Mother knows best? Feeding styles and child obesity
Gerald Hurowitz, M.D.·Published 19 March 2008·22 min read
Key points
Too many American children are overweight, and they're only getting fatter, with deleterious consequences for their health.
Many of the behaviors discussed in this article are innate behavioral dispositions or culturally mediated attitudes about food, which have not changed in generations.
Why it matters: Children who are less inhibited temperamentally also seem to be less inhibited about eating, and this behavioral style has been linked with a higher risk of overweight.
The issue: Some mothers think they need restrictive rules about eating.
Too many American children are overweight, and they're only getting fatter, with deleterious consequences for their health. But concerned pediatricians need help in designing effective interventions. This examination of how mother/child feeding interactions factor into a complex situation can help.
On a daily basis, the busy pediatric provider is faced with the task of helping parents keep their children healthy in an environment where TV promotes the consumption of high-calorie food, and overweight is so common it looks normal.
The individual pediatrician's ability to alter this obesity-inducing environment is limited. But they can and do have influence on the way parents and their children behave. While fathers play an important part in this framework, this review focuses exclusively on the mother/child dyad, for the simple reason that very few studies of fathers' role in feeding have been published.
A central theme in the study of the dyadic interaction is its reciprocal nature: maternal feeding style is altered by child behavior, and child behavior is altered by maternal feeding style. Neither is independent of the other. Therefore, one cannot assume that a child's weight status is due entirely to the mother's feeding practices. The pediatrician's role is to find the point in the relationship where effective intervention is possible. Don't expect this task to be easy. According to a recent survey, most pediatricians (81%) find the lack of parental involvement one of the greatest barriers to treating childhood obesity. But when the effort succeeds, the rewards are considerable.
A word about nature vs. nurture
Many of the behaviors discussed in this article are innate behavioral dispositions or culturally mediated attitudes about food, which have not changed in generations. These relatively stable genetically or culturally mediated behaviors may have been highly functional at one time. But as the environment in which they are expressed changes, these same characteristics can contribute to increasing rates of obesity.
For example, during the Depression, or in war-torn Europe and Asia, or at any time in history when food supplies were uncertain, mothers who urged their children to "clean their plates" were engaging in a highly adaptive behavior. But in the US today, where food in large portions is available to almost everyone, a belief system built on an imperative that food must not be wasted can contribute to childhood obesity.
Fifty years ago, when television ads for high-calorie foods were not ubiquitous, a child's genetic predisposition to respond to external rather than internal cues to eat may not have been problematic. Today, children are barraged by ads designed to increase their consumption of junk food—children 8 to 12 years of age see more than 7,600 food ads a year (more than 50 hours) on TV alone.5 Therefore a genetic predisposition to be more responsive to external food cues may be much more dangerous today than it was decades ago, when children had less media exposure. It's a factor worth considering when examining how kids today respond to food.{pagebreak}
Written and revised by
Gerald Hurowitz, M.D.
Our doctors write and review articles for accuracy and keep them up to date.
health.am provides general information, not medical advice. Always consult a qualified health professional about your own health.
As we noted earlier, children may exhibit a variety of behaviors and attitudes about food, some of which may be genetically or culturally mediated. Eating in the absence of hunger (EAH) is an example of a behavioral phenotype that is relatively stable in individual children, and is also believed to be genetically mediated.
Imagine two school-age children who have just finished lunch on a Saturday afternoon. Both children are presumably satiated. An hour later, one child asks her mother for a snack, even though she couldn't possibly be hungry. The other child, offered popcorn by a teenage brother watching a football game, turns it down and runs off to play. The first child is displaying a behavioral phenotype of high EAH. The second child has low EAH.
Children with high EAH seem to eat in response to social cues in the environment; they don't have to be hungry. Children with low EAH, once they are satiated, are relatively impervious to prompts to eat from the environment. Children with high EAH have a higher body mass index (BMI), and are more likely to be overweight. These children presumably elicit responses from their parents that are different from responses to low EAH children, and require different types of parenting where food is concerned.
The issue: Children who demand food, even when they're not hungry.
Why it matters: Eating in the absence of hunger (EAH) is a behavioral phenotype that seems to be genetic, and has been linked to a higher risk of becoming overweight. Mothers may be reluctant to withhold food from a child who seems to be "always hungry." It may be worthwhile to help mothers recognize that a child like this may have a genetically-driven behavioral trait that puts her or him at risk, and to therefore try to figure out whether the child is truly hungry before providing food.
