake among children. Therefore, further interventions should discourage the 313

use of “instrumental feeding” and “emotional feeding” in parents of children with a 314

“Moroccan/Turkish” background. 315

Although previous studies suggested that an authoritative parenting style was associated 316

with lower unhealthy snack consumption of children, we found no association between parenting 317

style and children’s unhealthy snack consumption in most of the ethnic groups. The lack of 318

association in most of the ethnic groups might be due to the low variability on the scores of both 319

“involvement” and “strictness” dimension among parents. While in the group of children with an 320

‘other’ ethnic background, a ‘neglectful’ parenting style which characterized by low 321

“involvement” and low “strictness” was associated with a higher unhealthy snack consumption. 322

The result in the group of children with an ‘other’ background is consistent with previous 323

researches.16 18

324

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Our study suggests that the associations of feeding styles and parenting styles with child 325

unhealthy snack consumption differed according to the ethnic background of the child. 326

Differences in parental beliefs, knowledge practices (e.g.: modeling, food provision) between 327

ethnic groups19 21

may contribute to the differential associations in the present study. We 328

recommend that further qualitative and quantitative studies to be done to gain more insight in 329

ethnic-group differences in associations between feeding styles and children’s snacking behavior. 330

Increased understanding maybe helpful in developing tailored interventions for reducing 331

unhealthy snack consumption in different ethnic groups. 332

The main strengths of our study include the ethnically diverse study population, which 333

enabled us to analyze the moderation effect of ethnicity on the associations of feeding style and 334

parenting style with children’s unhealthy snacking behaviors, and the use of validated 335

questionnaires, which allowed comparisons with other studies. Several limitations of this study 336

should be noted. Firstly, as we relied on parents’ self-reports for the child’s snack consumption, 337

social desirability and recall bias are possible. Parental reports have shown to be an accurate 338

method to estimate dietary intake in school aged children.40

However, further studies may 339

include a combination of parental report, child report and observational measures to estimate 340

snacking behavior. Secondly, given the observational nature of cross-sectional design, this study 341

does not allow firm conclusions with regard to causality. 342

Conclusion 343

Our results suggest that ‘control over eating’ may be associated with less unhealthy snack 344

consumption in children. The associations of feeding styles and parenting styles with children’s 345

unhealthy snacking behavior differ between children with different ethnic background. However, 346

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due to the limitations of cross-sectional design, future longitudinal studies with larger sample 347

sizes are recommended. In the meantime, to improve the effectiveness of interventions focusing 348

on parenting behaviors to reduce unhealthy snacking of children, developers should take into 349

account the potential role of children’s ethnic background. 350

Contributors 351

HR and WJ had the original idea for the study and its design, and were responsible for acquiring 352

the study grant. VMvdG further developed the study protocol and is responsible for data 353

collection. LW did the data analysis and reported the results. All authors (LW, VMvdG, AvG, 354

WJ, HR) were involved in writing the paper and had final approval of the submitted manuscript. 355

This study is part of the Dutch project CIAO, which stands for Consortium Integrated Approach 356

Overweight. 357

Funding statement 358


Overweight. This study is funded by a grant from the major funding body ZonMw (the 360

Netherlands Organization for Health Research and Development) project no.200100001. 361

Conflict of interest 362

All authors declare that they have no competing interests. 363

Ethical approval 364

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This study was conducted according to the guidelines laid down in the Declaration of Helsinki, 365

and all procedures involving human subjects were approved by the Medical and Ethical Review 366

Committee of the Erasmus Medical Centre study (reference number MEC-2011-183). Written 367

informed consent was obtained from all subjects/patients. 368

Data sharing statement 369

Data is available by emailing the corresponding author at [email protected] 370

References 371

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33. De Bourdeaudhuij I, Te Velde SJ, Maes L, et al. General parenting styles are not strongly associated 445

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34. Lamborn SD, Mounts NS, Steinberg L, et al. Patterns of competence and adjustment among 448

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Supporting information captions 465

S1 Table Descriptive results of feeding style dimensions, parenting style dimensions, parenting style 466

categories according to children’s snacking behavior 467

468

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Table S1 Descriptive results of feeding style dimensions, parenting style dimensions, parenting style categories according to children’s snacking

behavior

Eating unhealthy snacks every day Unhealthy snacks frequency per day

Yes No P-value* <=1 >1 P-value

*

Feeding style dimensions (mean (SD))

Control over eating 3.07(0.39) 3.08(0.37) 0.921 3.09(0.37) 3.05(0.38) 0.248

Emotional feeding 1.75(0.85) 1.78(0.79) 0.784 1.73(0.75) 1.88(0.91) 0.048

Encouragement to eat 3.72(0.7) 3.8(0.65) 0.296 3.8(0.68) 3.75(0.62) 0.362

Instrumental feeding 2.11(0.94) 2.16(0.88) 0.636 2.13(0.87) 2.2(0.94) 0.370

Parenting style dimensions (mean (SD))

Involvement 4.47(0.53) 4.59(0.38) 0.011 4.59(0.39) 4.53(0.45) 0.170

Strictness 4.57(0.58) 4.5(0.62) 0.317 4.53(0.59) 4.45(0.65) 0.139

Parenting style category(n (%))

Authoritative 38(17.27) 182(82.73) 0.032 159(71.95) 62(28.05) 0.123

Authoritarian 11(15.71) 59(84.29) 50(71.43) 20(28.57)

Indulgent 4(5.26) 72(94.74) 57(76) 18(24)

Neglectful 33(17.19) 159(82.81) 132(69.11) 59(30.89)

*Continuous variables were compared using Wilcoxon text and categorical variables were compared using Chi-Square test.

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STROBE 2007 (v4) Statement—Checklist of items that should be included in reports of cross-sectional studies

Section/Topic Item

# Recommendation Reported on page #

Title and abstract 1 (a) Indicate the study’s design with a commonly used term in the title or the abstract 2

(b) Provide in the abstract an informative and balanced summary of what was done and what was found 2

Introduction

Background/rationale 2 Explain the scientific background and rationale for the investigation being reported 3&4

Objectives 3 State specific objectives, including any prespecified hypotheses 4

Methods

Study design 4 Present key elements of study design early in the paper 5

Setting 5 Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data

collection

5

Participants

6

(a) Give the eligibility criteria, and the sources and methods of selection of participants 5

Variables 7 Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if

applicable

6&7&8

Data sources/

measurement

8* For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe

comparability of assessment methods if there is more than one group

20

Bias 9 Describe any efforts to address potential sources of bias 9

Study size 10 Explain how the study size was arrived at 5

Quantitative variables 11 Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and

why

6&7&8

Statistical methods 12 (a) Describe all statistical methods, including those used to control for confounding 9

(b) Describe any methods used to examine subgroups and interactions 9

(c) Explain how missing data were addressed 9

(d) If applicable, describe analytical methods taking account of sampling strategy Not applicable

(e) Describe any sensitivity analyses Not included

Results

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Participants 13* (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility,

confirmed eligible, included in the study, completing follow-up, and analysed

11

(b) Give reasons for non-participation at each stage Not included

(c) Consider use of a flow diagram Not included

Descriptive data 14* (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential

confounders

11

(b) Indicate number of participants with missing data for each variable of interest 11

Outcome data 15* Report numbers of outcome events or summary measures 11

Main results 16 (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence

interval). Make clear which confounders were adjusted for and why they were included

13&14

(b) Report category boundaries when continuous variables were categorized Not included

(c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period Not included

Other analyses 17 Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses 15

Discussion

Key results 18 Summarise key results with reference to study objectives 16

Limitations 19 Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and

magnitude of any potential bias

18

Interpretation 20 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from

similar studies, and other relevant evidence

16&17&18

Generalisability 21 Discuss the generalisability (external validity) of the study results 18

Other information

Funding 22 Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on

which the present article is based

19

*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies.

Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE

checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at http://www.plosmedicine.org/, Annals of Internal Medicine at

http://www.annals.org/, and Epidemiology at http://www.epidem.com/). Information on the STROBE Initiative is available at www.strobe-statement.org.

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Feeding styles, parenting styles and snacking behavior in

children attending primary schools in multi-ethnic

neighborhoods: a cross-sectional study

Journal: BMJ Open

Manuscript ID bmjopen-2016-015495.R1


Date Submitted by the Author: 23-Mar-2017

Complete List of Authors: Wang, Lu; Department of Public Health Van de Gaar, Vivian; Department of Public Health Jansen, Wilma; Gemeente Rotterdam

Mieloo, Cathelijne; Gemeente Rotterdam van Grieken, Amy; Erasmus Medical Center, Public Health Raat, Hein; Erasmus Medical Center, Department of Public Health


Public health




BMJ Open on F


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children attending primary schools in multi-ethnic 2

neighborhoods: a cross-sectional study 3


1, W Jansen

1,2, CL Mieloo

1,3, A van Grieken

1, H Raat

1* 4

5



3 Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, the Netherlands 8

9

10




PO Box 2040 14


The Netherlands 16

Telephone: +31615127884 17


Shortened Title: 19


Word count: 4884 (Including tables) 21

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Abstract 22






socio-demographic characteristics, feeding style dimensions (‘control over eating’, ‘emotional 28

feeding’, ‘encouragement to eat’ and ‘instrumental feeding’), parenting style dimensions 29

(‘involvement’ and ‘strictness’), and children’s unhealthy snacking behavior. Logistic regression 30

analyses were performed to determine whether feeding styles and parenting styles were 31

associated with children’s unhealthy snacking behavior. 32

Result: Over all, children whose parents had a higher extent of ‘control over eating’ had a lower 33


0.76). Further stratified analysis showed that ‘control over eating’ was associated with less 35

unhealthy snacking behavior only in children with a Dutch (OR, 0.37; 95% CI: 0.20 to 0.68), or a 36

