EXPLORING THE RESTRICTIVE FEEDING

PHENOMENON AND THE POTENTIAL

IMPACT ON CHILD FOOD PREFERENCES

KIM JACKSON

MSc (Health Planning & Financing), Postgrad. Diploma (Health Visiting), BN (Bachelor of Nursing)

Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy

Queensland University of Technology Institute of Health and Biomedical Innovation (IHBI)

School of Exercise and Nutrition Sciences Faculty of Health

2018

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences i

Keywords

Binary logistic regression, Child feeding practices, Childhood obesity,

Controlling feeding practices, Food liking, Food preferences, In-depth

interviews, Mixed methods, Parenting, Qualitative, Restriction, Restrictive

feeding practices.

ii Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences iii

Abstract

Background

Poor dietary habits in early life are important predictors for chronic disease and

obesity in adult life and in Australia, obesity now contributes the second largest

burden of disease of all the modifiable lifestyle risk factors. Parents’ influence on

their children’s diet is significant because they usually control the food provided to

their children. While there is a range of ways that a parent might influence their

child’s food environment, this study focuses on parents’ use of restrictive feeding to

control the foods and drinks their children consume. Restrictive feeding is one of a

group of feeding practices referred to as controlling feeding practices, which have

been implicated as increasing children’s risk of developing obesity. Restrictive

feeding was selected as the focus of research for this study because it is unclear

from existing studies whether this type of feeding practice has positive or negative

effects on child dietary health. A selection of studies concluding that parents should

refrain from restricting children’s access to “unhealthy” foods because this practice

may be harmful has been consistently cited in peer reviewed papers. However,

these findings contradict other studies examining restrictive feeding and another

related body of evidence suggesting that early and repeated exposure to a food is

associated with development of child liking for a food. This later evidence suggests

that child liking for an “unhealthy” food may be enhanced by not restricting their

access and ultimately be harmful to children’s long-term dietary health. Closer

examination of existing studies revealed concerns regarding the quality of study

designs and validity of measures of parent restrictive feeding. Development of a

more construct valid measure of parent restrictive feeding was identified as a priority

for this area of research before the effects of this phenomenon on children’s dietary

health can be effectively assessed.

Aim of the study and research methods This study aimed to explore the restrictive feeding phenomenon in-depth and

identify key dimensions of this phenomenon that may contribute to 5 to 6 year old

children’s preferences for restricted foods and drinks. A sequential complementary

mixed methods approach (QUAL → quant) was selected for research. This

commenced with an exploratory qualitative component using a pragmatic approach.

iv Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

Data was collected by telephone interviews and subject to thematic analysis. The

subsequent quantitative component included descriptive analysis of patterns of data

over time and analysis of cross-sectional associations to further explore the key

themes arising from the qualitative component of the study. The total sample

included 211 Australian first time mothers and their 5 to 6 year old children. Data

were collected by the candidate for the qualitative component of this study from a

subset of the sample (n = 29). Quantitative data available from the NOURISH

randomised control trial (Daniels et al., 2009) was used as a secondary source to

complete the quantitative component of this study (n = 211). Child early exposure,

current child intake frequency and mothers’ liking for a selection of commonly

restricted foods and drinks were selected as predictor variables and child liking for

the same foods and drinks was selected as the outcome variable for quantitative

analysis by binary logistic regression.

Key findings and conclusions Qualitative data contributed a number of novel findings to this field of research. Data

suggested that mothers have two characteristically different overall restrictive

feeding intentions, total restriction and restriction in moderation. While intentions of

total restriction were to avoid child access to a food or drink altogether, restriction in

moderation was intended to allow periodic child access to the restricted food or

drink. This intention tended to be associated with mothers’ overt communication to

children with positive connotations about the restricted item, including common

reference to restricted items as “treats”. Qualitative data also suggested that

restriction in moderation was commonly associated with mothers’ own liking for the

same restricted item, whereas totally restricted items were more likely to be items

mothers’ disliked or were not interested in consuming themselves.

Another novel qualitative finding was that individual mothers have different

restrictive feeding intentions for different restricted foods and drinks. Individual

mothers operationalise their restrictive feeding intentions towards specific restricted

foods and drinks by using a range of different restrictive feeding practices.

Commonality in the differential targeting of restricted foods and drinks by mothers in

this sample suggested greater variation in practices applied to different foods and

drinks by individual mothers, than variations in practices between mothers. This

finding suggests that restrictive feeding should be examined in relation to specific

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences v

restricted foods and drinks rather than by composite measures including a range of

different restricted foods and drinks.

Quantitative analysis found lower levels of restriction of a sweet food or drink (lollies,

sweet biscuits, cake, soft drink, fruit drink) to be cross-sectionally associated with

higher child liking for the same sweet food or drink, which was consistent with

qualitative reports. However, quantitative analysis did not provide evidence of a

similar association for the savoury foods examined (fast foods, potato chips, savoury

biscuits) as suggested by qualitative reports. Likewise, mothers’ uncanvassed

qualitative reports of associations between early exposure and child liking for

restricted foods was not confirmed by quantitative analysis. However, quantitative

analysis showed a unique association between mothers’ own liking for a restricted

food or drink and their child’s liking for the same restricted food or drink, beyond

child age of first exposure or current level of restriction (child intake).

Overall, the combination of existing and new evidence suggests that two prominent

dimensions of the restrictive feeding phenomenon may explain associations

between parent restrictive feeding and child liking for restricted foods and drinks.

These are the level of child restriction (child intake) and the connotations of the

restricted food or drink conveyed in mothers’ communication associated with her

restrictive feeding practices. However, further research is required to clarify whether

different parent restrictive feeding behaviours (such as rules, flexible judgement and

avoiding access) and child early exposure exert additional effects on child liking for

restricted foods and drinks.

Significance of research and original contribution to knowledge This study provides a greater understanding of mothers’ use of restrictive feeding. It

proposes an initial conceptual framework and the key dimensions of this

phenomenon that might influence children’s liking for restricted foods and drinks.

The findings will assist parents and practitioners to make better informed decisions

in relation to restrictive feeding, which may contribute to child dietary health. While

further research is required, the key dimensions of this phenomenon proposed by

this study could inform future development of a more construct valid measure of

parents’ restrictive feeding than existing measures. Such a measure would then be

available to the research community to enable better assessment of the effect of

vi Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

parents’ use of restrictive feeding on child diet-related outcomes in future research

studies.

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences vii

Table of Contents

Keywords.................................................................................................................................... i

Abstract .................................................................................................................................... iii

Table of Contents .................................................................................................................... vii

List of Abbreviations ............................................................................................................... xiv

Statement of Original Authorship ............................................................................................ xv

Acknowledgements ................................................................................................................ xvi CHAPTER 1: INTRODUCTION................................................................................................ 1

1.1 BACKGROUND AND CONTEXT ...................................................................................1

1.2 PURPOSE AND SCOPE ................................................................................................6

1.3 CONTRIBUTION TO KNOWLEDGE ..............................................................................7

1.4 OVERVIEW OF THE THESIS ........................................................................................7 CHAPTER 2: LITERATURE REVIEW ..................................................................................... 9

2.1 INTRODUCTION ............................................................................................................9 2.1.1 Overview ...............................................................................................................9 2.1.2 Literature search strategy .................................................................................. 10

2.2 CONCEPTUALISATION AND MEASUREMENT OF RESTRICTIVE FEEDING ........ 10

2.3 STUDIES OF RESTRICTIVE FEEDING USING EXPERIMENTAL DESIGNS........... 14 2.3.1 Experimental study designs and measures ....................................................... 14 2.3.2 Analysis of experimental study results .............................................................. 16 2.3.3 Summary of evidence from experimental studies ............................................. 20

2.4 STUDIES OF RESTRICTIVE FEEDING USING COHORT DESIGNS ....................... 25 2.4.1 Introduction ........................................................................................................ 25 2.4.2 Measures of parent restrictive feeding used in cohort studies .......................... 26 2.4.3 Analysis of cross-sectional study findings ......................................................... 33 2.4.4 Analysis of longitudinal study findings ............................................................... 48 2.4.5 Effect modification by sample characteristics. ................................................... 55

2.5 OVERALL EVIDENCE OF EFFECTS OF PARENT RESTRICTIVE FEEDING.......... 55

2.6 TOWARDS AN EVIDENCE BASED CONCEPTUAL FRAMEWORK FOR THE RESTRICTIVE FEEDING PHENOMENON ................................................................. 61 2.6.1 Introduction ........................................................................................................ 61 2.6.2 Parents’ motivation for restrictive feeding ......................................................... 63 2.6.3 Levels of restriction and types of foods and drinks restricted ........................... 65 2.6.4 Restrictive feeding practices .............................................................................. 67 2.6.5 The way parents’ deliver restrictive feeding practices ....................................... 69 2.6.6 The restrictive feeding phenomenon over time ................................................. 71 2.6.7 The restrictive feeding phenomenon and other control feeding practices......... 74 2.6.8 Summary ........................................................................................................... 75

2.7 GAPS IN KNOWLEDGE .............................................................................................. 75

2.8 AIM AND RESEARCH QUESTIONS ........................................................................... 76 CHAPTER 3: METHODOLOGY & METHOD ........................................................................79