Starting the conversation: "Some parents tell me they have to remind their kids to eat, and others tell me their children are always looking for food, even when they've just eaten a good meal. What is your child like? Is it hard to figure out whether your child is really hungry? How do you tell? What do you do if the child says he's hungry, but you're pretty sure he can't be? Why do you think your child says she's hungry when she probably isn't? Are there times of day when this seems to happen? After school but before dinner time, when the child may be bored? After dinner but before bedtime, when she's probably tired? Can you think of anything you could do to make the child less likely to think she's hungry?"
A child with an innately voracious eating style is also more likely to become overweight. Infants with a fast and strong suck are more likely to become overweight by the time they are 2 to 3 years old. And children who eat fast and chew each bite less are more likely to be overweight even by the time they're a year and a half old. These "good eaters" may elicit joy and praise from grandmothers the world over, but their mothers' response may be different, depending on her own goals.
For example, a mother who has struggled with her own weight most of her life may view this type of voracious eating as a harbinger of future weight problems, and may, for that reason, adopt a particularly restrictive feeding style. On the other hand, a mother whose vision of a healthy child is one who is actually overweight may encourage and reinforce this type of eating with more frequent and enthusiastic feedings.
{pagebreak} "Look how well she eats!"
The issue: A voracious eating style that goes all the way back to infancy or toddlerhood has been linked to an increased risk of overweight. Like EAH, being a voracious eater is also thought to be a genetic trait.
Why it matters: The mother may perceive a child like this as having a robust appetite, and may respond by feeding the child more than she would a child who doesn't have this trait.
Starting the conversation: "Some children are very careful, selective, and slow in their eating. Others are enthusiastic eaters who dive right in, eat a lot, eat it quickly, and really enjoy it. What's your child's eating style? Most people really like to see children who love to eat. Do you feel that way about it? Do you think it's a good thing, or does it seem like a problem? Have you ever changed the way you feed her because of her eating style? What do you think is the best way for a mother to respond to different eating styles?"
Particular temperaments, or styles of interacting with the environment, have also been linked to an increased risk of overweight. Children who are particularly distractible, active, inattentive, and unpredictable are more likely to be overweight. Children with externalizing behavior problems or attention deficit hyperactivity disorder (ADHD) are also known to be at risk for being overweight.
To function well, these uninhibited children may need more external control from their parents in all areas of life. Controlling how the child eats may be just one more example of how mothers modify their feeding behavior to meet the behavioral needs of the child.
The child who lacks inhibitions
The issue: A child with a disinhibited temperament.
Why it matters: Children who are less inhibited temperamentally also seem to be less inhibited about eating, and this behavioral style has been linked with a higher risk of overweight.
Starting the conversation: "Children have different ways of reacting to new situations. Some hang back and want to come to understand the situation, while others like to jump right in. Some parents tell me their child is very focused, selective, and careful about eating, while other parents say their children are uninhibited, enthusiastic, busy eaters. How would you describe your child? Does your child's way of approaching eating have an effect on their nutrition, do you think? Is that ever a problem for you? What works well in dealing with it?" {pagebreak} What mom brings to the table
Broadly conceptualized, mothers' feeding styles fall into one of three possible modes: pushing, restricting, and controlling. Each of these styles has been the subject of extensive study in relation to child overweight, and the jury is still out on whether there is a clear causal relationship between any one of the these styles and the child's risk of becoming overweight. Data from these studies will be reviewed briefly here. A more extensive review is available elsewhere.
Studies on the impact of maternal pushing, pressuring, or prompting children to eat have had conflicting results. Some show thinner children are prompted more often to eat, others show heavier children getting more prompts, and still others show no relationship at all. Mothers who restrict access to food or to particular foods tend to be more concerned about their child's being too heavy, and they tend to have children who are heavy. This link between restrictive maternal feeding styles and overweight appears to be particularly true for girls, possibly because mothers may be more concerned about having an overweight daughter than an overweight son.
Of course, there are also mothers who allow children a relatively free choice in what they eat. This "hands off" style, like restrictive styles, has not been consistently linked to weight status. Some studies show that mothers of heavier children allow more choice. Others show mothers of thinner children tend to have this feeding style. And some show no relationship. The upshot of all this seems to be that the link, if any, between maternal feeding style per se and childhood obesity remains unclear.
"I don't allow eating between meals"
The issue: Some mothers think they need restrictive rules about eating.
Why it matters: Parents tend to exert more control over the eating behavior of children who are already somewhat heavy. There is evidence that this only increases the child's risk of becoming obese.