Moroccan/Turkish (OR, 0.44; 95% CI: 0.25 to 0.77) ethnic background. ‘Encouragement to eat’ 37

was associated with a lower odds of eating unhealthy snacks every day in children with a Dutch 38






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children’s unhealthy snacking behavior differed between children with different ethnic 44

backgrounds. 45






• We relied on parents’ self-reports for children’s unhealthy snacking behavior, social 51

desirability and recall bias could have been possible. 52



Introduction 55




Studies performed among children living in both developed and developing 58

countries showed that the consumption of unhealthy snack foods among children has largely 59

increased during the past few decades.5-10

According to the 2007-2010 Netherlands’ national 60

food consumption survey, children aged 7 to 12 years had an average of 3.3 events during the 61

day eating energy-dense snack foods, with 90% of children consuming more energy from 62

unhealthy snack foods than is recommended (837 to 1255 kJ per day).11

Given that snacking 63

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habits are established during childhood and often persist into adulthood 12

, unhealthy snacking 64

behavior should be discouraged at an early age. 65

Parents play an important role in shaping children’s eating behaviors, through feeding 66

styles and parenting styles.13-19

Parental feeding styles can be measured using the Parental 67

Feeding Style Questionnaire.20

This measure assesses four commonly used aspects of parental 68

feeding, including ‘control over eating’ (controlling the child’s food intake),13 15

‘encouragement 69

to eat’ (encouraging the child to eat a variety of foods),14 15

‘instrumental feeding’ (using food as 70

a reward) and ‘emotional feeding’ (offering food to soothe the child’s negative emotions).20

71

Previous studies have indicated that ‘control over eating’13 15

and ‘encouragement to eat’14

are 72

associated with lower child unhealthy snack intake. While ‘instrumental feeding’ and ‘emotional 73

feeding’ have been associated with a higher unhealthy snack intake among children.13-15

74

Parenting style can be defined as a constellation of attitudes and beliefs towards the child 75

that create an emotional climate in which parents’ behaviors are expressed.21

Based on variations 76

in two parenting dimensions – ‘involvement’ (also called responsiveness), and ‘strictness’ (also 77

called demandingness) – four parenting styles can be defined: authoritative, authoritarian, 78

indulgent and neglectful.21 22

In general, an authoritative parenting style is characterized by high 79

involvement and high strictness and is associated with healthier dietary behaviors of the child,17

80

18 23 24 including lower unhealthy snack intake.

16 81

To date, only limited studies have investigated the associations of feeding styles and 82

parenting styles with children’s unhealthy snacking behavior. The majority of these studies have 83

focused on native European populations.14-16

The impact of parental feeding style and parenting 84

styles may differ by ethnic subgroups.25-31

For instance, a study in the US indicated that among 85

children with Hispanic background, parental ‘emotional feeding’ and ‘instrumental feeding’ 86

predicted increased child sweet beverage consumption.32

However, among children with an 87

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Afro- American background, this study observed no association between parental feeding styles 88

and child sweet beverage consumption.32

In the Netherlands, to the best of our knowledge, thus 89

far no studies have been published evaluating differences in feeding styles or parenting styles 90

among groups with differential ethnic background. With regard to the development of 91

interventions in diverse populations, it is important to study the differential influence of feeding 92

styles and parenting styles on children’s unhealthy snack consumption in each ethnic subgroup 93

separately. 94


parenting styles are associated with children’s unhealthy snacking behavior, and to explore 96

whether the associations differ according to the children’s ethnic background. We hypothesized 97

that 1) ‘control over eating’ and ‘encouragement to eat’ were associated with less unhealthy 98

snacking behavior among children, 2) ‘instrumental feeding’ and ‘emotional feeding’ were 99

associated with more unhealthy snacking behavior among children, 3) an authoritative parenting 100

style was associated with less unhealthy snacking behavior among children. In addition, we 101

hypothesized that the associations of feeding styles and parenting styles with child unhealthy 102

snacking behavior differed between distinct ethnic subgroups. 103


Study population 105

Our cross-sectional study used baseline data from the population-based ‘Water campaign’ 106

study.33

This controlled trial assessed the effects of a combined school- and community-based 107

intervention on children’s sugar- sweetened beverages consumption. Four primary schools 108

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located in disadvantaged multi-ethnic neighborhoods in Rotterdam, the Netherlands, were 109

included in the study. The ‘Water Campaign’ study is an extension of the municipal overweight 110

intervention program ‘Enjoy being Fit’.34

111


years) were invited to participate. Passive parental consent was obtained; parents (and children) 113

were informed about the intervention and the study and were free to refuse participation without 114

giving any explanation (reference number MEC-2011-183). 115

Measurements were performed at baseline and after one year, using questionnaires (child 116

and parental) and observations at school. The questionnaires were shown to be feasible during 117

pre-testing in a comparable population before the start of the study. Parents of all children in 118

grades 2 to 8 (aged 6 to 13 years) at participating schools received the baseline questionnaires on 119

paper from the teachers. The parental questionnaire could be completed at home by the main 120

caregiver of the child, within a period of maximum 4 weeks.33

For the present study, data from 121

the baseline parental questionnaire (administered March/April 2011) was used. A study 122

population of 644 parent-child dyads was available for analyses. 123

Measures 124



questionnaire: age (years), gender (boy/girl), ethnic background. The child’s ethnic background 127

was based on the country of birth of the parents, according to definitions given by Statistics 128

Netherlands.35

The child’s ethnic background was Dutch only if both parents had been born in 129

the Netherlands; if one of the parents had been born in another country, then the ethnic 130

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background of the child was defined according to that country. If both of the parents had been 131

born in other countries, the ethnic background of the child was defined according to the mother’s 132

country of birth.35

The ethnic background of the child was categorized as Dutch, 133

Surinamese/Antillean, Moroccan/Turkish, or other.33

Children categorized to the ‘other’ 134

subgroup were of mixed ethnic background, including among others German, Cape-Verdean. 135

Respondents were either the father or the mother of the child, and parental gender was based on 136

this item (male/female). Parental age (years) and educational level were also reported. According 137

to the standard Dutch cut-off points, the educational level of the responding parent(s) was 138

categorized as ‘low’ (no education; primary school; ≤ 3 years of general secondary school); 139

‘mid-low’ (>3 years of general secondary school); ‘mid-high’ (higher vocational training; 140

undergraduate programs); or ‘high’ (higher academic education).36

Respondents reported 141

whether the child lived with both parents vs. single parent, and how many siblings the child had. 142



personnel, according to the Youth Health Care protocol.37


was calculated as weight/(height).2 Children’s weight status were categorized as being ‘non-146

overweight’, ‘overweight or obese’ based on the age- and gender specific BMI cut-off points 147

published by the International Obesity Task Force.38

148

Feeding style 149


was used to 150


items), ‘instrumental feeding’ (5 items) and ‘encouragement to eat’ (8 items). Parents were asked 152

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to respond on a five-point Likert scale ranging from ‘never’ (1 point) to ‘always’ (5 points). 153

Average scores on each scale were calculated when less than half of the items in that scale were 154

missing. For each dimension, less than 2% of the scores were missing (Table 2). A higher score 155

indicated a greater tendency for parents to apply a specific feeding style. In the present study, the 156

Cronbach’s α was 0.78 for the ‘control over eating’ scale, 0.87 for the ‘emotional feeding’ scale, 157

0.79 for the ‘instrumental feeding’ scale and 0.77 for the ‘encouragement to eat’ scale. 158

Parenting style 159

The validated Dutch version of the Steinberg parenting style instrument 39-41


the two parenting style dimensions: ‘involvement’ and ‘strictness’. The ‘involvement’ scale 161

contains nine items that assess indicators of parental loving, responsiveness, and involvement. 162

An example item is ‘My child can count on me when he or she has some kind of problem’. The 163

‘strictness’ scale contains six items that asses parental monitoring and supervision of the child. 164

An example item is: ‘I know what my child does in his or her free time’. Parents were asked to 165

respond to each item on a five-point Likert scale ranging from ‘strongly disagree’ (1 point) to 166

‘strongly agree’ (5 points). Average scores on each scale were calculated when less than half of 167

the items in that scale were missing. For each dimension, less than 2% of the scores were 168

missing (Table 2). Based on the median split of both scales,40

the dimensions of parenting style 169

were further defined into the following categories: authoritative (high involvement and high 170

strictness), authoritarian (low involvement and high strictness), indulgent (high involvement and 171

low strictness), and neglectful (low involvement and low strictness). 172

Unhealthy snacking behavior of the child 173

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Two items in the parental questionnaire were used to assess children’s unhealthy snacking 174

behavior. The questionnaire items were based on previously used questionnaires, mainly used in 175

earlier Dutch studies.42 43

In the present study, unhealthy snacks were defined as energy-dense 176

nutrient-poor foods eaten between the three main meals. Parents were provided with the 177

following examples of unhealthy snacks: crisps, nuts, chocolate, mars bars, pastry, iced cake, ice 178

cream, pizza, meatballs, and burgers. Parents reported how many days in a normal week the 179

child ate unhealthy snacks (response categories: ‘every day’ and ‘not every day’) and the 180

frequency of eating unhealthy snacks on such a day (response categories ranged from ‘none’, ‘1 181

per day’ to ‘5 or more per day’). The frequency of eating unhealthy snacks per day was 182

dichotomized into ‘≤1 snack per day’ and ‘>1 snack per day’. 183




the child’s ethnic background were compared using a ANOVA or Kruskal-Wallis test for 187

continuous variables and a Chi-square test for categorical variables. 188


parenting styles were associated with the children’s unhealthy snacking behavior. Unhealthy 190

snacking behavior of the child was assessed using two variables: unhealthy snacks every day 191