3.1 INTRODUCTION ......................................................................................................... 79

3.2 OVERALL STUDY DESIGN AND PARTICIPANTS .................................................... 80 3.2.1 Study design ...................................................................................................... 80 3.2.2 Participants ........................................................................................................ 84

viii Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

3.3 QUALITATIVE COMPONENT OF THE STUDY .......................................................... 88 3.3.1 Introduction ........................................................................................................ 88 3.3.2 Research question ............................................................................................. 89 3.3.3 Methodology ....................................................................................................... 89 3.3.4 Research method ............................................................................................... 95

CHAPTER 4: QUALITATIVE FINDINGS ............................................................................ 107

4.1 INTRODUCTION ........................................................................................................ 107

4.2 THEME 1: FOODS AND DRINKS RESTRICTED AND LEVEL OF RESTRICTION . 108 4.2.1 Foods and drinks targeted for restriction ......................................................... 108 4.2.2 Child preferences for restricted foods and drinks ............................................ 109

4.3 THEME 2: MOTHERS’ MOTIVATION FOR RESTRICTING FOODS AND DRINKS 110 4.3.1 Mothers’ motivation, beliefs and perceptions ................................................... 110 4.3.2 Relative “nutritional values” .............................................................................. 112 4.3.3 Child weight and gender .................................................................................. 113

4.4 THEME 3: HOW MOTHERS RESTRICT FOODS AND DRINKS: RESTRICTIVE FEEDING PRACTICES. ............................................................................................. 113 4.4.1 Sub-theme 3a: Mothers’ restrictive feeding behaviours .................................. 115 4.4.2 Sub-theme 3b: Mothers’ restrictive feeding communication ............................ 126

4.5 THEME 4: PATTERNS OF RESTRICTIVE FEEDING OVER TIME ......................... 130 4.5.1 Changes in restrictive feeding over time .......................................................... 130 4.5.2 Experiences of restrictive feeding over time .................................................... 131

4.6 THEME 5: ASSOCIATIONS WITH OTHER CONTROLLING FEEDING PRACTICES ............................................................................................................... 134 4.6.1 Pressure and encouragement to eat ............................................................... 134 4.6.2 Instrumental Feeding ....................................................................................... 135

4.7 THEME 6: THE INFLUENCE OF MOTHERS’ OWN PREFERENCES ..................... 138

4.8 SUMMARY OF KEY THEMES EMERGING FROM THE FINDINGS ........................ 141 4.8.1 Overall Summary ............................................................................................. 145

CHAPTER 5: QUANTITATIVE METHOD & FINDINGS ..................................................... 147

5.1 INTRODUCTION ........................................................................................................ 147

5.2 SELECTION OF VARIABLES FROM THE NOURISH DATABASE .......................... 151 5.3 PART I: PATTERNS OF DESCRIPTIVE DATA ......................................................... 152

5.3.1 Introduction ...................................................................................................... 152 5.3.2 Measures and method of data preparation ...................................................... 153 5.3.3 Findings ............................................................................................................ 154

5.4 PART II: ASSOCIATIONS WITH CHILD LIKING FOR RESTRICTED FOODS AND DRINKS ...................................................................................................................... 157 5.4.1 Introduction ...................................................................................................... 157 5.4.2 Method ............................................................................................................. 158 5.4.3 Findings ............................................................................................................ 163

5.5 SUMMARY OF FINDINGS ......................................................................................... 167 CHAPTER 6: DISCUSSION & CONCLUSIONS ................................................................. 169

6.1 INTRODUCTION ........................................................................................................ 169

6.2 TOWARDS A CONCEPTUAL FRAMEWORK: REVISITED ...................................... 170 6.2.1 Dimension 1: Foods and drinks restricted and level of restriction ................... 171 6.2.2 Dimension 2: Mothers’ motivation for restrictive feeding ................................. 174 6.2.3 Dimension 3: Restrictive feeding practices ...................................................... 177 6.2.4 Dimension 4: Patterns of restrictive feeding over time .................................... 185 6.2.5 Dimension 5: Associations with other controlling feeding practices ................ 188 6.2.6 Dimension 6: Mothers’ own liking for restricted foods and drinks .................... 191 6.2.7 Summary of characteristics of restrictive feeding across dimensions ............. 193

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences ix

6.3 PROGRESS TOWARDS A CONCEPTUAL FRAMEWORK ..................................... 194

6.4 IMPLICATIONS OF FINDINGS FOR EXISTING MEASURES OF PARENT RESTRICTIVE FEEDING .......................................................................................... 196

6.5 HOW RESTRICTIVE FEEDING MIGHT BE MEASURED ........................................ 198 6.5.1 Restricted foods and drinks. ............................................................................ 199 6.5.2 Early exposure ................................................................................................. 200 6.5.3 Level of restriction............................................................................................ 200 6.5.4 Restrictive feeding practices: parent behaviours ............................................. 201 6.5.5 Restrictive feeding practices: parent communication ...................................... 202 6.5.6 Potential confounding variables ....................................................................... 203

6.6 FURTHER RESEARCH TO PROGRESS TOWARDS AN EVIDENCE-BASED CONCEPTUAL FRAMEWORK. ................................................................................ 204 6.6.1 Further research for the concept and measurement of restrictive feeding. .... 204 6.6.2 An appropriate child outcome measure for assessing the effects of

restrictive feeding............................................................................................. 206

6.7 DEVELOPING A PRACTICAL MEASURE OF RESTRICTIVE FEEDING ................ 208 6.7.1 Potential restrictive feeding typologies ............................................................ 208 6.7.2 Other factors relevant to developing a measure of restrictive feeding ............ 210

6.8 IMPLICATIONS FOR PRACTICE .............................................................................. 212 6.8.1 Implications for parenting practice ................................................................... 212 6.8.2 Implications for broader community based initiatives ...................................... 213

6.9 STRENGTHS AND LIMITATIONS OF THE STUDY ................................................. 214 6.9.1 Strengths of the study ...................................................................................... 214 6.9.2 Limitations of the qualitative component ......................................................... 215 6.9.3 Limitations of the quantitative component ....................................................... 216

6.10 CONCLUSION ........................................................................................................... 220 REFERENCES ......................................................................................................................223

APPENDICES .......................................................................................................................247 Appendix A Literature review search strategies ....................................................... 247 Appendix B Cohort studies examining restrictive feeding ........................................ 252 Appendix C Potential effect modification by sample characteristics ........................ 264 Appendix D Qualitative studies examining restrictive feeding .................................. 267 Appendix E Participant invitation letter and enclosures............................................ 278 Appendix F Information for interview participants ..................................................... 281 Appendix G Commencing and final interview schedules .......................................... 285 Appendix H Record of main changes to the interview schedule as the study

progressed ....................................................................................................... 289 Appendix I First cycle main group and sub-group codes.......................................... 291 Appendix J Sample of summary table ...................................................................... 296 Appendix K Final second cycle codes: modified main group and additional complex sub-group codes ............................................................... 299 Appendix L Variables selected for analyses ............................................................. 300 Appendix M Frequency and percentage of data for child exposure, intake and

liking. ................................................................................................................ 302 Appendix N Data characteristics of dichotomised groups ........................................ 304 Appendix O Covariates included in binary logistic regression .................................. 307 Appendix P Findings for regression analysis for prediction of child liking for

restricted foods and drinks .............................................................................. 308 Appendix Q Adjusted predictions including characteristic covariates ...................... 311 Appendix R Early exposure: bivariate models and models adjusted for child

intake ............................................................................................................... 313

x Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

List of Figures

Figure 2.1. Strategies of restriction and structure in feeding. ................................................. 13

Figure 2.2. Short-term experiment study designs. ................................................................. 14

Figure 3.1. Sequential mixed methods design ....................................................................... 83

Figure 4.1. Words used by mothers to describe foods and drinks they restrict “in moderation” ........................................................................................................... 138

Figure 4.2. Interim conceptual framework showing associations between emergent themes of the restrictive feeding phenomenon ..................................................... 146

Figure 5.1. Child intake frequency of selected foods and drinks at 5 years ........................ 154

Figure 5.2. Percentage of child sample responses who had tried selected foods and drinks by stated child age .................................................................................... 156

Figure 5.3. Percentage of child sample with high liking (likes a lot) for selected restricted foods and drinks by stated child age ..................................................... 157

Figure 5.4. Prediction model for research question 3. ......................................................... 161

Figure 6.1. Initial conceptual framework for associations between key dimensions of the restrictive feeding phenomenon and child liking for a restricted food or drink....................................................................................................................... 194

Figure 6.2. Potential restrictive feeding typologies: levels of restriction and communication. ..................................................................................................... 209

Figure 6.3. Potential restrictive feeding typologies: context and communication. ................ 210

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences xi

List of Tables

Table 2.1 Child Outcome Measures Used in Experimental Studies of Restrictive Feeding ................................................................................................................... 15

Table 2.2 Summary of Experimental Studies Examining the Effects of Restricting Foods on Children’s Responses ............................................................................. 22