Starting the conversation: "Some parents find they need to have a lot of rules and restrictions about eating, or else their children would not eat a healthy diet. Other families don't feel they need many food rules. What's your family like? What kind of rules and restrictions do you have? Which ones work best? Which don't work so well? Why do you think that is? Do you think some children need more rules about eating than others? Why is that?"
A mother's feeding style may interact with other factors that lead to an increased risk of overweight. Obese mothers express more concern about their child's eating and becoming overweight. These mothers seem to at tune their feeding behavior more carefully to their child's weight status than do non-obese mothers. That may be because they are more invested in preventing their heavy child's progression to obesity.
Yet despite their efforts, genetically mediated behavioral traits may continue to increase the child's risk for overweight. In one study, for example, obese and non-obese mothers were compared as to how frequently they prompted their children about eating. It turned out that both groups of mothers prompted their children with similar frequency, but the children of the obese mothers were more likely to comply with the prompts they received. This study suggests that children who are genetically predisposed to obesity may respond to the same maternal feeding behaviors differently than children who are not genetically predisposed. {pagebreak} Mom and child behaviors
So far, we have considered the feeding behaviors of mothers and children separately. We now turn to the rather limited data available on how the interaction of these factors affects the risk of overweight.
The way a child's EAH affects and is affected by maternal feeding behavior is a classic example. EAH is an independent risk factor for obesity, but its effect can be modified by parenting practices. These parenting behaviors, in turn, may feed back to either promote or reduce EAH. Studies have shown that children of obese mothers demonstrate more EAH than children of non-obese mothers, and disinhibition in maternal eating style has been linked to more EAH in their children.
But these data cannot distinguish between nature and nurture, inherited and learned behavior. Do these mothers and children exhibit disinhibition and EAH because they share a similar genetic makeup, or do the children learn these behaviors from their mothers?
The science seems to suggest that both factors—genetic endowment and learning—are involved. A mother faced with either an overweight child or a child exhibiting robust EAH must decide how to respond. Not surprisingly, the more EAH the child demonstrates and the higher the child's BMI, the more restrictive the mother tends to be in her feeding practices.
That response, though understandable, seems to have the unfortunate effect of leading over time to greater EAH and greater additional weight gain, particularly in children who are already overweight. When overweight children with EAH are restricted at home, they may be more likely to overeat and consume unhealthy foods at a friend's house or at school, where mom can't enforce restrictions.
The mother with an overweight child who exhibits a great deal of EAH is in a catch-22. Without the external control provided by her restrictions, the child's food intake may be excessive. But the more control she tries to exert, the less—in theory—the child is able to develop internal controls and respond appropriately to hunger and satiety. Research does not provide any clear-cut recommendations on how to intervene effectively in this situation.
Temperament may also impact the interaction between mother and child. The child who is temperamentally negative, emotional, easily angered, poorly adaptable, and intense is more like to be overweight. These temperamental characteristics have been linked to more frequent tantrums (see "If I don't let him have the food he wants, he throws a fit") over food, which are in turn linked to a greater risk of becoming overweight. The mother coping with a difficult child might not only use food to quell a tantrum, but also be faced with more food tantrums rooted in the child's intense and persistent temperament. {pagebreak} "If I don't let him have the food he wants, he throws a fit"
The issue: Tantrums over food
Why it matters: Food tantrums have been linked to an increased risk of overweight, and may lead the mother to perceive the child as hungry more often than he actually is.
Starting the conversation: "Sometimes parents tell me that if they don't provide food when the child asks for it, the child has a tantrum. The parents often tell me that it's really difficult to tell if the child is actually hungry, or is having a tantrum for some other reason. Do you ever think your child demands food when she (or he) really isn't hungry? Why do you think she (or he) does that? Have you found any good ways of dealing with this behavior?"
"She's such a difficult child"
The issue: The child is emotional, intense, and persistent.
Why it matters: Children with this kind of difficult temperament may induce parents to use food to get them to calm down. Children like this may be more persistent and intense in demanding food, and have food tantrums more frequently. This temperamental style has been linked to a higher risk of becoming overweight.
Starting the conversation: "People vary in how intense and persistent they are in approaching different problems in life. As an adult, being intense and persistent can really pay off. Often people who are very successful in their work have these traits. But when children have this kind of temperament, it can be a real challenge for their parents. How intense and persistent is your child when he wants something from you? Can you say 'no' and redirect him pretty easily, or is it hard to get him to focus on something else? Sometimes parents tell me their child is very intense and persistent about getting food, even when they're pretty sure he isn't really hungry. Is your child ever like that? How do you deal with it?" {pagebreak} Cultural influences
Understanding how feeding beliefs and practices differ among various cultural and socio-demographic groups can be helpful. For example, African American mothers report more frequent monitoring, restricting, pressuring, and controlling their children's eating than Caucasian mothers of similar socio-economic status (SES). When low-income Hispanic mothers are compared to low-income African American mothers, the feeding styles the Hispanic mothers describe are both more controlling (demanding, threatening, bribing) and more indulgent (reasoning, encouraging) than the African American styles.