(yes/no), and unhealthy snack frequency per day (≤1 or >1 per day). Descriptive results of the 192

dimensions of feeding style, dimensions of parenting style, the parenting style categories and 193

child snacking behavior are presented in supplemental table S1. Separate logistic regression 194

models were built for each dimension of feeding style, dimension of parenting style and 195

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parenting style categories, adjusted for potential confounders. In order to select potential 196

confounders, we used logistic and general linear regression to examine the associations between 197

potential confounders and children’s unhealthy snacking behavior, and dimensions of feeding 198

style, and dimensions of parenting style and parenting style categories. Factors were considered 199

as potential confounders if they were associated with both the children’s unhealthy snacking 200

behavior and any of the dimensions of feeding style, dimensions of parenting style and parenting 201

style categories. The following factors were evaluated as potential confounders: responding 202

parents’ age, gender, education level, weight status, single parent vs both parents, and child age, 203

gender, weight status, and number of siblings. 204

To examine whether the associations between dimensions of feeding style, dimensions of 205

parenting style, parenting style categories and the children’s unhealthy snacking behavior 206

differed according to the children’s ethnic background, an interaction term of the independent 207

variable with child ethnic background was added to the model. The interaction term was 208

considered significant at a level of p<0.10.44

In Table 4, the significant interaction terms are 209

indicated. The logistic regression models were repeated for subgroups of children with a Dutch, 210

Surinamese/Antillean, Moroccan/Turkish, and other ethnic background respectively. Assuming a 211

random missing pattern of data, complete–subject analyses were chosen to handle the missing 212

values.45

All analyses were conducted using the statistical software SAS (version 9.3, SAS 213

Institute Inc., Cary, NC, 2010). 214

Results 215


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the overall sample as well as for each subgroup based on the children’s ethnic background. The 218

mean age of the children in our study was 9.4 (SD 1.8) years; 45.9% of them were boys and 30.3% 219

had a Dutch ethnic background. Based on the parents’ report, 14.6% of the children ate 220

unhealthy snacks on a daily basis, and 29.7% ate unhealthy snacks more than once a day. The 221

mean age of the responding parents was 37.9 (SD 7.4), 87.4% of them were mothers, and 18.5% 222

indicated having completed a high level of education. 223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

238

239

240

241

242

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Overall

sample

(n=644)

Dutch

(n=195)

Surinamese/

Antillean

(n=142)

Moroccan/

Turkish

(n=186)

Other ethnic

background

(n=121)

p-

value*



Gender, girl, n (%) (missing

n=12)

342 (54.1) 107 (55.2) 76 (53.9) 89 (50.0) 70 (58.8) 0.50

Number of siblings, n>1 (%)

(missing n=2)

530 (82.6) 157 (80.5) 114 (80.3) 167 (90.3) 92 (76.7) <0.001


(missing n=45)

138 (23.0) 25 (13.8) 35 (26.1) 54 (31.8) 24 (21.1) 0.002

Unhealthy snacks daily, n (%)

(missing n=12)

92 (14.6) 32 (16.8) 20 (14.2) 21 (11.4) 19 (16.2) 0.45

Unhealthy snacks per day, n

(%) (missing n=17)

0.37

>1 snack per day 186 (29.7) 55 (28.8) 37 (26.1) 56 (30.4) 38 (32.8)


Gender, female, n (%) (missing

n=47)

522 (87.4) 166 (88.8) 127 (94.8) 140 (82.4) 89 (84.0) 0.007


Education level of the parent

(missing n=21)

<0.001

Low 137 (22.0) 20 (10.6) 16 (11.4) 75 (41.2) 26 (23.2)

Mid-low 156 (25.0) 58 (30.7) 33 (23.6) 46 (25.3) 19 (17.0)

Mid-high 215 (34.5) 61 (32.3) 66 (47.1) 45 (24.7) 43 (38.4)

High 115 (18.5) 50 (26.5) 25 (17.9) 16 (8.8) 24 (21.4)

Single parent, n(%) (missing,

n=5)

171(26.76) 45(23.4) 59(41.5) 29(15.6) 38(31.9) <0.001



Force. 247

Over all, the scores for all the dimensions of feeding styles , parenting style and parenting 248

style categories were different between the ethnic subgroups (p<0.05) (Table 2). In addition, post 249

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hoc analysis showed that parents of children with a Dutch ethnic background reported using the 250

highest levels of ‘control over eating’, and ‘encouragement to eat’, but the lowest levels of 251

‘instrumental feeding’ and ‘emotional feeding’(p<0.05). Parents of children with a 252

Surinamese/Antillean ethnic background had similar levels of ‘encouragement to eat’, 253

‘instrumental feeding’, and ‘emotional feeding’ compared to parents of children with a Dutch 254

ethnic background, but a lower level of ‘control over eating’ (p<0.05). Parents of children with a 255

Moroccan/Turkish ethnic background reported using the highest levels of ‘instrumental feeding’ 256

and ‘emotional feeding’ (p<0.05). With regard to the dimensions of parenting style, the levels of 257

parental ‘involvement’ and ‘strictness’ were similar between parents of children with a Dutch, 258

Surinamese/Antillean, and Moroccan/Turkish ethnic background (p>0.05). Parents of children 259

with Surinamese/Antillean ethnic background used ‘authoritarian’ parenting style less often than 260

as Dutch parents did (p<0.05). 261

Table 2 Average scores on feeding style dimensions, parenting style dimensions and parenting style categories 262

according to the children’s ethnic background (n=644) 263

Dutch

(n=195)

Surinamese/

Antillean

(n=142)

Moroccan/

Turkish

(n=186)

Other ethnic

background

(n=121)

p-value

Feeding style dimensions,

mean (SD)

Control over eating 4.03 (0.55) 3.72 (0.63) 3.76 (0.58) 3.56 (0.72) <0.001

Emotional feeding 1.58 (0.66) 1.58 (0.60) 2.02 (0.87) 2.03 (0.94) <0.001

Encouragement to eat 3.86 (0.62) 3.80 (0.69) 3.74 (0.66) 3.72 (0.67) 0.03

Instrumental feeding 1.93 (0.78) 1.90 (0.77) 2.56 (0.91) 2.28 (0.93) <0.001

Parenting style dimensions,

mean (SD)

Involvement 4.58 (0.33) 4.65 (0.36) 4.55 (0.42) 4.48 (0.51) 0.02

Strictness 4.58 (0.58) 4.52 (0.63) 4.50 (0.57) 4.41 (0.71) 0.03

Parenting style categories,

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n (%)

Authoritative 70 (37.63) 66 (47.83) 67 (37.43) 40 (34.78) 0.007

Authoritarian 36 (19.35) 8 (5.80) 16 (8.94) 15 (13.04)

Indulgent 25 (13.44) 21 (15.22) 27 (15.08) 13 (11.30)

Neglectful 55 (29.57) 43 (31.16) 69 (38.55) 47 (40.87)

* p-value derived from Kruskal-Wallis test (feeding style dimensions and parenting style dimensions) or Chi-square 264

test (parenting style categories). 265

Associations between dimensions of feeding style, parenting style, 266

parenting style categories and children’s unhealthy snacking 267

behavior 268

Table 3 presents the associations between dimensions of feeding style, dimensions of parenting 269

style and parenting style categories and children’s unhealthy snacking behavior. With regard to 270

the dimensions of feeding style, children whose parents had a higher score on ‘control over 271

eating’ had a lower odds of eating unhealthy snacks every day (OR 0.63; 95% CI :0.44 to 0.91), 272

and of eating unhealthy snacks more than once per day (OR 0.57; 95% CI :0.42 to 0.76). With 273

regard to the dimensions of parenting style, no significant association was observed for neither 274

the ‘involvement’ nor the ‘strictness’ dimension with children’s unhealthy snacking behavior. 275

Children of parents having an ‘indulgent’ parenting style were less likely to eat unhealthy snacks 276

every day (OR 0.25; 95% CI :0.09 to 0.73), compared to children having parents using an 277

‘authoritative’ parenting style. 278

279

Table 3. Results of the logistic regression analyses for the associations of feeding style dimensions, parenting 280

style dimensions and parenting style categories with children’s unhealthy snacking behavior (n=644) 281

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Unhealthy snacks every day

(Yes vs No)

Unhealthy snack frequency per day

(>1 vs ≤1)



Adjusted

†



Control over eating

0.63 (0.45, 0.88) 0.63 (0.44, 0.91) 0.54 (0.41, 0.71) 0.57 (0.42, 0.76)

Emotional feeding 0.92 (0.69, 1.23) 0.95 (0.69, 1.30) 1.24 (1.01, 1.53) 1.18 (0.93, 1.48)

Encouragement to eat 0.80 (0.57, 1.11) 0.73 (0.52, 1.04) 0.87 (0.67, 1.13) 0.97 (0.73, 1.28)

Instrumental feeding 0.92 (0.71, 1.19) 0.92 (0.69, 1.22) 1.10 (0.90, 1.33) 0.99 (0.80, 1.23)

Parenting style

dimensions

Involvement 0.56 (0.33, 0.93) 0.60 (0.35, 1.04) 0.68 (0.45, 1.04) 0.78 (0.50, 1.21)

Strictness 1.23 (0.83, 1.82) 1.43 (0.92, 2.21) 0.80 (0.61, 1.05) 0.89 (0.66, 1.20)



Authoritarian 1.14 (0.57, 2.27) 1.10 (0.53, 2.28) 1.20 (0.68, 2.11) 1.31 (0.72, 2.38)

Indulgent 0.26 (0.09, 0.76) 0.25 (0.09, 0.73) 0.90 (0.51, 1.60) 0.87 (0.48, 1.56)