Table 2.3 Comparison of Scale Items Included in the Main Questionnaires Used in Cohort Studies to Measure Parent Restrictive Feeding ......................................... 31

Table 2.4 The Restricted Access Questionnaire (RAQ) (Fisher & Birch, 1999b) .................. 32

Table 2.5 Cross-Sectional Associations Between Parent Restrictive Feeding and Child Weight Status ......................................................................................................... 36

Table 2.6 Cross-Sectional Associations Between Parent Restrictive Feeding and Child Total Daily Energy Intake........................................................................................ 37

Table 2.7 Cross-Sectional Associations Between Parent Restrictive Feeding and Child Intake of Specific Nutrients or Foods Potentially Targeted for Restriction ............. 41

Table 2.8 Cross-Sectional Associations Between Parent Restrictive Feeding and Child Eating Behaviours Potentially Related to Restrictive Feeding ............................... 45

Table 2.9 Cross-Sectional Associations Between Parent Restrictive Feeding, Measured by the CFPQ Restriction Scales (Musher-Eizenman & Holub, 2007), and Child Liking for Selected Foods and Drinks ......................................... 47

Table 2.10 Longitudinal Studies Examining Associations Between Parent Restrictive Feeding and Child Diet-Related Outcomes ............................................................ 53

Table 2.11 Parent Restrictive Feeding Practices Reported in Qualitative Studies or Included in Restrictive Feeding Measurement Scales ........................................... 68

Table 3.1 Characteristics of the Study Sample of Mother and Child Dyads in Comparison to Other NOURISH Trial Control Participants Lost to Follow-Up ....... 86

Table 3.2 Characteristics of the Sample of Mother and Child Dyads Interviewed in Comparison to Those Invited but not Interviewed .................................................. 87

Table 3.3 Methods Included in the Study to Support Trustworthiness .................................. 92

Table 3.4 Key Elements of the Interview Technique ........................................................... 100 Table 4.1 Restrictive Feeding Behaviours Commonly Used by Mothers in Different

Contexts ................................................................................................................ 125

Table 5.1 Variables Included in Descriptive Analysis .......................................................... 153

Table 5.2 Variables Included in Binary Logistic Regression Analysis ................................. 159

Table 5.3 Matching of Restricted Food and Drink Items Between Variables ...................... 160

Table 5.4 Child and Maternal Characteristic Covariates Included in Binary Logistic Regression Analysis ............................................................................................. 161

Table 5.5 Prediction of Child High Liking by Child High Intake Frequency, Mothers’ Own High Liking and Child Early Exposure for Eight Selected Restricted Food and Drink Items at Child Aged 5 Years ....................................................... 165

Table 6.1 Comparison of Restrictive Feeding Behaviours Reported in the Present Study with Those Reported in Existing Qualitative Studies or Included in Measurement Scales in Quantitative Studies ....................................................... 178

Table 6.2 Characteristics Associated with Mothers’ Restrictive Feeding Intentions Across Dimensions ............................................................................................... 193

xii Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

Table 6.3 Summary of Associations Between Restrictive Feeding Dimensions and Child Preferences/Liking for a Restricted Food or Drink, Indicated by Existing Literature and Findings of the Present Study........................................................ 195

Table 6.4 Further Research Required to Progress Towards an Evidence-Based Conceptual Framework of the Restrictive Feeding Phenomenon ........................ 205

Table B.1 Cross-Sectional Studies Examining Associations Between Restrictive

Feeding and Child Diet-Related Outcomes .......................................................... 252

Table B.2 Longitudinal Studies Examining Associations Between Restrictive Feeding Practices and Children’s Diet Related Outcomes and BMI .................................. 261

Table I.1 Main Group Codes and Definitions ....................................................................... 291

Table I.2 First Cycle Main Group and Sub-Group Codes .................................................... 292

Table J.1 Example of Summary Table Used for Analysis of Data. ...................................... 296

Table K.1 Final Second Cycle Codes: Modified Main Group and Additional Complex Sub-Group Codes ................................................................................................. 299

Table L.1 Variables Included in Descriptive Analysis and Binary Logistic Regression ........ 300

Table M.1 Original NOURISH Data: Child Weekly Frequency of Intake of Selected Food and Drink Items ............................................................................................ 302

Table M.2 Original NOURISH Data as Shown in Figure 5.1: Child Weekly Frequency of Intake of Selected Food and Drink Items. ......................................................... 302

Table M.3 Frequency of Child Sample who had ‘Tried’ Selected Food and Drink Items by Stated Years old. .............................................................................................. 303

Table M.4 Frequency of Child Sample With a High Liking (Likes a Lot) for Selected Restricted Foods and Drinks. ................................................................................ 303

Table N.1 Dichotomised Data Used for Analysis of Child Intake Frequency ....................... 304

Table N.2 Dichotomised Data Used for Statistical Analysis of Child Early Exposure .......... 304 Table N.3 Relabelled Dichotomised Data Used for Analysis of Child Liking ....................... 305

Table N.4 Original Data Frequency of Mothers’ Sample With a High Liking (Likes a Lot) for Selected Restricted Foods and Drinks, When Child was 2 Years old. ..... 305

Table N.5 Relabelled Dichotomised Data Used for Statistical Analysis of Mothers’ own Liking ..................................................................................................................... 306

Table O.1 Covariates Included in Binary Logistic Regression ............................................. 307 Table P.1 Logistic Regression Findings: Child High Liking for Fruit Drink Associated

With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Soft Drink ............................................................... 308

Table P.2 Logistic Regression Findings: Child High Liking for Fruit Drink Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Fruit Drink .............................................................. 308

Table P.3 Logistic Regression Findings: Child High Liking for Sweet Biscuits Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Sweet Biscuits ................................................ 308

Table P.4 Logistic Regression Findings: Child High Preference for Cake Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Cake ...................................................................... 309

Table P.5 Logistic Regression Findings: Child High Preference for Lollies Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Lollies ..................................................................... 309

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences xiii

Table P.6 Logistic Regression Findings: Child High Preference for Fast Food Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Fast Food ....................................................... 309

Table P.7 Logistic Regression Findings: Child High Preference for Savoury Biscuits Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ own High Liking for Savoury Biscuits ............................................. 310

Table P.8 Logistic Regression Findings: Child High Preference for Chips Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Chips ..................................................................... 310

Table Q.1 Adjusted Prediction of Child High Liking by Child High Intake Frequency, Mothers’ own High Liking and Child Early Exposure for Eight Selected Restricted Food and Drink Items at Child Aged 5 Years ...................................... 311

Table R.1 Logistic Regression Findings: Early Exposure Predicting Child High Preference for Food and Drink Items, raw Bivariate Models and Models Adjusted for Child Intake....................................................................................... 313

xiv Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

List of Abbreviations

ABS Australian Bureau of Statistics

AIHW Australian Institute of Health and Welfare

BMI Body Mass Index

BMIz Body Mass Index z-score

CBQ Children’s Behaviour Questionnaire

CDQ Child Dietary Questionnaire

CEBQ Child Eating Behaviour Questionnaire

CFPQ Comprehensive Feeding Practices Questionnaire

CFQ Child Feeding Questionnaire

CI Confidence Intervals

DEBQ Dutch Eating Behaviour Questionnaire

DEXA Dual-energy X-ray absorptiometry

EAH Eating in the Absence of Hunger

EDF Energy-Dense, Micronutrient-Poor Foods and Beverages.

EFA Exploratory Factor Analysis

FBT Family-Based Behavioral Treatment program

FFQ Food Frequency Questionnaire

FPSQ Feeding Practices Structure Questionnaire

KCFQ Kids Child Feeding Questionnaire

NHMRC National Health & Medical Research Council

OR Odds ratio

PALS Preschool Adapted Food Liking Survey

PROP 6-n-Propylthiouracil

RAQ Restricted Access Questionnaire

RCT Randomised Controlled Trial

RRV Relative Reinforcing Value

TAAT Total Abdominal Adipose Tissue

TFM Total Fat Mass

WHO World Health Organisation

Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences xv

Statement of Original Authorship

The work contained in this thesis has not been previously submitted

to meet requirements for an award at this or any other higher education

institution. To the best of my knowledge and belief, the thesis contains no

material previously published or written by another person except where due

reference is made.

QUT Verified Signature

xvi Exploring the Restrictive Feeding Phenomenon and the Potential Impact on Child Food Preferences

Acknowledgements

This PhD study was supported with an Australian Postgraduate Award

scholarship provided by the Department of Industry, Innovation Science, Research

and Tertiary Education, Australian Government, for which I am grateful. I am also

grateful to the NOURISH trial staff for access to their study participants and

invaluable data.

I would like to thank my supervisory team for the tireless hours of guidance

they have each individually given me. Most prominently I would like to thank my

principal supervisor, Dr Kimberley Mallan for her insightful guidance and support

over these years; Dr John Rosenberg for his valuable support and guidance in

relation to the qualitative component of this study; and Dr Elena Jansen for her

overall guidance on this topic. I would also like to say a special thank you to

Professor Lynne Daniels for her assistance with identifying this topic for research

and guidance in the early stages of this thesis, as well as enabling access to the

NOURISH trial database to support this study. My thanks are also extended to Dr

Judy Gregory and Lee Jones in the Research Methods Group (Institute of Health

and Biomedical Innovation, QUT), both of whom provided expert advice for specific

parts of this study.