Mothers of lower SES, regardless of ethnicity, seem to prompt their children to eat more than mothers with higher SES, a difference that may be due to their concerns about inconsistent or inadequate food supplies. Studies like these are, of necessity, over-generalized. Pediatricians will need to assess for themselves whether they apply to particular families in their care. But observations like these do provide some insight into how cultural and socioeconomic differences affect maternal feeding behavior. They can offer a launching point for a discussion with a particular mother about her feeding beliefs and practices.
Evaluation of a child's weight status is often in the eye of the beholder. When the beholder is the child's mother, the perception is often inaccurate. Maternal accuracy in evaluating a child's weight status has ranged, in various studies, from 15% to 68%. The inability to recognize overweight in one's child transcends SES, race, nationality, and the mother's own weight status.36-42 Mothers have a particularly difficult time recognizing overweight in younger children, and generally speaking, the younger the child, the less concerned the mother. Why is this so? Several factors seem to be involved: community norms for children's weight, the naturally shifting range of adiposity over the course of childhood, and the body type that seems ideal to a particular mother.
Let's start with community norms. Mothers are likely to judge their child's weight status in comparison with the child's peers. Given the rapidly rising prevalence of overweight among children, particularly in low-income and minority populations, a BMI in the 95th percentile or above may be the norm among the child's classmates and neighbors (see "The other kids on the block").
The other kids on the block
The issue: "My mother says he's thinner than most other boys in the neighborhood."
Why it matters: In some communities, half the children are overweight or at risk of overweight. That's been the case for the last decade. When families live in an environment like that, their frame of reference for what constitutes a normal body type has very likely shifted to accommodate this new norm.
Starting the conversation: "Sometimes when parents look back at their own childhood, they remember only one or two kids who were really overweight. When you look at your child's classroom or neighborhood today, do you see more overweight kids than when you were growing up? Sometimes it's hard to tell what a normal weight is any more, since so many grownups and children are overweight. Do you think it's hard to tell if a child is overweight?"
What not to say: Don't ask a mother to compare her child's weight to other children in the same class. Children may find that kind of comparison very distressing.
A second factor that may skew a mother's assessment is the way adiposity shifts over the course of childhood. Babies have a lot of body fat, which they shed as they grow older. Somewhere between the ages of 4 and 6, this process reaches its nadir and children are at their skinniest (see "Losing the baby fat"). Because of this phenomenon, any 5-year-old tends to look skinnier (have less body fat) than a 3-year-old or an 11-year-old. But when that 5-year-old—the one who looks "too skinny" to his mother—is compared with children his own age, he may actually be overweight. {pagebreak} Losing the baby fat
The issue: Somewhere between the ages of 4 and 6, most children have lost their baby fat and are as skinny as they'll ever be.
Why it matters: Parents sometimes respond by prompting the child to eat well beyond satiety. That forms an image of their child as skinny, which persists well beyond the age when natural weight gain has made it inappropriate. Parents may need reassurance that this "skinny age" is natural, appropriate, and typical.
Starting the conversation: "When you look at photographs of yourself growing up, when do you think you were skinniest? How old were you when you started to put on a little more weight? Does your child take after you, do you think? Most children are at their skinniest between the ages of 4 and 6, and after that they start putting more weight on. Some parents worry that their child is always going to grow up to be too thin. Do you ever worry about this?"
A third factor that may be operative has to do with maternal concepts of an ideal body type for a child. If her ideal body type is heavy, a mother may see her normal-weight child as needing to gain weight, and feed her or him accordingly. There are no strong data to support the notion that low-income or minority mothers prefer a heavier body type for children, however.
Pediatricians should also be aware that talk about growth charts, BMI, and percentiles may not be meaningful to many mothers. Several studies of low-income mothers report that they don't understand growth charts, or think the charts have no relevance for their children.
"I don't care what the growth chart shows. I know he's too skinny!"