Neglectful 0.94 (0.57, 1.57) 0.84 (0.48, 1.46) 1.33 (0.89, 1.98) 1.21 (0.78, 1.87)


confounders. 283




children’s unhealthy snacking behavior. 287

Analyses according to the children’s ethnic background 288

Table 4 shows the associations of dimensions of feeding style, dimensions of parenting style, and 289

parenting style categories with children’s unhealthy snacking behavior according to the 290

children’s ethnic background. With regard to feeding style dimensions, a higher score on the 291

‘control over eating’ was associated with a lower possibility of eating unhealthy snacks every 292

day for children with a Dutch ethnic background (OR 0.41; 95% CI: 0.21 to 0.79), and for 293

children with a Moroccan/Turkish ethnic background (OR 0.40; 95% CI: 0.19 to 0.88). A higher 294

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score on the ‘encouragement to eat’ was associated with lower possibility of eating unhealthy 295

snacks every day for children with Dutch ethnic background only (OR 0.48; 95% CI: 0.25 to 296

0.90). In addition, a higher score on the ‘control over eating’ was associated with a lower 297

possibility of eating unhealthy snacks more than once per day for children with a Dutch ethnic 298

background (OR 0.37; 95% CI: 0.20 to 0.68), and for children with a Moroccan/Turkish ethnic 299

background (OR 0.44; 95% CI: 0.25 to 0.77). Finally, ‘instrumental feeding’ was associated with 300

a higher possibility of eating unhealthy snacks more than once per day for children with a 301

Moroccan/Turkish ethnic background only (OR 1.43; 95% CI: 1.01 to 2.04). 302

With regard to parenting style dimensions, a higher score on parental ‘involvement’ was 303



background whose parents had a ‘neglectful’ parenting style were more likely to eat unhealthy 306

snacks more than once a day (OR 2.78; 95% CI :1.05 to 7.33) compared to children from parents 307

that had an ‘authoritative’ parenting style. 308

Table 4. Results of the logistic regression analyses for the associations feeding style dimensions, parenting 309

style dimensions and parenting style categories with the children’s unhealthy snacking behavior, stratified by 310

the children’s ethnic background 311

Dutch

n=195

Surinamese/

Antillean

n=142

Moroccan/

Turkish

n=186

Other ethnic

background

n=121

OR (95% CI) †

OR (95% CI) †

OR (95% CI) †

OR (95% CI) †



Control over eating*

0.41 (0.21, 0.79) 1.17 (0.52, 2.64) 0.40 (0.19, 0.88) 0.66 (0.33, 1.31)



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Involvement* 1.00 (0.32, 3.17) 1.74 (0.39, 7.86) 0.51 (0.18, 1.41) 0.25 (0.09, 0.67)

Strictness* 2.04 (0.86, 4.85) 2.60 (0.84, 8.09) 0.92 (0.41, 2.06) 0.67 (0.35, 1.29)

Parenting style categories*


Authoritarian 1.25 (0.48, 3.22) 0.58 (0.07, 5.16) 1.77 (0.31, 10.09) 0.49 (0.05, 4.54)

Indulgent -‡ 0.20 (0.03, 1.66) 1.55 (0.34, 6.99) -

‡

Neglectful 0.53 (0.20, 1.40) 0.31 (0.08, 1.18) 2.01 (0.68, 6.51) 2.33 (0.74, 7.33)

Unhealthy snacks >1 times per

day


Control over eating* 0.37 (0.20, 0.68) 1.02(0.56, 1.85) 0.44 (0.25, 0.77) 0.44 (0.24, 0.79)



Instrumental feeding* 1.10 (0.74, 1.64) 0.84 (0.51, 1.38) 1.43 (1.01, 2.04) 0.80 (0.52, 1.25)


Involvement 1.26 (0.48, 3.29) 0.88 (0.31, 2.49) 0.65 (0.31, 1.37) 0.45 (0.20, 1.02)

Strictness 1.13 (0.64, 2.00) 0.77 (0.43, 1.38) 0.83 (0.48, 1.44) 0.58 (0.33, 1.00)



Authoritarian 1.79 (0.77, 4.14) -‡ 1.15 (0.35, 3.75) 0.94 (0.21, 4.14)

Indulgent 0.97 (0.35, 2.68) 0.83 (0.27, 2.61) 0.46 (0.14, 1.51) 2.68 (0.67,

10.73)

Neglectful 0.64 (0.28, 1.48) 1.03 (0.44, 2.44) 1.62 (0.79, 3.33) 2.78 (1.05, 7.33)







Discussion 318

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In this study, we investigated the associations of dimensions of feeding style, dimensions of 319

parenting style and parenting style categories with unhealthy snack consumption in school-aged 320

children from a multi-ethnic population. In line with our hypothesis ‘control over eating’ was 321

associated with lower unhealthy snacking behavior of the child. We did not observe significant 322

associations between ‘encouragement to eat’, ‘instrumental feeding’ and ‘emotional feeding’ and 323

child unhealthy snacking behavior. Also, no association between an ‘authoritative’ parenting 324

style and child unhealthy snacking behavior was observed. Our hypothesis with regard to 325

different associations of dimensions of feeding style, dimensions of parenting style and parenting 326

style categories with children’s unhealthy snack consumption according to the ethnic background 327

of the child, was confirmed for some of the ethnic subgroups. 328

In line with previous studies, the present study found that children whose parents had a 329


Further 330


consumption in most of the ethnic subgroups, except for the subgroup of children with a 332

Surinamese/Antillean ethnic background. An explanation for the lack of finding among the 333

Surinamese/Antillean ethnic subgroup may be their compliance to their traditional dietary 334

pattern.46

This traditional dietary pattern contains more vegetables and fruits and less unhealthy 335

snack food.46

Therefore, parents may facilitate child’s healthy snacking behavior, without having 336

to use control over eating. 337

In the present study, ‘encouragement to eat’ was associated with a lower unhealthy snack 338

consumption only in the subgroup of children with a Dutch ethnic background. It is possible that 339

the association between ‘encouragement to eat’ and lower unhealthy snack consumption only 340

exists when parents provide the child with more healthy alternative foods instead of unhealthy 341

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snack foods. Further studies examining the association between parental encouragement and 342

children’s unhealthy snack consumption should consider the potential influence of food 343

provision. 344

Previous research suggested that ‘emotional feeding’ and ‘instrumental feeding’ were 345




intake only existed among children with a Moroccan/Turkish ethnic background and in children 348

with an ‘other’ ethnic background. In addition, our study results showed that parents of children 349

with a Moroccan/Turkish ethnic background were also more likely to apply, i.e. scored higher on 350

these dimensions, ‘instrumental feeding’ and ‘emotional feeding’ compared to the Dutch, 351

Surinamese/Antillean and other ethnic background subgroups. These findings combined are 352

comparable to previous findings indicating that parents mainly offer unhealthy snack food in the 353

context of ‘emotional’ and ‘instrumental’ feeding styles.47

As a consequence hereof, using 354

snacks as a reward may increase children’s preference for the rewarding snack.48

Consequently, 355

higher exposure together with increased preference for the unhealthy snack food may contribute 356

to an increased risk of high unhealthy snack intake among children. Therefore, further 357

interventions should discourage the use of ‘instrumental feeding’ and ‘emotional feeding’ in 358

parents of children with a Moroccan/Turkish ethnic background. 359

Although previous studies suggested that having an ‘authoritative’ parenting style was 360

associated with lower unhealthy snack consumption of children, we found no association 361

between this parenting style category and children’s unhealthy snack consumption. The lack of 362

association might be due to the low variability on the scores of both the ‘involvement’ and 363

‘strictness’ dimensions among parents. Only in the subgroup of children with an ‘other’ ethnic 364

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background, a ‘neglectful’ parenting style, which is characterized by low ‘involvement’ and low 365

‘strictness’, was associated with a higher unhealthy snack consumption. This observation, of an 366

association between having a neglectful parenting style and more unhealthy snacking behavior is 367

in line with previous research.16 17

However, the contribution of ethnic background in this 368

association is difficult to explain due to the diverse population (i.e. children with mixed ethnic 369

background) within this subgroup. 370

Our study suggests that the associations of feeding style dimensions, parenting style 371

dimensions and parenting style categories with child unhealthy snack consumption differed 372

according to the ethnic background of the child. Moreover, the findings suggest differences 373

between subgroups in the appliance of the different feeding styles and parenting styles. 374

Differences in parental beliefs, knowledge practices (e.g.: modeling, food provision) and 375

children’s food preferences between ethnic subgroups25 27

may contribute to these differential 376

applications and associations. We recommend conducting further qualitative and quantitative 377

research to gain more insight in these ethnic-group differences in associations between feeding 378

styles and children’s snacking behavior. Increased understanding may be helpful in developing 379

tailored interventions for reducing unhealthy snack consumption in different ethnic subgroups. 380


enabled us to analyze the associations of feeding style and parenting style with children’s 382

unhealthy snacking behaviors in different ethnic subgroups, and the use of validated 383



social desirability and recall bias could have been possible. Parental reports have shown to be an 386

accurate method to estimate dietary intake in school aged children.49

However, further studies 387

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may include a combination of parental report, child report and observational measures to 388

estimate the child’s snacking behavior. In addition, the questionnaires were provided in Dutch 389

only, which could have been a barrier for some parents given the diverse ethnicity of our study 390

population. We did not collect data related to language spoken, however parents in all ethic 391

subgroups were living in the Netherlands for, on average, over 20 years, indicating a familiarity 392

with the Dutch language and culture (data not shown). Secondly, performing stratified analysis, 393

reduced our sample size and therewith power to detect differences. Finally, given the 394

observational nature of cross-sectional design, this study does not allow firm conclusions with 395

regard to causality. 396

Conclusion 397








Contributors 405




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CM, WJ, HR) were involved in writing the paper and had final approval of the submitted 409

manuscript. 410


Overweight. 412








The Medical and Ethical Review Committee of the Erasmus Medical Centre issued a 420