A special thank you goes to the mothers who volunteered their time to

participate in interviews that were a vital part of this study. I really enjoyed talking to

you and found the insight you gave me into your experiences invaluable. Lastly, I

would like to thank the many staff at QUT in Research Services, the Library and the

Faculty of Health who had supported me along the way, with a particular thank you

to Emma Kirkland.

An editor was engaged to advise and assist with APA style formatting only.

Chapter 1: Introduction 1

Chapter 1: Introduction

1.1 BACKGROUND AND CONTEXT

Poor diet quality, such as high consumption of transfats, sugar or salt and

low consumption of fruits, vegetables and whole grains, has been found to be

independently associated with a greater risk of developing chronic diseases, such

as coronary heart disease, stroke, diabetes and some cancers (Chiuve et al., 2012;

Conlin, 1999; Hu, Van Dam, & Liu, 2001; Hu & Willett, 2002; Hur & Reicks, 2012;

Ruel et al., 2014; World Health Organisation [WHO], 2003). Poor diet quality is also

likely to be a major contributor to overweight and obesity, although the independent

contribution of diet quality is difficult to assess due to the complex interplay of

different foods and other lifestyle factors. Overweight and obesity contributed the

second largest burden of disease of the 29 disease risk factors examined in the

most recent Australian Burden of Disease Study (Australian Institute of Health and

Welfare [AIHW], 2017a). It was reported to be responsible for 7% of the burden of

disease from all diseases and injuries in Australia in 2011 (Australian Institute of

Health and Welfare [AIHW], 2017b). This was greater than the burden of disease

attributed to alcohol use, physical inactivity and high blood pressure. The size of the

obesity problem in Australia is substantial, with 63% of Australians over 18 years old

classified as overweight or obese in 2014 (Australian Bureau of Statistics [ABS],

2015). In addition, the Australian National Health Survey (2011-12) found that 25%

of Australia children between 5 and 17 years and 23% of 2 to 4 year olds were

classified as overweight or obese (Australian Bureau of Statistics [ABS], 2013).

Childhood dietary experiences are likely to be an important contributor to

this growing burden of disease, with poor dietary habits and food preferences

established in early life being associated with diet-related diseases and obesity in

adult life (Birch, 1999; Kelder, Perry, Klepp, & Lytle, 1994; Klesges, Stein, Eck,

Isbell, & Klesges, 1991; Morales, Demory-Luce, Nicklas, & Baranowski, 2002;

Nicklaus, Boggio, Chabanet, & Issanchou, 2004; Skinner Carruth, Bounds, &

Ziegler, 2002). Diet related blood lipid levels have been found to track through from

childhood into adulthood (Berenson et al., 1989; Lauer & Clarke, 1990; Porkka,

Viikari, Taimela, Dahl, & Akerblom, 1994) and rapid infant weight gain and obesity in

childhood track through to adult obesity (Baird et al., 2005; Ekelund et al., 2006;

2 Chapter 1: Introduction

Magarey, Daniels, Boulton, & Cockington, 2003; Whittaker, Wright, Pepe, Seidel, &

Dietz, 1997).

Recent attention on factors contributing to poor quality diets has focused on

children’s snacking and consumption of ‘discretionary’ foods and drinks1 such as

lollies, cakes, biscuits, chips and sweet drinks (National Health & Medical Research

Council [NHMRC], 2013). Such foods and drinks are surplus to nutritional

requirements for a healthy diet and a high consumption of these foods and drinks

appears to be common amongst Australian children. The 2011-12 National Health

Survey (ABS, 2013), reported that 30% of 2 to 3 year old children’s total daily

energy was consumed from discretionary foods or drinks, gradually rising to 41%

amongst 14 to 18 year olds. Furthermore, these non-core foods are commonly

introduced to Australian children at an early age. Koh, Scott, Oddy, and Binns

(2010) study of a sample of children living in Western Australia showed that 92%

had been introduced to sweet biscuits and cakes, 79% introduced to hot

chips/french fries and 68% introduced to ice-cream by the time they reach their first

birthday (n = 587).

The home food environment and the approach parents take to feeding their

child is likely to be an important influence on children’s diets and as a consequence,

associated risk of diet-related diseases and obesity. Poti and Popkin’s (2011) study

highlights that 71% of energy intake of 2 to 6 year old children takes place at home

where parents and particularly mothers, have most control over children’s diets. De

Bourdeandhuij (1997) also found that greater access to high fat and high sugar

foods within the family environment at 10 years old was associated with

consumption of more snacks and less healthy food choices in adolescence. It is also

possible that parents’ beliefs in relation to food exposure are likely to contribute to

children’s access to foods outside the home, particularly for younger children where

parents exert greater control. Therefore, a parent’s approach to feeding their child

may be an important influence on childhood food experiences. Such parenting

approaches have been defined in studies as child feeding practices, which refers to

situation specific behaviours or strategies that parents use to manage how much,

when and what children eat (Ventura & Birch, 2008).

1 Discretionary foods are defined as ‘foods and drinks not necessary to provide the nutrients the body needs... many are high in saturated fats, sugars, salt and/or alcohol, and are therefore described as energy dense.’ (NHMRC, 2013). These items are also referred to as ‘non-core’ foods and drinks by some authors (see Chapter 2, Section 2.4).

Chapter 1: Introduction 3

While the diet a parent provides to their child is likely to be important, the

way a parent controls what their child eats through specific feeding practices has

also been proposed to contribute to a child’s risk of obesity. Such feeding practices

have commonly been referred to in research literature as controlling feeding

practices and have been proposed to increase children’s risk of obesity by

undermining their innate hunger-satiety mechanism (Costanzo & Woody, 1985;

Johnson & Birch, 1994). Birch (1999) proposed that controlling feeding practices

consist of three domains: pressuring children to eat; restricting children’s access to

foods; and parent monitoring. A fourth group of controlling feeding practices,

instrumental feeding, has also been identified (Birch, 1999; Wardle, Sanderson,

Guthrie, Rapoport, & Plomin, 2002). This involves provision of a food as a reward for

approved behaviour or for eating other foods. While Wardle et al. (2002) identified

these practices as a separate domain, Birch et al. (2001) included practices of giving

food as a reward within their measure of restricting children’s access to foods.

Furthermore, while Birch (1999) proposed parent monitoring as a third controlling

feeding practice, this measure reflects an observational activity that involves parents

keeping track of their child’s consumption of sweet, snack and high fat foods (Birch

et al., 2001). Such activity may precede restricting access or pressure to eat but

would not in itself directly affect a child’s dietary experience. This study, therefore,

considers that controlling feeding practices encompass pressure to eat, restricting

access and instrumental feeding (food rewards).

The proposed underlying physiological mechanisms related to these

controlling feeding practices are that they undermine children’s ability to respond to

their internal homeostatic hunger-satiety mechanism, resulting in them learning to

eat in the absence of hunger in response to external cues related to parental control

(Costanzo & Woody, 1985; Birch, 1999). Literature has described two mechanisms

whereby parents’ controlling feeding practices may encourage a child to eat in the

absence of hunger. The first is pressure to eat, which involves coercing, bargaining

or encouraging a child to complete a meal or consume healthy components of a

meal they are reluctant to eat, such as vegetables. This form of control has been

found to undermine the physiological mechanism of self-regulation (internal hunger-

satiety mechanism), as well as increase children’s psychological dislike for the very

foods parents are trying to encourage (Birch, Birch, Marlin, & Kramer, 1982; Birch,

Marlin, & Rotter, 1984; Newman & Taylor, 1992). The second form of parental

control that may encourage a child to eat in the absence of hunger is the provision

of foods as a reward for approved behaviour (instrumental feeding). The use of

4 Chapter 1: Introduction

foods as a reward has been found to increase children’s liking of and preferential

selection of the reward food (Birch et al., 1982; Mikula, 1989; Newman & Taylor,

1992), which may encourage a child to over-ride internal cues of satiety to consume

the psychologically desired reward food. While foods given as rewards tend to be

highly palatable energy dense foods that all children innately like, the proposed

consequences of presenting a food as a reward is that this enhances a child’s

hedonic liking for and wanting to consume that food. This then results in a greater

propensity to override internal satiety mechanisms and consume the food in the

absence of hunger (Birch, 1999).

Restricting access to a food, which is referred to as restrictive feeding in

this study, involves parent practices of restricting what, how much and when a child

consumes and is typically used to reduce access to “unhealthy” foods or drinks

(Birch, 1999). This is fundamentally different from the other controlling feeding

practices (pressure to eat and instrumental feeding) because the child is not being

encouraged to eat a food in the absence of internal hunger cues. Rather the child is

being prevented from eating a highly palatable food that he/she may want to eat or

eat more of. Therefore, the proposed physiological or psychological mechanism by

which parent restriction may disrupt children’s self-regulation capacity is less clear

for this form of controlling feeding.