You pull the chart from the bin on the door for the next well-child exam. Jaden is a 5-year-old boy who has always been healthy, with attentive and conscientious parents eager to follow your every recommendation. You anticipate a smooth well-child visit, but sigh as you flip to the growth chart and note the pattern so many of your patients have taken on in the past 10 years. Jaden's BMI has crept up from the 85th percentile to over the 95th, which puts him in the "overweight" category.
You prepare to discuss nutrition, exercise, and media exposure, and hope that since this family has so eagerly sought and followed your advice in the past, they will take your recommendations to heart. After catching up on events in the family's life over the past year, you ask Jaden's mother if she has any concerns she'd like to address today.
"He's too skinny!" she exclaims. She recounts the concerns of both grandmothers that he is losing too much of his baby fat, and that he is thinner than most other boys in the neighborhood. She concludes by explaining to you that this is just not normal for their family, which is full of people who are naturally "big." As you begin to explain the meaning of his BMI on the chart, she politely cuts you off and says, "Those charts just don't apply to my son, doctor. I know my son and what he should look like, and he's too skinny." {pagebreak} Granny says
The issue: "His grandmother says..."
Why it matters: Parents are more likely to turn to family members than to doctors for advice about feeding. Grandparents, particularly those who have emigrated from countries where food is sometimes scarce, often have views about how children should be fed and how much they should weigh. This often runs counter to standard pediatric advice.
Starting the conversation: "Most parents find family members' advice about feeding really helpful. What advice have you been given that you agree with? What do you disagree with, or question? Sometimes doctors give advice that's different from what grandparents say: What does your mother think about the advice doctors give today? Why do you think she feels that way? Why does your mother think your child should weigh more and be bigger? How did your mother feed you when you were a child? Would you do it the same way, or differently? Do you think the way your mother fed you has influenced the way you eat today?"
Getting parents to care
As many healthcare professionals know to their frustration, parents often seem unconcerned about their children's overweight. Why they are not concerned is a complex question, not well understood. However, we do have some clues. Studies show that parents are more likely to be concerned about a child's overweight and ready to make some changes when:
They perceive the child as less active and slower than other children
They recall a doctor raising concerns about the child's weight in the past, although this, in fact, seems to occur in only about 22% of families
The child is 8 years old or older
The parent is overweight
The child's weight is perceived as a health problem
Overweight parents
The issue: They way parents perceive their child's weight has a lot to do with their own weight status.
Why it matters: Parents are more likely to shape their feeding behavior in response to their child's weight status when they themselves are overweight. These parents are also more likely to address a child's overweight as a problem that needs intervention.
Starting the conversation: "Is being overweight a common problem in your family? How do your family members feel about their weight? Was being overweight something that concerned you as a child? How did you deal with it? What tactics do you find helpful in managing your own weight? What do you find hardest? Do you think the challenges are the same for your child, or different?"
Family history re: weight and health
The issue: Overweight is linked to many health problems.
Why it matters: Parents are more likely to address a child's weight problem if they believe overweight is having an adverse effect on the child's health.
Starting the conversation: "Some families have many members with diabetes or heart disease, and that's particularly likely if they are overweight. Is this true of your family? Is there anyone in the family you think has had health problems related to weight? Why do you think they've had such a difficult time with their weight? Are you worried that your child could have these health problems? What do you think you could do to prevent that?" {pagebreak} Your role as an advocate
Nothing we've said here offers a "quick fix" for the problem of overweight in children. What we have done is to raise points for discussion with mothers who often don't recognize their child's overweight. The pediatrician's goal in raising these topics may not be to change a mother's mind; most parents have strong opinions about the way they feed their children, and are steadfast to change.
Rather, what the pediatrician can do is encourage mothers to think about feeding her child in ways she may not have considered before. The non-confrontational "sometimes" statements ("sometimes mothers say..." or "sometimes parents feel...") suggested as conversation starters throughout this article allow parents a variety of ways to think about a problem, and perhaps reconsider their original view. Indeed, the questions highlighted throughout this article encourage Mom (and Dad) to reflect on their parenting styles and beliefs, and come to their own conclusions about what works and what doesn't.
REFERENCES
1. Faith MS, Berkowitz RI, Stallings VA, et al: Parental feeding attitudes and styles and child body mass index: prospective analysis of gene-environment interaction. Pediatrics 2004;114:e429
2. Birch LL, Fisher JO, Davison KK: Learning to overeat: maternal use of restrictive feeding practices promotes girls' eating in the absence of hunger. Am J Clin Nutr 2003;78:215
3. Spruijt-Metz D, Lindquist CH, Birch LL, et al: Relation between mothers' child-feeding practices and children's adiposity. Am J Clin Nutr 2002;75:581
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