‘declaration of no objection’ (i.e. formal waver) for this study (reference number MEC-2011-421

183). Passive parental consent was obtained; parents (and children) were informed about the 422

intervention and the study, and were free to refuse participation without giving any explanation. 423



References 426

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Nutrition 2014;30(5):538-43. 430




62. 434



6. Ford CN, Slining MM, Popkin BM. Trends in dietary intake among US 2- to 6-year-old children, 1989-437

2008. J Acad Nutr Diet 2013;113(1):35-42. 438

7. Juul F, Hemmingsson E. Trends in consumption of ultra-processed foods and obesity in Sweden 439

between 1960 and 2010. Public Health Nutr 2015;18(17):3096-107. 440

8. Wang Z, Zhai F, Zhang B, et al. Trends in Chinese snacking behaviors and patterns and the social-441

demographic role between 1991 and 2009. Asia Pac J Clin Nutr 2012;21(2):253-62. 442

9. Duffey KJ, Pereira RA, Popkin BM. Prevalence and energy intake from snacking in Brazil: analysis of the 443

first nationwide individual survey. Eur J Clin Nutr 2013;67(8):868-74. 444

10. Macdiarmid J, Loe J, Craig LCA, et al. Meal and snacking patterns of school-aged children in Scotland. 445

European journal of clinical nutrition 2009;63(11):1297-304. 446



Nutr 2015:1-10. 449









2014;17(5):960-9. 458







19. Hughes SO, Frankel LA, Beltran A, et al. Food parenting measurement issues: working group 465

consensus report. Child Obes 2013;9 Suppl:S95-102. 466




1993;113(3):487. 470

22. Steinberg L, Elmen JD, Mounts NS. Authoritative parenting, psychosocial maturity, and academic 471

success among adolescents. Child development 1989:1424-36. 472

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J Am Diet Assoc 2004;104(2):215-21. 479














2004;18(4):651-7. 493



32. Lora KR, Hubbs-Tait L, Ferris AM, et al. African-American and Hispanic children's beverage intake: 496

Differences in associations with desire to drink, fathers' feeding practices, and weight concerns. 497

Appetite 2016;107:558-67. 498



Nutr Phys Act 2014;11:98. 501

34. Jansen W, Raat H, Zwanenburg EJ, et al. A school-based intervention to reduce overweight and 502

inactivity in children aged 6-12 years: study design of a randomized controlled trial. BMC Public 503

Health 2008;8:257. 504














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1991;62(5):1049-65. 520

42. van der Horst K, Oenema A, van de Looij-Jansen P, et al. The ENDORSE study: research into 521

environmental determinants of obesity related behaviors in Rotterdam schoolchildren. BMC 522

Public Health 2008;8:142. 523

43. Veldhuis L, Struijk MK, Kroeze W, et al. 'Be active, eat right', evaluation of an overweight prevention 524

protocol among 5-year-old children: design of a cluster randomised controlled trial. BMC Public 525

Health 2009;9:177. 526







2015;59:26317. 533









S1 Table Descriptive results of feeding style dimensions, parenting style dimensions, parenting style 542


544

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behavior


Yes No P-value* <=1 >1 P-value

*


Control over eating 3.07(0.39) 3.08(0.37) 0.921 3.09(0.37) 3.05(0.38) 0.248





Involvement 4.47(0.53) 4.59(0.38) 0.011 4.59(0.39) 4.53(0.45) 0.170

Strictness 4.57(0.58) 4.5(0.62) 0.317 4.53(0.59) 4.45(0.65) 0.139


Authoritative 38(17.27) 182(82.73) 0.032 159(71.95) 62(28.05) 0.123

Authoritarian 11(15.71) 59(84.29) 50(71.43) 20(28.57)

Indulgent 4(5.26) 72(94.74) 57(76) 18(24)

Neglectful 33(17.19) 159(82.81) 132(69.11) 59(30.89)

*Continuous variables were compared using Wilcoxon text and categorical variables were compared using Chi-Square test.

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Section/Topic Item




Introduction



Methods



collection

5

Participants

6



applicable

6&7&8

Data sources/

measurement



20




why

6&7&8






Results

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11




confounders

11





13&14




Discussion




18



16&17&18


Other information



19





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Feeding styles, parenting styles and snacking behavior in

children attending primary schools in multi-ethnic

neighborhoods: a cross-sectional study

Journal: BMJ Open

Manuscript ID bmjopen-2016-015495.R2


Date Submitted by the Author: 02-May-2017

Complete List of Authors: Wang, Lu; Department of Public Health Van de Gaar, Vivian; Department of Public Health Jansen, Wilma; Gemeente Rotterdam

Mieloo, Cathelijne; Gemeente Rotterdam van Grieken, Amy; Erasmus Medical Center, Public Health Raat, Hein; Erasmus Medical Center, Department of Public Health


Public health




BMJ Open on F


http://bmjopen.bm

j.com/

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children attending primary schools in multi-ethnic 2

neighborhoods: a cross-sectional study 3


1, W Jansen

1,2, CL Mieloo

1,3, A van Grieken

1, H Raat

1* 4

5



3 Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, the Netherlands 8

9

10




PO Box 2040 14


The Netherlands 16

Telephone: +31615127884 17


Shortened Title: 19


Word count: 4884 (Including tables) 21

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Abstract 22






socio-demographic characteristics, feeding style dimensions (‘control over eating’, ‘emotional 28

feeding’, ‘encouragement to eat’ and ‘instrumental feeding’), parenting style dimensions 29

(‘involvement’ and ‘strictness’), and children’s unhealthy snacking behavior. Logistic regression 30

analyses were performed to determine whether feeding styles and parenting styles were 31

associated with children’s unhealthy snacking behavior. 32

Result: Over all, children whose parents had a higher extent of ‘control over eating’ had a lower 33


0.76). Further stratified analysis showed that ‘control over eating’ was associated with less 35

unhealthy snacking behavior only in children with a Dutch (OR, 0.37; 95% CI: 0.20 to 0.68), or a 36

Moroccan/Turkish (OR, 0.44; 95% CI: 0.25 to 0.77) ethnic background. ‘Encouragement to eat’ 37

was associated with a lower odds of eating unhealthy snacks every day in children with a Dutch 38






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children’s unhealthy snacking behavior differed between children with different ethnic 44

backgrounds. 45






• We relied on parents’ self-reports for children’s unhealthy snacking behavior, social 51

desirability and recall bias could have been possible. 52



Introduction 55




Studies performed among children living in both developed and developing 58

countries showed that the consumption of unhealthy snack foods among children has largely 59

increased during the past few decades.5-10

According to the 2007-2010 Netherlands’ national 60

food consumption survey, children aged 7 to 12 years had an average of 3.3 events during the 61

day eating energy-dense snack foods, with 90% of children consuming more energy from 62

unhealthy snack foods than is recommended (837 to 1255 kJ per day).11

Given that snacking 63

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habits are established during childhood and often persist into adulthood 12

, unhealthy snacking 64

behavior should be discouraged at an early age. 65

Parents play an important role in shaping children’s eating behaviors, through feeding 66

styles and parenting styles.13-19

Parental feeding styles can be measured using the Parental 67

Feeding Style Questionnaire.20

This measure assesses four commonly used aspects of parental 68

feeding, including ‘control over eating’ (controlling the child’s food intake),13 15

‘encouragement 69

to eat’ (encouraging the child to eat a variety of foods),14 15

‘instrumental feeding’ (using food as 70

a reward) and ‘emotional feeding’ (offering food to soothe the child’s negative emotions).20

71

Previous studies have indicated that ‘control over eating’13 15

and ‘encouragement to eat’14

are 72

associated with lower child unhealthy snack intake. While ‘instrumental feeding’ and ‘emotional 73

feeding’ have been associated with a higher unhealthy snack intake among children.13-15

74

Parenting style can be defined as a constellation of attitudes and beliefs towards the child 75

that create an emotional climate in which parents’ behaviors are expressed.21

Based on variations 76

in two parenting dimensions – ‘involvement’ (also called responsiveness), and ‘strictness’ (also 77

called demandingness) – four parenting styles can be defined: authoritative, authoritarian, 78

indulgent and neglectful.21 22

In general, an authoritative parenting style is characterized by high 79

involvement and high strictness and is associated with healthier dietary behaviors of the child,17

80

18 23 24 including lower unhealthy snack intake.