An initial review of quantitative studies examining restrictive feeding

(conducted by the PhD Candidate) suggested that existing literature was

inconclusive regarding the effects of parents’ restrictive feeding practices on

children’s diet-related outcomes. Experimental studies examining food restriction

suggested a hedonic mechanism whereby restriction increases a child’s preference

for the restricted food because it is forbidden (Birch, Fisher, & Davison, 2003; Fisher

& Birch, 1999a, 1999b; Jansen Mulkens, Emond, & Jansen, 2008; Jansen, Mulkens,

& Jansen, 2007). These experimental studies consistently reported that their

findings suggest that restrictive feeding increases the risk of obesity because it

leads to a higher child preference for the restrictive food and higher consumption of

this food when made available to the child. However, the longitudinal cohort studies

identified suggested that restrictive feeding either has no significant effect on child

weight status or is protective against weight gain (Campbell et al., 2010; Farrow &

Blissett, 2008; Gregory, Paxton, & Brozovic, 2010a; Gubbels et al., 2011;

Montgomery, Jackson, Kelly, & Reilly, 2006; Spruijt-Metz, Li, Cohen, Birch, & Goran,

2006; Webber, Cooke, Hill, & Wardle, 2010).

Chapter 1: Introduction 5

The experimental study findings also appear to contradict another

substantial body of evidence, which suggests that children’s food preferences are

shaped by early and repeated exposure, with children learning to like and thus

favouring familiar foods relative to unfamiliar foods (Addessi, Galloway, Visalberghi,

& Birch 2005; Añez, Remington, Wardle, & Cooke, 2013; Beauchamp & Moran

1982; Beauchamp & Mennella 1998; Birch, 1979a, 1979b, 1987, 1998; Birch &

Marlin 1982; Breen, Plomin, & Wardle, 2006; Cashden, 1994; Cooke, 2007; Cooke

et al., 2004; Cooke & Wardle, 2005; Liem & deGraaf, 2004; Mennella, Jagnow, &

Beauchamp, 2001; Schwartz, Scholtens, Lalanne, Weenen, & Nicklaus, 2011;

Skinner et al., 2002; Sullivan & Birch, 1990, 1994; Wardle, 1995; Wardle, Herrera,

Cooke, & Gibson, 2003; Wardle & Cooke, 2008; Zajonc, 1968). These studies

appear to suggest that lower rather than higher restricted access is likely to increase

children’s preferences for a food. However, the focus of this research has been on

measuring responses to “healthy” foods that children may be initially reluctant to eat

due to an innate tendency to reject sour and bitter tastes e.g. vegetables (Birch,

McPhee, Steinberg, & Sullivan, 1990). As children also have innate taste

preferences for the high-sugar, high-salt and energy dense foods and drinks likely to

be targeted for restriction (Beauchamp Cowart, & Moran, 1986; Birch, 1992; Birch et

al., 1990), early and repeated exposure to these items may not have the same effect

as for less palatable foods. While only a few studies examining responses to more

palatable items were identified, these also indicated a positive association between

repeated exposure and higher child preference for the item (Birch & Marlin, 1982;

Grimm, Harnack, & Story, 2004; Hartvig, Hausner, Wendin, Ritz, & Bredie, 2015;

Liem & de Graaf, 2004; Pliner, 1982; Sullivan & Birch, 1990). However, despite this

overall evidence of the effects of parent restrictive feeding being inconclusive,

evidence from experimental studies suggesting a negative effect from restricting

children’s access to palatable foods has been consistently cited in peer reviewed

papers and study reviews (Academy of Nutrition & Dietetics, 2004; Clark, Goyer,

Bissell, Blank, & Peters, 2007; Cooke, 2007; Faith, Scanlon, Birch, Francis, &

Sherry, 2004; Schwartz et al., 2011).

The reason why this controversy regarding the impact of restrictive feeding

on child food preferences is important to examine is firstly because the practice of

restricting what, how much and when a child eats certain foods appears to be

widespread. Qualitative studies have shown that all but a few mothers restrict their

children’s intake of some foods (Baughcum, Burklow, Deeks, Powers, & Whitaker,

1998; Moore, Tapper, & Murphy, 2007; Sherry et al., 2004; Ventura, Gromis, &

6 Chapter 1: Introduction

Lohse, 2010). Secondly, advice suggesting that parents should refrain from

restricting palatable foods, based on the prominence of experimental study findings,

may be harmful to children’s health if the alternative evidence is correct.

The initial review of studies revealed concerns regarding the conclusions

drawn from short-term experimental studies but also minimal validation of

instruments used to measure parent restrictive feeding in cohort studies. In addition,

the review failed to identify a universally agreed definition of restrictive feeding and

how parent restrictive feeding practices, commonly referred to within the literature,

might fit within the broader phenomenon of restrictive feeding. Clarification of what

constitutes the restrictive feeding phenomenon experienced by children in the

natural world was, therefore, identified as the priority for this field of research.

Extending knowledge of the dimensions2 of this phenomenon and how they may or

may not influence children’s diet-related outcomes3 was considered necessary prior

to developing an effective measure to represent this phenomenon and subsequently

examine the effects of this phenomenon on child outcomes.

1.2 PURPOSE AND SCOPE

The purpose of this study was to gain an in-depth understanding of the

restrictive feeding phenomenon and identify the key dimensions that might influence

children’s longer-term risks of diet-related diseases and obesity. It was intended that

this study would provide an initial conceptual framework of the restrictive feeding

phenomenon and identify the key dimensions of this phenomenon potentially

influencing child diet-related outcomes. However, this study was only proposed to

be the first step towards developing an evidence-based universally agreed

conceptual framework. Further research is required to fully develop an evidence

based conceptual framework to underpin development of more construct valid

measures of this understudied phenomenon.

The scope of this study was limited to examining the restrictive feeding

phenomenon and identifying the key dimensions of this phenomenon that may

influence children’s preferences for restricted foods and drinks. The methodology

selected was sequential mixed methods (QUAL → quant). As existing studies 2 Referring to an aspect or feature of a social phenomenon. 3 Measures of child outcomes that are influenced by children’s diets e.g. weight status, food intake, eating behaviours, food preferences, food liking or wanting to consume a food.

Chapter 1: Introduction 7

provided limited knowledge of this phenomenon, it was intended that an initial

exploratory qualitative component would inform the specific research questions for

the subsequent quantitative component of the study. The intention was to seek

complementary information, encompassing the benefits of both forms of analysis.

1.3 CONTRIBUTION TO KNOWLEDGE

This study provides a critical review of research pertaining to parents’

restrictive feeding and its potential effects on child diet-related outcomes. The

findings of this study also bring new knowledge of the dimensions of the restrictive

feeding phenomenon to this field of research and present these as an initial

conceptual framework. While further research is required, the analysis of existing

knowledge and the contribution of new knowledge assisted with conceptualising the

restrictive feeding phenomenon. In addition, it sets out the additional research

required to clarify the potential effects of this phenomenon on child-diet related

outcomes, as well as proposals for how this phenomenon might be measured. This

study makes an important contribution to this field of research by highlighting the

potentially important dimensions of this phenomenon that may be included in a more

construct valid, evidence based measure of parent restrictive feeding.

1.4 OVERVIEW OF THE THESIS

Chapter 2 - Literature Review. This chapter commences with a review of

quantitative studies measuring the effects of parents’ restrictive feeding on at least

one child diet-related outcome measure. The findings of this review established that

the priority was to develop a conceptual framework of parent restrictive feeding to

underpin future development of more construct valid measures of this phenomenon.

This Chapter progresses to outline the potential dimensions of the restrictive feeding

phenomenon based on existing quantitative and qualitative knowledge. It finishes by

outlining the gaps in our existing knowledge and presenting the aim and research

questions for this study.

Chapter 3 – Methodology and Methods. This chapter outlines the

selected sequential mixed methods study design, with the qualitative component of

the study being undertaken first followed by a quantitative component (QUAL →

quant). It also presents the characteristics of the NOURISH sample (Daniels et al.,

2009) from which participants of the study were drawn. The Chapter includes

8 Chapter 1: Introduction

presentation of the pragmatic qualitative methodology and methods applied, which

involved telephone interviews with 29 mothers of first born children aged 5 to 6

years.

Chapter 4 – Qualitative Findings. This chapter presents the findings for

the qualitative component of the study, structured by the emergent themes. Findings

are supported by participant quotes and a supplementary document of further

supporting quotes is provided in Addendum 4.1. The findings for this component of

the study were reviewed in the context of current literature to inform the design of

the quantitative component reported in Chapter 5. However, full discussion of this

analysis was reserved until Chapter 6, which provides an integrated discussion of

the qualitative and quantitative components of the study. A brief summary of

analysis at this stage and a preliminary conceptual framework is provided to assist

with understanding the rationale for the quantitative research questions and

proposed quantitative analysis.

Chapter 5 – Quantitative Method and Findings. This chapter presents

the research questions, method and findings for the quantitative component of the

study. This component of the study was limited to data available from the secondary

source, the NOURISH sample (Daniels et al., 2009). Quantitative analysis consisted

of two parts. Part I examined patterns of descriptive data to clarify and extend

findings from the qualitative component of the study. Part II includes analyses of

associations between potential dimensions of restrictive feeding and child liking for a

selection of restricted foods and drinks using binary logistic regression. A brief

summary of findings are reported, with more detailed discussion included in Chapter

6 as an integrated discussion.