16 81

To date, only limited studies have investigated the associations of feeding styles and 82

parenting styles with children’s unhealthy snacking behavior. The majority of these studies have 83

focused on native European populations.14-16

The impact of parental feeding styles and parenting 84

styles may differ by ethnic subgroups.25-31

For instance, a study in the US indicated that among 85

children with Hispanic background, parental ‘emotional feeding’ and ‘instrumental feeding’ 86

predicted increased child sweet beverage consumption.32

However, among children with an 87

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Afro-American background, this study observed no association between parental feeding styles 88

and child sweet beverage consumption.32

In the Netherlands, to the best of our knowledge, thus 89

far no study has been published evaluating differences in feeding styles or parenting styles 90

among groups with differential ethnic background. With regard to the development of 91

interventions in ethnically diverse populations, it is important to study the differential influence 92

of feeding styles and parenting styles on children’s unhealthy snack consumption in each ethnic 93

subgroup separately. 94


parenting styles are associated with children’s unhealthy snacking behavior, and to explore 96

whether the associations differ according to the children’s ethnic background. We hypothesized 97

that 1) ‘control over eating’ and ‘encouragement to eat’ were associated with less unhealthy 98

snacking behavior among children, 2) ‘instrumental feeding’ and ‘emotional feeding’ were 99

associated with more unhealthy snacking behavior among children, 3) an authoritative parenting 100

style was associated with less unhealthy snacking behavior among children. In addition, we 101

hypothesized that the associations of feeding styles and parenting styles with child unhealthy 102

snacking behavior differed between distinct ethnic subgroups. 103


Study population 105

Our cross-sectional study used baseline data from the population-based ‘Water campaign’ 106

study.33

This controlled trial assessed the effects of a combined school- and community-based 107

intervention on children’s sugar- sweetened beverages consumption. Four primary schools 108

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located in disadvantaged multi-ethnic neighborhoods in Rotterdam, the Netherlands, were 109

included in the study. The ‘Water Campaign’ study is an extension of the municipal overweight 110

intervention program ‘Enjoy being Fit’.34

111


years) were invited to participate. Passive parental consent was obtained; parents (and children) 113

were informed about the intervention and the study and were free to refuse participation without 114

giving any explanation (reference number MEC-2011-183). 115

Measurements were performed at baseline and after one year, using questionnaires (child 116

and parental) and observations at school. The questionnaires were shown to be feasible during 117

pre-testing in a comparable population before the start of the study. Parents of all children in 118

grades 2 to 8 (aged 6 to 13 years) at participating schools received the baseline questionnaires on 119

paper from the teachers. The parental questionnaire could be completed at home by the main 120

caregiver of the child, within a period of maximum 4 weeks.33

For the present study, data from 121

the baseline parental questionnaire (administered March/April 2011) was used. A study 122

population of 644 parent-child dyads was available for analyses. 123

Measures 124



questionnaire: age (years), gender (boy/girl), ethnic background. The child’s ethnic background 127

was based on the country of birth of the parents, according to definitions given by Statistics 128

Netherlands.35

The child’s ethnic background was Dutch only if both parents had been born in 129

the Netherlands; if one of the parents had been born in another country, then the ethnic 130

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background of the child was defined according to that country. If both of the parents had been 131

born in other countries, the ethnic background of the child was defined according to the mother’s 132

country of birth.35

The ethnic background of the child was categorized as Dutch, 133

Surinamese/Antillean, Moroccan/Turkish, or other.33

Children categorized to the ‘other’ 134

subgroup were of mixed ethnic background, such as German, or Cape-Verdean. Respondents 135

were either the father or the mother of the child, and parental gender was based on this item 136

(male/female). Parental age (years) and educational level were also reported. According to the 137

standard Dutch cut-off points, the educational level of the responding parent was categorized as 138

‘low’ (no education; primary school; ≤ 3 years of general secondary school); ‘mid-low’ (>3 years 139

of general secondary school); ‘mid-high’ (higher vocational training; undergraduate programs); 140

or ‘high’ (higher academic education).36

Respondents reported whether the child lived with both 141

parents vs single parent, and how many siblings the child had. 142



personnel, according to the Youth Health Care protocol.37


was calculated as weight/(height).2 The child’s weight status was categorized as being ‘non-146

overweight’, ‘overweight or obese’ based on the age and gender specific BMI cut-off points 147

published by the International Obesity Task Force.38

148

Feeding style 149


was used to 150


items), ‘instrumental feeding’ (5 items) and ‘encouragement to eat’ (8 items). Parents were asked 152

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to respond on a five-point Likert scale ranging from ‘never’ (1 point) to ‘always’ (5 points). 153

Average scores on each scale were calculated for each parent, and the score was considered as 154

missing if 50% or more of the items of the scale were missing. The percentage of parents with 155

any missing item ranged from 4.6% to 10.1% for the four scales (Table S1). There was no 156

difference in the percentage of parents with any missing item or with 50% or more missing items 157

between ethnic subgroups (p>0.05). In addition we did a sensitivity analyses using complete-158

cases only, results were comparable (data not shown). A higher score indicated a greater 159

tendency for parents to apply a specific feeding style. In the present study, the Cronbach’s α was 160

0.78 for the ‘control over eating’ scale, 0.87 for the ‘emotional feeding’ scale, 0.79 for the 161

‘instrumental feeding’ scale and 0.77 for the ‘encouragement to eat’ scale. 162

Parenting style 163

The validated Dutch version of the Steinberg parenting style instrument 39-41


the two parenting style dimensions: ‘involvement’ and ‘strictness’. The ‘involvement’ scale 165

contains nine items that assess indicators of parental loving, responsiveness, and involvement 166

(e.g. ‘My child can count on me when he or she has some kind of problem’). The ‘strictness’ 167

scale contains six items that assess parental monitoring and supervision of the child (e.g. ‘I know 168

what my child does in his or her free time’). Parents were asked to respond on a five-point Likert 169

scale ranging from ‘strongly disagree’ (1 point) to ‘strongly agree’ (5 points). Average scores on 170

each scale were calculated for each parent, and the score was considered as missing if 50% or 171

more of the items of the scale were missing. The percentage of parents with any missing item 172

was 7.1% and 10.1% for the involvement and strictness scale respectively.(Table S1). There was 173

no difference in the percentage of parents with 50% or more missing items between ethnic 174

subgroups (p>0.05). In addition we did a sensitivity analyses using complete-cases only, results 175

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were comparable (data not shown). Based on the median split of both scales,40

the dimensions of 176

parenting style were further defined into the following categories: authoritative (high 177

involvement and high strictness), authoritarian (low involvement and high strictness), indulgent 178

(high involvement and low strictness), and neglectful (low involvement and low strictness). 179

Unhealthy snacking behavior of the child 180

Two items in the parental questionnaire were used to assess children’s unhealthy snacking 181

behavior. The questionnaire items were based on previously used questionnaires, mainly used in 182

earlier Dutch studies.42 43

In the present study, unhealthy snacks were defined as energy-dense 183

nutrient-poor foods eaten between the three main meals. Parents were provided with the 184

following examples of unhealthy snacks: crisps, nuts, chocolate, mars bars, pastry, iced cake, ice 185

cream, pizza, meatballs, and burgers. Parents reported how many days in a normal week the 186

child ate unhealthy snacks (response categories: ‘every day’ and ‘not every day’) and the 187

frequency of eating unhealthy snacks on such a day (response categories ranged from ‘none’, ‘1 188

per day’ to ‘5 or more per day’). The frequency of eating unhealthy snacks per day was 189

dichotomized into ‘≤1 snack per day’ and ‘>1 snack per day’. 190




the child’s ethnic background were compared using a ANOVA or Kruskal-Wallis test for 194

continuous variables and a Chi-square test for categorical variables. 195

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parenting styles were associated with the children’s unhealthy snacking behavior. Unhealthy 197

snacking behavior of the child was assessed using two variables: unhealthy snacks every day 198

(yes/no), and unhealthy snack frequency per day (≤1 or >1 per day). Descriptive results of the 199

dimensions of feeding style, dimensions of parenting style, the parenting style categories 200

according to child snacking behavior are presented in supplemental material (Table S2). Separate 201

logistic regression models were built for each dimension of feeding style, dimension of parenting 202

style and parenting style categories, adjusted for potential confounders. In order to select 203

potential confounders, we used logistic and general linear regression to examine the associations 204

between potential confounders and children’s unhealthy snacking behavior, and dimensions of 205

feeding style, and dimensions of parenting style and parenting style categories. Factors were 206

considered as potential confounders if they were associated with both the children’s unhealthy 207

snacking behavior and any of the dimensions of feeding style, dimensions of parenting style and 208

parenting style categories. The following factors were evaluated as potential confounders: 209

responding parents’ age, gender, education level, weight status, single parent vs both parents, and 210

child age, gender, weight status, and number of siblings. 211

To examine whether the associations between dimensions of feeding style, dimensions of 212

parenting style, parenting style categories and the children’s unhealthy snacking behavior 213

differed according to the children’s ethnic background, an interaction term of the independent 214

variable with child ethnic background was added to the model. The interaction term was 215

considered significant at a level of p<0.10.44

In Table 4, the significant interaction terms are 216

indicated. The logistic regression models were repeated for subgroups of children with a Dutch, 217

Surinamese/Antillean, Moroccan/Turkish, and other ethnic background respectively. Assuming a 218

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random missing pattern of data, complete–subject analyses were chosen to handle the missing 219

values.45

All analyses were conducted using the statistical software SAS (version 9.3, SAS 220

Institute Inc., Cary, NC, 2010). 221

Results 222



the overall sample as well as for each subgroup based on the children’s ethnic background. The 225

mean age of the children in our study was 9.4 (SD 1.8) years; 45.9% of them were boys and 30.3% 226

had a Dutch ethnic background. Based on the parents’ report, 14.6% of the children ate 227

unhealthy snacks on a daily basis, and 29.7% ate unhealthy snacks more than once a day. The 228

mean age of the responding parents was 37.9 (SD 7.4), 87.4% of them were mothers, and 18.5% 229

indicated having completed a high level of education. 230



Overall

sample

(n=644)

Dutch

(n=195)

Surinamese/

Antillean

(n=142)

Moroccan/

Turkish

(n=186)

Other ethnic

background

(n=121)

p-

value*



Gender, girl, n (%) (missing

n=12)

342 (54.1) 107 (55.2) 76 (53.9) 89 (50.0) 70 (58.8) 0.50

Number of siblings, n>1 (%)

(missing n=2)

530 (82.6) 157 (80.5) 114 (80.3) 167 (90.3) 92 (76.7) <0.001


(missing n=45)

138 (23.0) 25 (13.8) 35 (26.1) 54 (31.8) 24 (21.1) 0.002

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Unhealthy snacks daily, n (%)

(missing n=12)

92 (14.6) 32 (16.8) 20 (14.2) 21 (11.4) 19 (16.2) 0.45

Unhealthy snacks per day, n

(%) (missing n=17)

0.37

>1 snack per day 186 (29.7) 55 (28.8) 37 (26.1) 56 (30.4) 38 (32.8)


Gender, female, n (%) (missing

n=47)

522 (87.4) 166 (88.8) 127 (94.8) 140 (82.4) 89 (84.0) 0.007


Education level of the parent

(missing n=21)

<0.001

Low 137 (22.0) 20 (10.6) 16 (11.4) 75 (41.2) 26 (23.2)

Mid-low 156 (25.0) 58 (30.7) 33 (23.6) 46 (25.3) 19 (17.0)

Mid-high 215 (34.5) 61 (32.3) 66 (47.1) 45 (24.7) 43 (38.4)

High 115 (18.5) 50 (26.5) 25 (17.9) 16 (8.8) 24 (21.4)

Single parent, n(%) (missing,

n=5)

171(26.76) 45(23.4) 59(41.5) 29(15.6) 38(31.9) <0.001



Force. 235

Over all, the scores for all the dimensions of feeding styles , parenting style and parenting 236

style categories were different between the ethnic subgroups (p<0.05) (Table 2). In addition, post 237

hoc analysis showed that parents of children with a Dutch ethnic background reported using the 238

highest levels of ‘control over eating’, and ‘encouragement to eat’, but the lowest levels of 239

‘instrumental feeding’ and ‘emotional feeding’(p<0.05). Parents of children with a 240

Surinamese/Antillean ethnic background had similar levels of ‘encouragement to eat’, 241

‘instrumental feeding’, and ‘emotional feeding’ compared to parents of children with a Dutch 242

ethnic background, but a lower level of ‘control over eating’ (p<0.05). Parents of children with a 243

Moroccan/Turkish ethnic background reported using the highest levels of ‘instrumental feeding’ 244

and ‘emotional feeding’ (p<0.05). With regard to the dimensions of parenting style, the levels of 245

parental ‘involvement’ and ‘strictness’ were similar between parents of children with a Dutch, 246

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Surinamese/Antillean, and Moroccan/Turkish ethnic background (p>0.05). Parents of children 247

with Surinamese/Antillean ethnic background used ‘authoritarian’ parenting style less often than 248

as Dutch parents did (p<0.05). 249

Table 2 Average scores on feeding style dimensions, parenting style dimensions and parenting style categories 250

according to the children’s ethnic background (n=644) 251

Dutch

(n=195)

Surinamese/

Antillean

(n=142)

Moroccan/

Turkish

(n=186)

Other ethnic

background

(n=121)

p-value

Feeding style dimensions,

mean (SD)

Control over eating 4.03 (0.55) 3.72 (0.63) 3.76 (0.58) 3.56 (0.72) <0.001

Emotional feeding 1.58 (0.66) 1.58 (0.60) 2.02 (0.87) 2.03 (0.94) <0.001

Encouragement to eat 3.86 (0.62) 3.80 (0.69) 3.74 (0.66) 3.72 (0.67) 0.03

Instrumental feeding 1.93 (0.78) 1.90 (0.77) 2.56 (0.91) 2.28 (0.93) <0.001

Parenting style dimensions,

mean (SD)

Involvement 4.58 (0.33) 4.65 (0.36) 4.55 (0.42) 4.48 (0.51) 0.02

Strictness 4.58 (0.58) 4.52 (0.63) 4.50 (0.57) 4.41 (0.71) 0.03

Parenting style categories,

n (%)

Authoritative 70 (37.63) 66 (47.83) 67 (37.43) 40 (34.78) 0.007

Authoritarian 36 (19.35) 8 (5.80) 16 (8.94) 15 (13.04)

Indulgent 25 (13.44) 21 (15.22) 27 (15.08) 13 (11.30)

Neglectful 55 (29.57) 43 (31.16) 69 (38.55) 47 (40.87)

* p-value derived from Kruskal-Wallis test (feeding style dimensions and parenting style dimensions) or Chi-square 252

test (parenting style categories). 253

Associations between dimensions of feeding style, parenting style, 254

parenting style categories and children’s unhealthy snacking 255

behavior 256

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Table 3 presents the associations between dimensions of feeding style, dimensions of parenting 257

style and parenting style categories and children’s unhealthy snacking behavior. With regard to 258

the dimensions of feeding style, children whose parents had a higher score on ‘control over 259

eating’ had a lower odds of eating unhealthy snacks every day (OR 0.63; 95% CI :0.44 to 0.91), 260

and of eating unhealthy snacks more than once per day (OR 0.57; 95% CI :0.42 to 0.76). With 261

regard to the dimensions of parenting style, no significant association was observed for neither 262

the ‘involvement’ nor the ‘strictness’ dimension with children’s unhealthy snacking behavior. 263

Children of parents having an ‘indulgent’ parenting style were less likely to eat unhealthy snacks 264

every day (OR 0.25; 95% CI :0.09 to 0.73), compared to children of parents using an 265

‘authoritative’ parenting style. 266

Table 3. Results of the logistic regression analyses for the associations of feeding style dimensions, parenting 267

style dimensions and parenting style categories with children’s unhealthy snacking behavior (n=644) 268


(Yes vs No)

Unhealthy snack frequency per day

(>1 vs ≤1)



Adjusted

†



Control over eating

0.63 (0.45, 0.88) 0.63 (0.44, 0.91) 0.54 (0.41, 0.71) 0.57 (0.42, 0.76)




Parenting style

dimensions

Involvement 0.56 (0.33, 0.93) 0.60 (0.35, 1.04) 0.68 (0.45, 1.04) 0.78 (0.50, 1.21)

Strictness 1.23 (0.83, 1.82) 1.43 (0.92, 2.21) 0.80 (0.61, 1.05) 0.89 (0.66, 1.20)



Authoritarian 1.14 (0.57, 2.27) 1.10 (0.53, 2.28) 1.20 (0.68, 2.11) 1.31 (0.72, 2.38)

Indulgent 0.26 (0.09, 0.76) 0.25 (0.09, 0.73) 0.90 (0.51, 1.60) 0.87 (0.48, 1.56)

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Neglectful 0.94 (0.57, 1.57) 0.84 (0.48, 1.46) 1.33 (0.89, 1.98) 1.21 (0.78, 1.87)


confounders. 270




children’s unhealthy snacking behavior. 274

Analyses according to the children’s ethnic background 275

Table 4 shows the associations of dimensions of feeding style, dimensions of parenting style, and 276

parenting style categories with children’s unhealthy snacking behavior according to the 277

children’s ethnic background. With regard to feeding style dimensions, a higher score on the 278

‘control over eating’ was associated with a lower possibility of eating unhealthy snacks every 279

day for children with a Dutch ethnic background (OR 0.41; 95% CI: 0.21 to 0.79), and for 280

children with a Moroccan/Turkish ethnic background (OR 0.40; 95% CI: 0.19 to 0.88). A higher 281

score on the ‘encouragement to eat’ was associated with lower possibility of eating unhealthy 282

snacks every day for children with Dutch ethnic background only (OR 0.48; 95% CI: 0.25 to 283

0.90). In addition, a higher score on the ‘control over eating’ was associated with a lower 284

possibility of eating unhealthy snacks more than once per day for children with a Dutch ethnic 285

background (OR 0.37; 95% CI: 0.20 to 0.68), and for children with a Moroccan/Turkish ethnic 286

background (OR 0.44; 95% CI: 0.25 to 0.77). Finally, ‘instrumental feeding’ was associated with 287

a higher possibility of eating unhealthy snacks more than once per day for children with a 288

Moroccan/Turkish ethnic background only (OR 1.43; 95% CI: 1.01 to 2.04). 289

With regard to parenting style dimensions, a higher score on parental ‘involvement’ was 290



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background whose parents had a ‘neglectful’ parenting style were more likely to eat unhealthy 293

snacks more than once a day (OR 2.78; 95% CI :1.05 to 7.33) compared to children from parents 294

that had an ‘authoritative’ parenting style. 295

Table 4. Results of the logistic regression analyses for the associations feeding style dimensions, parenting 296

style dimensions and parenting style categories with the children’s unhealthy snacking behavior, stratified by 297

the children’s ethnic background 298

Dutch

n=195

Surinamese/

Antillean

n=142

Moroccan/

Turkish

n=186

Other ethnic

background

n=121

OR (95% CI) †

OR (95% CI) †

OR (95% CI) †

OR (95% CI) †



Control over eating*

0.41 (0.21, 0.79) 1.17 (0.52, 2.64) 0.40 (0.19, 0.88) 0.66 (0.33, 1.31)





Involvement* 1.00 (0.32, 3.17) 1.74 (0.39, 7.86) 0.51 (0.18, 1.41) 0.25 (0.09, 0.67)

Strictness* 2.04 (0.86, 4.85) 2.60 (0.84, 8.09) 0.92 (0.41, 2.06) 0.67 (0.35, 1.29)

Parenting style categories*


Authoritarian 1.25 (0.48, 3.22) 0.58 (0.07, 5.16) 1.77 (0.31, 10.09) 0.49 (0.05, 4.54)

Indulgent -‡ 0.20 (0.03, 1.66) 1.55 (0.34, 6.99) -

‡

Neglectful 0.53 (0.20, 1.40) 0.31 (0.08, 1.18) 2.01 (0.68, 6.51) 2.33 (0.74, 7.33)

Unhealthy snacks >1 times per

day


Control over eating* 0.37 (0.20, 0.68) 1.02(0.56, 1.85) 0.44 (0.25, 0.77) 0.44 (0.24, 0.79)



Instrumental feeding* 1.10 (0.74, 1.64) 0.84 (0.51, 1.38) 1.43 (1.01, 2.04) 0.80 (0.52, 1.25)


Involvement 1.26 (0.48, 3.29) 0.88 (0.31, 2.49) 0.65 (0.31, 1.37) 0.45 (0.20, 1.02)

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Strictness 1.13 (0.64, 2.00) 0.77 (0.43, 1.38) 0.83 (0.48, 1.44) 0.58 (0.33, 1.00)