Chapter 6 - Discussion and Conclusions. This Chapter presents an

integrated discussion of the qualitative and quantitative components of this study. It

also presents an initial conceptual framework for the restrictive feeding phenomenon

based on this study’s findings and existing quantitative and qualitative evidence. A

program for further research to progress towards a greater evidence-based

conceptual framework is also presented. In addition, this Chapter discusses the

implications for development of a measure of parent restrictive feeding to assess the

effects of this phenomenon on child diet-related outcomes. The Chapter ends with

the final conclusions of the study.

Chapter 2: Literature Review 9

Chapter 2: Literature Review

2.1 INTRODUCTION 2.1.1 Overview

An initial review of literature established that quantitative studies examining

restrictive feeding have produced conflicting findings. Further investigation revealed

that a major deficiency within this area of research is a lack of universal agreement

and evidence base to the conceptualisation and measurement of the restrictive

feeding phenomenon. This then became the focus of research for this thesis (see

Chapter 1, Section 1.2).

This chapter presents the review of related literature. It initially provides an

overview of how restrictive feeding has been conceptualised and measured in

quantitative studies (see Section 2.2). This is followed by a review of quantitative

studies examining restrictive feeding, which includes analysis of experimental studies

(see Section 2.3) and cohort studies (see Section 2.4). These two sections examine

study findings in the context of study designs, measures of restrictive feeding and

child outcome measures selected. In addition, potential effect modification by different

sample characteristics (e.g. child age) was examined, as well as other study quality

considerations such as sample sizes and controlling for relevant covariates. Section

2.5 subsequently provides an overall summary of the evidence of the effects of

parents using restrictive feeding.

As a starting point for progressing towards an evidence-based conceptual

framework of the restrictive feeding phenomenon, Section 2.6 proposes a potential

set of dimensions of this phenomenon based on current knowledge. This draws on

the analysis of quantitative studies presented in Sections 2.3 and 2.4 and further

knowledge of parent experiences of restrictive feeding arising from a review of related

qualitative studies. Consideration is also given to how these dimensions might

influence child diet-related outcomes. This is augmented with evidence from another

body of research that suggests early and repeated exposure to a food is associated

with the development of child preferences for a food. These associations are

important to identifying the contribution these dimensions of restrictive feeding might

10 Chapter 2: Literature Review

make to child outcomes and hence its potential inclusion in a quantitative measure

aiming to assess the effects of this phenomenon on child diet-related outcomes. The

Chapter concludes with Section 2.7 summarising the current gaps in knowledge of

the restrictive feeding phenomenon and Section 2.8 outlines the aim and research

questions for this study.

2.1.2 Literature search strategy

The initial literature search included quantitative studies examining restrictive

feeding. Criteria for this search included measurement of restrictive feeding

associated with at least one quantified child outcome measure for samples of children

aged 0-18 years. This included child outcome measures related to diet (e.g. child

weight status, child food intake, child eating behaviour, child preferences for, liking for

or wanting to consume a food). All quantitative study designs presented in peer

reviewed papers and published in English from 1980 onwards were potentially

included, although relevant studies did not commence until 1999.

A subsequent search for qualitative studies was undertaken. Criteria

included some reference to parent feeding practices that resembled restriction of child

food intake. Only information potentially pertaining to restrictive feeding was extracted

for analysis from these studies. All qualitative study designs presented in peer

reviewed papers and published in English from 1980 onwards were potentially

included. Initial reviews were undertaken in 2012 with periodic searching for updates.

The last updated review was undertaken in April 2017. See Appendix A for details of

search strategies and databases used for searches.

2.2 CONCEPTUALISATION AND MEASUREMENT OF RESTRICTIVE FEEDING

There is no universally agreed definition of restrictive feeding and

researchers have tended to operationalise measurement of restrictive feeding without

a clear underlying concept of this phenomenon or how it might relate to other aspects

of parent feeding. While there appears to be general agreement that feeding practices

refers to situation specific behaviours or strategies that parents use to manage how

much, when and what children eat (Ventura & Birch, 2008), various authors have

proposed different taxonomies of feeding practices (Birch et al., 2001; Jansen,

Mallan, Nicholson, & Daniels, 2014; Musher-Eizenman & Holub, 2007; Ogden,

Chapter 2: Literature Review 11

Reynolds, & Smith 2006; Rollins, Savage, Fisher, & Birch, 2015; Schwartz et al.,

2011; Vaughn et al., 2016; Wardle et al., 2002). Furthermore, some authors have not

distinguished restrictive feeding from other types of controlling feeding practices

(Wardle et al., 2002; Ogden et al., 2006).

Broader concepts of general parenting have also been transposed to the

child feeding context, with the most familiar one being four parenting styles

(authoritative, authoritarian, uninvolved and indulgent) underpinned by dimensions of

parental responsiveness and demandingness (Hughes, Power, Fisher, Mueller, &

Nicklas, 2005; Maccoby & Martin, 1983). While a number of authors have assessed

how these broader parental styles might relate to child feeding practices and

specifically restrictive feeding practices, there is no clear evidence that such general

parenting styles can be extrapolated to the parent feeding context. A recent

systematic review found only weak to moderate associations between parenting

styles and child feeding practices using current self-report questionnaires (Collins,

Duncanson, & Burrows, 2014) (see Section 2.6.5 for more details).

Fisher and Birch (1999a) first brought attention to the concept of restrictive

feeding in their pioneering experimental study examining children’s responses to

restricted foods when made available. While they did not specifically define restrictive

feeding in this study it was described as, “restricting children’s access to palatable

foods” as a “means of promoting moderate intakes of foods high in fat and sugar”.

(Fisher & Birch, 1999a, p. 1264). This implied that the nature of restrictive feeding

being examined was intended to restrict specific palatable foods rather than control

overall energy intake. Such a description also assumes that parents aim to moderate

intake of these palatable foods rather than prevent children accessing them

altogether. This concept has been reflected in the design of all experimental studies

identified (Birch et al., 2003; Fisher & Birch, 1999a, 1999b; Jansen et al., 2008;

Jansen et al., 2007; Ogden, Cordey, Cutler, & Thomas, 2013; Rollins, Loken, Savage,

& Birch, 2014a) and the most common self-administered questionnaire used in cohort

studies, the Child Feeding Questionnaire (CFQ) 8-item restriction scale (Birch et al.,

2001) (see Section 2.4.2 for details).

Musher-Eizenman and Holub (2007) differentiate between two types of

restrictive feeding with two different parent motivations, restriction for health and

restriction for weight control. The restriction for health scale they developed reflected

a similar concept to Fisher and Birch (1999a) but restriction for weight control

12 Chapter 2: Literature Review

reflected a concept of more generalised calorie control. Ogden et al. (2006) expanded

the concept of restrictive feeding further by pointing out that the different ways a

parent might control their child’s eating may have differing effects on child outcomes,

with some aspects of parent control potentially being beneficial and others potentially

harmful. While Ogden et al. did not differentiate restrictive feeding from other domains

of controlling feeding practices (e.g. pressure to eat) they made an important

contribution to this body of research. They proposed two types of controlling feeding,

overt and covert, with overt referring to feeding practices that the child is aware of and

covert referring to more subtle practices of which the child is unaware. They

developed two separate scales to measure these concepts and used these to

demonstrate that these two different approaches to controlling feeding had different

effects on children’s intake of “healthy” and “unhealthy” snacks foods (Brown, Ogden,

Vogel, & Gibson, 2008; Ogden et al., 2006). Jansen et al., (2014) later applied the

concept of overt and covert to restrictive feeding and presented a modified version of

Ogden et al.’s covert scale and the CFQ restriction scale (Birch et al., 2001) as

representing covert and overt restriction in their Feeding Practices and Structure

Questionnaire (FPSQ) (see Section 2.4.2 for details of these scales).

Rollins et al. (2015) has more recently proposed a narrowing of the definition

of restrictive feeding, attempting to differentiate between concepts of responsive and

unresponsive (coercive) feeding. They propose that “the term ‘restrictive feeding’ be

defined as intrusive, coercive and authoritarian feeding practices used to enforce

constraints on children’s access to and intake of foods” (p. 2) and differentiated this

from the preferred approach of “structured-oriented practices that parents use to

provide routines and guidance” (p. 2). These concepts have been transposed from

Grolnick and Pomerantz’s (2009) concepts relating to general parenting, where they

propose a differentiation between parental control and parental structure. Rollins et al.

also proposed an alignment of these concepts with a range of feeding strategies, see

Figure 2.1. However, no evidence is presented in Rollins et al.’s paper to support the

transposition of these general parenting concepts to child feeding and the

reclassification of particular aspects of restrictive feeding as structure.