Authoritarian 1.79 (0.77, 4.14) -‡ 1.15 (0.35, 3.75) 0.94 (0.21, 4.14)

Indulgent 0.97 (0.35, 2.68) 0.83 (0.27, 2.61) 0.46 (0.14, 1.51) 2.68 (0.67,

10.73)

Neglectful 0.64 (0.28, 1.48) 1.03 (0.44, 2.44) 1.62 (0.79, 3.33) 2.78 (1.05, 7.33)







Discussion 305

In this study, we investigated the associations of dimensions of feeding style, dimensions of 306

parenting style and parenting style categories with unhealthy snack consumption in school-aged 307

children from a multi-ethnic population. In line with our hypothesis, ‘control over eating’ was 308

associated with lower unhealthy snacking behavior of the child. We did not observe significant 309

associations between ‘encouragement to eat’, ‘instrumental feeding’ and ‘emotional feeding’ and 310

child unhealthy snacking behavior. Also, no association between an ‘authoritative’ parenting 311

style and child unhealthy snacking behavior was observed. Our hypothesis with regard to 312

different associations of dimensions of feeding style, dimensions of parenting style and parenting 313

style categories with children’s unhealthy snack consumption according to the ethnic background 314

of the child, was confirmed for some of the ethnic subgroups. 315

In line with previous studies, the present study found that children whose parents had a 316


Further 317

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consumption in most of the ethnic subgroups, except for the subgroup of children with a 319

Surinamese/Antillean ethnic background. An explanation for the lack of finding among the 320

Surinamese/Antillean ethnic subgroup may be their compliance to their traditional dietary 321

pattern.46

This traditional dietary pattern contains more vegetables and fruits and less unhealthy 322

snack food.46

Therefore, parents may facilitate child’s healthy snacking behavior, without having 323

to use control over eating. 324

In the present study, ‘encouragement to eat’ was associated with a lower unhealthy snack 325

consumption only in the subgroup of children with a Dutch ethnic background. It is possible that 326

the association between ‘encouragement to eat’ and lower unhealthy snack consumption only 327

exists when parents provide the child with more healthy alternative foods instead of unhealthy 328

snack foods. Further studies examining the association between parental encouragement and 329

children’s unhealthy snack consumption should consider the potential influence of food 330

provision. 331

Previous research suggested that ‘emotional feeding’ and ‘instrumental feeding’ were 332




intake only existed among children with a Moroccan/Turkish ethnic background and in children 335

with an ‘other’ ethnic background. In addition, our study results showed that parents of children 336

with a Moroccan/Turkish ethnic background were also more likely to apply, i.e. scored higher on 337

these dimensions, ‘instrumental feeding’ and ‘emotional feeding’ compared to the Dutch, 338

Surinamese/Antillean and other ethnic background subgroups. These findings combined are 339

comparable to previous findings indicating that parents mainly offer unhealthy snack food in the 340

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context of ‘emotional’ and ‘instrumental’ feeding styles.47

As a consequence hereof, using 341

snacks as a reward may increase children’s preference for the rewarding snack.48

Consequently, 342

higher exposure together with increased preference for the unhealthy snack food may contribute 343

to an increased risk of high unhealthy snack intake among children. Therefore, further 344

interventions should discourage the use of ‘instrumental feeding’ and ‘emotional feeding’ in 345

parents of children with a Moroccan/Turkish ethnic background. 346

Although previous studies suggested that having an ‘authoritative’ parenting style was 347

associated with lower unhealthy snack consumption of children, we found no association 348

between this parenting style category and children’s unhealthy snack consumption. The lack of 349

association might be due to the low variability on the scores of both the ‘involvement’ and 350

‘strictness’ dimensions among parents. Only in the subgroup of children with an ‘other’ ethnic 351

background, a ‘neglectful’ parenting style, which is characterized by low ‘involvement’ and low 352

‘strictness’, was associated with a higher unhealthy snack consumption. This observation, of an 353

association between having a neglectful parenting style and more unhealthy snacking behavior is 354

in line with previous research.16 17

However, the contribution of ethnic background in this 355

association is difficult to explain due to the diverse population (i.e. children with mixed ethnic 356

background) within this subgroup. 357

Our study suggests that the associations of feeding style dimensions, parenting style 358

dimensions and parenting style categories with child unhealthy snack consumption differed 359

according to the ethnic background of the child. Moreover, the findings suggest differences 360

between subgroups in the appliance of the different feeding styles and parenting styles. 361

Differences in parental beliefs, knowledge practices (e.g.: modeling, food provision) and 362

children’s food preferences between ethnic subgroups25 27

may contribute to these differential 363

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applications and associations. We recommend conducting further qualitative and quantitative 364

research to gain more insight in these ethnic-group differences in associations between feeding 365

styles and children’s snacking behavior. Increased understanding may be helpful in developing 366

tailored interventions for reducing unhealthy snack consumption in different ethnic subgroups. 367


enabled us to analyze the associations of feeding styles and parenting styles with children’s 369

unhealthy snacking behaviors in different ethnic subgroups, and the use of validated 370



social desirability and recall bias could have been possible. Parental reports have shown to be an 373

accurate method to estimate dietary intake in school aged children.49

However, further studies 374

may include a combination of parental report, child report and observational measures to 375

estimate the child’s snacking behavior. In addition, the questionnaires were provided in Dutch 376

only, which could have been a barrier for some parents given the diverse ethnicity of our study 377

population. We did not collect data related to language spoken, however parents in all ethic 378

subgroups were living in the Netherlands for, on average, over 20 years, indicating a familiarity 379

with the Dutch language and culture (data not shown). Secondly, performing stratified analysis, 380

reduced our sample size and therewith power to detect differences. Finally, given the 381

observational nature of cross-sectional design, this study does not allow firm conclusions with 382

regard to causality. 383

Conclusion 384

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Contributors 392




CM, WJ, HR) were involved in writing the paper and had final approval of the submitted 396

manuscript. 397


Overweight. 399






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The Medical and Ethical Review Committee of the Erasmus Medical Centre issued a 407

‘declaration of no objection’ (i.e. formal waver) for this study (reference number MEC-2011-408

183). Passive parental consent was obtained; parents (and children) were informed about the 409

intervention and the study, and were free to refuse participation without giving any explanation. 410



References 413




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62. 421



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9. Duffey KJ, Pereira RA, Popkin BM. Prevalence and energy intake from snacking in Brazil: analysis of the 430

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S1 Table. Description of missing items for each dimension of feeding style and parenting style according 529

to child ethnic background. 530

S2 Table. Descriptive results of feeding style dimensions, parenting style dimensions, parenting style 531


533

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Table S1 Description of missing items for each dimension of feeding style and parenting style according to child ethnic background.

Total

population

(n=644)

Dutch

(n=195)

Surinamese/

Antillean

(n=142)

Moroccan/

Turkish

(n=186)

Other ethnic

background

(n=121)

p-

value*

n (%) n (%) n (%) n % n (%)


Control over eating (10 items) >0a

46(7.14) 12(6.15) 10(7.04) 13(6.99) 11(9.09) 0.804

≥50% b

11(1.71) 3(1.54) 0(0) 3(1.61) 5(4.13) 0.080

Emotional feeding (4 items) >0 a 39(6.06) 16(8.21) 6(4.23) 11(5.91) 6(4.96) 0.443

≥50% b 11(1.71) 4(2.05) 0(0) 2(1.08) 5(4.13) 0.063

Encouragement to eat (5

items)

>0 a

65(10.09)

21(10.77) 8(5.63) 19(10.22) 17(14.05) 0.151

≥50% b 11(1.71) 3(1.54) 1(0.7) 2(1.08) 5(4.13) 0.135

Instrumental feeding (8 items) >0 a 30(4.66) 11(5.64) 3(2.11) 10(5.38) 6(4.96) 0.434

≥50% b 12(1.86) 4(2.05) 0(0) 3(1.61) 5(4.13) 0.102

Parenting style dimensions.

Involvement (9 items) >0 a 46(7.14) 13(6.67) 8(5.63) 15(8.06) 10(8.26) 0.796

≥50% b 17(2.64) 5(2.56) 0(0) 6(3.23) 6(4.96) 0.084

Strictness (6 items) >0 a 65(10.09) 30(15.38) 13(9.15) 12(6.45) 10(8.26) 0.025

≥50% b 24(3.73) 9(4.62) 3(2.11) 6(3.23) 6(4.96) 0.551

*p-value derived from Chi-square test. Bold printed values indicate significant difference between ethnic subgroups.

a:Number and percentage of parent with any missing item on this specific dimension.

b:Number and percentage of parents with at least 50% of the items on this specific dimension missing.

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behavior


Yes No P-value* <=1 >1 p-value

*


Control over eating 3.82(0.60) 3.62(0.78) 0.006 3.87(0.60) 3.61(0.68) <0.001





Involvement 4.47(0.53) 4.59(0.38) 0.011 4.59(0.39) 4.53(0.45) 0.170

Strictness 4.57(0.58) 4.5(0.62) 0.317 4.53(0.59) 4.45(0.65) 0.139


Authoritative 38(17.27) 182(82.73) 0.032 159(71.95) 62(28.05) 0.123

Authoritarian 11(15.71) 59(84.29) 50(71.43) 20(28.57)

Indulgent 4(5.26) 72(94.74) 57(76) 18(24)

Neglectful 33(17.19) 159(82.81) 132(69.11) 59(30.89)

* p-value derived from Wilcoxon test (feeding and parenting style dimensions) or Chi-square test (parenting style categories).

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Introduction



Methods



collection

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Participants

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applicable

6&7&8

Data sources/

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why

6&7&8






Results

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confounders

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13&14




Discussion




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16&17&18


Other information



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BMJ Open · For peer review only Feeding styles, parenting styles and snacking behavior in school...

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