Chapter 2: Literature Review 13

Restriction vs. Structure

Routines around access • Provides no access to palatable foods • Hides food • Considers only the parent perspective • Requires obedience with no exceptions • Access is determined by the parent and

the child is unclear when access will be available (ie. inconsistency)

Guidance on how much to eat • Serves portions based on the parent

perspective • Takes food away • Uses guilt or physiological control

(‘Mommy will be sad if you eat too much candy’)

Routines around access • Allows some access to palatable

foods, but avoids bringing large amounts into the home

• Has routines around when children can access palatable foods

• Considers the child’s perspective when creating and administering routines around access to palatable foods

• Consistent in the use of routines, yet flexible

Guidance on how much to eat • Serves child-sized amounts, but allows

child to determine how much • Considers the child’s perspective when

deciding how much to serve

Figure 2.1. Strategies of restriction and structure in feeding.

Reproduced from “Alternative to restrictive feeding practices to promote self-regulation in

childhood: a developmental perspective,” by B. Y. Rollins, J. S. Savage, J. O. Fisher, and L. L.

Birch, 2015, Pediatric Obesity, 1-7, p. 2. Copyright 2015 by the World Obesity Federation.

Vaughn et al. (2016) have more recently expanded Rollins et al.’s (2015)

concept within their content map of food parenting practices. Three overarching

higher-order food parenting constructs of coercive control, structure and autonomy

support are presented. Restrictive feeding is classified under coercive control but

other concepts that might relate to restrictive feeding, such as rules and limits, food

availability and food accessibility, are classified under structure. These later concepts

presented by Rollins et al. and Vaughn et al. have not pursued Ogden et al.’s (2006)

and Jansen et al.’s (2014) idea of differentiating between overt and covert restriction,

concepts that arose from qualitative exploration undertaken by Ogden et al..

Furthermore, Jansen et al. included structure as a separate domain from restrictive

feeding within their FPSQ measure that included multiple scales of parent feeding

practices. The aspects of parenting that encompass restrictive feeding clearly require

further clarification.

A number of qualitative studies have reported a range of different restrictive

feeding practices and explored parents motivations for using restrictive feeding

practices (see Section 2.6). However, no studies identified had presented a

conceptual framework of the dimensions of restrictive feeding that could underpin

measurement of restrictive feeding for quantitative assessment of the effects on child

14 Chapter 2: Literature Review

diet-related outcomes. Therefore, it appears that the dimensions and boundaries of

this phenomenon, as well as how it may change as children grow and develop has

not been considered in-depth. This is needed in order to develop construct valid

measures that reflect how this complex social phenomenon might be experienced in

the natural world.

2.3 STUDIES OF RESTRICTIVE FEEDING USING EXPERIMENTAL DESIGNS

2.3.1 Experimental study designs and measures

Five papers that reported on seven experimental studies were identified (see

Table 2.2 for further details). Five studies used a similar design where they simulated

food restriction and access conditions and compared experimental and control groups

or sessions, using school snack sessions as the setting with children aged between 3

and 7 years old (Fisher & Birch, 1999a; Jansen et al., 2008; Jansen et al., 2007;

Rollins et al., 2014a). Figure 2.2 shows the generic design of these experiments.

These experiments were of 10 to 20 minutes duration and involved comparison of

experimental and control conditions. In the experimental conditions, children

experienced unlimited access to a control food but a short period of access to a

restricted food. In the control conditions, children had unlimited access to both the

control and restricted foods.

Experimental time period 10-20 minutes

Experimental phases Baseline Experimental Test ^ Experimental condition Control condition

Note. Baseline not included in Jansen et al. (2008) and Jansen et al. (2007). ^ = Experimental outcome measures applied. = Access to restricted food/s = No access to restricted food/s

Figure 2.2. Short-term experiment study designs.

Some of these studies used a between-subjects design, comparing groups of

randomly assigned children. Other studies used a within-subjects design, with all

participants subjected to alternate control and experimental conditions for a series of

experimental periods. However, this aspect of design did not appear to affect the

results observed. Experimental and control foods were palatable energy dense foods

of a similar type. In addition, to experiments involving palatable energy dense foods,

Chapter 2: Literature Review 15

Jansen et al. (2008) also applied the same experimental restriction conditions to fruits

(banana and pineapple). See Table 2.2 for details of foods used in studies. More

recently, Ogden et al. (2013) performed two longer experiments based in family

homes for 2 days (child aged 1 to 7years) and 2 weeks (child aged 4 to 11years)

duration. Parent/child dyads were randomly assigned to restriction and non-restriction

protocols for provision of chocolate coins and Easter eggs respectively (see Table 2.2

for details of protocols).

Child outcome measures used in these experimental studies consisted of

measuring children’s desire for the restricted food, either by observed behaviour

events towards the restricted food or by children’s ratings of the restricted food on a

Visual Analogue Scale. Most studies also measured child intake of the restricted food

and Fisher and Birch (1999a) and Rollins et al. (2014a) measured selection frequency

of the restricted food (see Table 2.1 for a summary and Table 2.2 for further details).

Studies compared child outcome measures between experimental and control

conditions occurring within the test period of the experiment immediately following the

period of restriction applied to the restriction groups (see Figure 2.2).

Table 2.1

Child Outcome Measures Used in Experimental Studies of Restrictive Feeding

Type Measure Studies (lead author, date)

Child behaviour

Observed: enumerated vocalisations and physical behaviour events associated with trying to access the food or expressed desire for the food.

Fisher, 1999a Rollins, 2014a Ogden, 2013

Visual Analogue Scale: Desire to eat, no desire at all to a very large desire.

Jansen, 2008 Jansen, 2007

Relative reinforcing value (RRV): scored by number of ‘observed’ behaviour events (vocal or physical as above) made for the restricted food divided by total behaviour events made for both restricted and control foods.

Rollins, 2014a

Child intake

Immediate intake: comparative intake (grams or kilojoules) of restricted food by restricted and control groups in the time period immediately following restriction of the restricted group.

Fisher, 1999a (2nd experiment only) Jansen, 2008 Jansen, 2007 Rollins, 2014a

Overall Intake: comparative intake (grams or kilojoules) of restricted food by restricted and control groups over the duration of the experiment.

Jansen, 2007 Ogden, 2013

Child selection

Number (frequency) of scoops taken of the restricted food in the time period immediately following restriction of the restricted group.

Fisher, 1999a (2nd experiment only) Rollins, 2014a

16 Chapter 2: Literature Review

2.3.2 Analysis of experimental study results

All studies found that the frequency of children’s behaviour events towards

the palatable restricted foods increased more for the restricted group (or session) in

the test phase immediately following restriction compared to the control group (or

session). Where children’s intake was measured, studies also showed a higher intake

amount (grams or kilojoules) of the restricted food for restricted groups in comparison

to control groups in the test phase immediately following restriction (see Figure 2.2)

(Fisher & Birch, 1999a; Jansen et al., 2008; Jansen et al., 2007; Rollins et al., 2014a).

These authors concluded that these experiments demonstrate that restricting a food

increases a child’s preference for that food. Fisher and Birch’s (1999a) explanation for

these findings was that “restricting access can sensitize children to external eating

cues while increasing their desire to obtain and consume the restricted food.” (p.

1271.).

Ogden et al.’s (2013) longer home-based studies had similar findings, where

child pre-occupation behaviours (demanding and eating behaviour) towards the

restricted foods (chocolate coins and Easter eggs) decreased more amongst the non-

restriction group over the duration of the studies (see Table 2.2 for details). They

concluded that restriction of a food increases children’s preferences for that food.

However, these studies also showed that the mean child intake (grams) of the

restricted food over the duration of the experiments was higher amongst the non-

restricted groups than the restricted groups (69% higher for the first experiment and

67% higher for the second experiment). In the short-term experiments, comparative

overall intake of the restricted food between control and experimental

groups/sessions received little attention (Fisher & Birch, 1999a; Jansen et al., 2008;

Jansen et al., 2007; Rollins et al., 2014a). Those studies only compared control and

experimental children’s intake in the test phase immediately following restriction. This

reflected a smaller portion of total access time for the control participants than for the

experimental participants. Jansen et al. (2007) was the only short-term study to

include reference to overall consumption of the restricted food, noting that the gram

intake of the restricted food was the same for experimental and control groups over

the duration of the experiments.

Furthermore, supporting evidence from animal studies cited by Fisher and

Birch (1999a) does not demonstrate that restriction has a subsequent effect on

Chapter 2: Literature Review 17

preferences for and consumption of restricted foods or drinks. These studies showed

findings similar to Ogden et al. (2013). They showed that highly restricted animals

consumed more ethanol and fat during periods of availability but the most restricted

animals consumed less ethanol and fat than less restricted animals over the duration

of these experiments (Corwin Wojnicki, Fisher, & Rice, 1995; Files, Lewis, & Samson,

1994). In addition, overall energy intake by rats in Corwin et al.’s (1995) study showed

compensation for eating more high fat foods by eating less of other foods, which does

not support the claim made by Costanzo and Woody (1985) and Birch et al. (2003),

that restriction causes a disruption to self-regulation (see Chapter 1, Section 1.1).

Corwin et al.’s study also found that the experience of food restriction did not produce

any long-term effects on daily consumption when restriction was lifted. This was

consistent with Fisher and Birch’s findings, with measures taken three weeks before

and after the experimental trials showing no significant effect on children’s intake or

selection of the restricted food. In fact, children’s consumption of both the restricted

and control foods significantly decreased between pre and post trial tests (p > 0.05).

Therefore, there does not appear to be clear evidence from these studies that

restriction affects subsequent preferences for and consumption of the restricted food.

These findings also need to be considered in the context of the hedonic

reward system, which has two distinct neurological circuits, liking and wanting

(Berridge, 1996). Liking is described as “the perceived impact of a food or its sensory

properties on subjective affect or some judgement of the pleasure it elicits” and

wanting is described as “subjective states of desire, craving, or literally to feel a lack

of something desirable or necessary” (Finlayson & Dalton, 2012, p. 44). It is the

wanting component of the hedonic system that is the motivational component of the

urge to eat a food, most represented by the outcome measures used during these

experiments. As wanting is a stronger determinant of food intake than liking it is likely

to be a better indicator of disordered eating beyond satiety and hence risk of obesity

(Epstein & Leddy, 2006; Epstein, Carr, Lin, & Fletcher, 2011; Epstein et al., 2015;

Rollins, Loken, Savage, & Birch, 2014b; Temple, Legierski, Giacomelli, Salvy, &

Epstein, 2008). However, wanting is less stable than liking and can alter in response

to satiety states and food variety (Epstein, Truesdale, Wojcik, Paluch, & Raynor,

2003; Epstein et al., 2011; Raynor & Epstein, 2003; Rolls & Rolls, 1997; Temple,

2014; Vervoot et al., 2016). In relation to this, Rolls and Rolls (1997) describe a

sensory-specific satiety response, where “the pleasantness of the sight and of the

taste of a food eaten to satiety decreases, and other foods not eaten to satiety remain

relatively pleasant” (p. 461). Such a response may explain the restriction

18 Chapter 2: Literature Review

experimental results observed, with children’s behavioural and intake responses

(representing wanting) towards a non-restricted food being lower than the restricted

food during the periods of no restriction. This is because prior access to the non-

restricted food would mean that it is likely to have been consumed to a higher satiety

level than the unconsumed restricted food presented at that point in the experiment.

Jansen et al. (2007) recognised this potential deficiency in study design and

attempted to address this problem by using two different coloured versions (red and

yellow) of the same food. However, while Jansen et al. demonstrated that the same

effect occurred with different colours of the same item, Rolls and Rolls also state that,

“The taste, texture and color of the food have been shown to be important factors in

these effects” (p. 461).

Ogden et al.’s (2013) study also presents findings suggestive of a sensory-

specific satiety response occurring amongst non-restricted children as their

experiments progressed. Non-restricted children’s scores for pre-occupation

(demanding & eating behaviour) towards other sweet foods were found to be greater

than for restricted children. At the end of the experiments, the combined pre-

occupation mean scores for the restricted foods and other sweet foods were similar

for the restricted and non-restricted groups. The authors concluded that their findings

represent differences in child preferences for the restricted food. Alternatively, these

findings might reflect a sensory-specific satiety response (Rolls & Rolls, 1997)

amongst the non-restriction group, with them switching their attention to other sweet

foods when they had consumed the experimental foods to satiety. This suggests that

further consideration needs to be given to how different access conditions staged in

these experiments might relate to both children’s liking and wanting (Berridge, 1996)

of restricted foods within their natural environments.

Another interesting aspect to Jansen et al.’s (2008) second study was that

they also examined whether restriction of fruit would demonstrate the same effect as

for highly palatable foods i.e. lollies [sweets]. While they found that restriction of fruits

(banana and pineapple) also resulted in higher child intake (grams) following

restriction, they did not find any difference in children’s pre-occupation behaviour

towards fruit in comparison to the control group. This suggests that another factor

may differentiate children’s responses to these different types of foods. As fruit is

probably less likely to be a food targeted for restriction, this raises a question

regarding children’s perceptions of different foods already developed by the age of

children participating in these studies (5 to 7 years). Wardle, Sanderson, Gibson, and

Chapter 2: Literature Review 19

Rapoport’s (2001) study showed that most children are likely to have been introduced

to and developed a liking for highly palatable foods potentially targeted for restriction4

by 4 years old (n = 214 twin pairs). While Jansen et al. did not provide an explanation

for their finding, this may indicate a difference in children’s perceptions of fruit as

opposed to other palatable foods, which may or may not be associated with restrictive

feeding.

A number of these studies also examined associations between parents’ use

of restrictive feeding at home and children’s experimental responses with mixed

results (see Table 2.2 for details). Fisher and Birch (1999a) used a preliminary

version of what was later developed into the Child Feeding Questionnaire (CFQ)

restriction scale (Birch et al., 2001)5 to measure parent restriction of the experimental

foods at home. They found higher scores for parent “restriction of experimental food

at home” (p. 1270) to be associated with higher child selection frequency of the

restricted food but not the amount consumed (gram intake) or behaviour events.

Other experimental studies measured parental restriction at home using the CFQ

restriction scale (see Section 2.4.2, Table 2.3 for details of this scale). Jansen et al.

(2007) found that child intake (grams) of the experimental restricted food showed a U-

shaped association with parent restriction and concluded that a moderate level of

parental restriction is preferable. However, they found no association between child

intake or behaviour events and parent restriction (using the same measure) in their

second experiment (Jansen et al., 2008). Rollins et al. (2014a) also found no

association between parent restriction scores and child experimental responses

(behaviour events, frequency of selection, gram intake) using both the CFQ restriction

scale and the Kids Child Feeding Questionnaire restriction scale6 (Carper, Fisher, &

Birch, 2000). Overall, these findings do not provide any clear evidence of an

association between parent restrictive feeding at home and experimental findings.

4 Chocolate, chocolate biscuits, crisps, ice cream, ice lolly, plain biscuits, cake and chips. 5 Details of this preliminary version of the Child Feeding Questionnaire, CFQ (Birch et al., 2001) were not provided in the study paper. It consisted of 6 items with two examples given, ‘Do you try to keep this food out of your child’s reach?’ and ‘Do you limit how often your child may have this food?’ 6 Version of the CFQ (Birch et al., 2001) adapted for use with children aged 3 to 6 years.

20 Chapter 2: Literature Review

2.3.3 Summary of evidence from experimental studies

While short-term experimental studies have consistently found greater child

pre-occupation behaviours towards and greater intake of foods immediately following

a period of restriction (see Section 2.3.2), it is unclear what these observations mean

in relation to parents’ restrictive feeding in natural home environments. Ogden et al.’s

(2013) longer experimental studies demonstrated that the alternative of allowing free

access may lead to higher intake of a restricted food and children turning their

attention to alternative sweet foods following consumption of the restricted food to

satiety. Attempts to examine child experimental outcomes with parents’ use of

restrictive feeding at home have not produced any conclusive evidence. Furthermore,

both child (Fisher & Birch, 1999a; Rollins et al., 2014a) and non-human animal

experiments (Corwin et al., 1995; Files et al., 1994) have not demonstrated that the

experience of restriction increases ongoing preference for the restricted food outside

of the experimental context nor disruption to self-regulation of eating. Therefore, it is

unclear whether child responses to different access conditions in these short-term

staged experiments reflect restrictive feeding experiences in the natural environment.

Observed responses may not represent differences in child preferences for restricted

foods but rather sensory specific satiety responses (Rolls & Rolls, 1997) to different

access conditions.

Another factor to consider is that children have innate preferences for the

high–sugar, high-fat, energy dense foods potentially targeted for restriction (Birch et

al., 1990; Birch, 1992) and Wardle, Sanderson, et al.’s (2001) study suggests that

children are likely to have been introduced to such foods and developed a liking for

them7 by 4 years old. Therefore, it is unclear how children’s innate preferences and

prior experiences with the types of foods targeted for restriction may have influenced

experimental observations. Notably, children did not display the same behavioural

responses of desire for fruit in Jansen et al.’s (2008) study, although their

consumption of fruit still increased in the immediate period following restriction.

Overall, despite authors claims that cited animal studies and their

experimental findings provide evidence of negative implications associated with the

use of restrictive feeding, this is not clearly evident from these experimental studies.

Associations between parent restrictive feeding at home and related child outcomes 7 Chocolate, chocolate biscuits, crisps, ice cream, ice lolly, plain biscuits, cake and chips.

Chapter 2: Literature Review 21

have been examined further by cohort studies, which are reviewed in the next

section.

22 Chapter 2: Literature Review

Table 2.2

Summary of Experimental Studies Examining the Effects of Restricting Foods on Children’s Responses Author/Sample Experimental design Dependent variables Results

Fisher & Birch, 1999a n=31 (3-5 years)

• Design: Between-subjects (observed at regular school snack session)

• Experimental Foods: Two similar sweet snack foods selected as restriction and control foods (apple bars and peach bars).

• Experiment Schedule: 20 minute sessions − Control group: free access to control and

restricted food items − Restriction group: free access to control food, 2

minute access to restricted food item in middle of 20 minutes. The restricted food was visible to children throughout the experiment.

Outside restriction testing context Forced choice ‘selection’ & 2-choice consumption tests: for restricted and control food items before and after experiment (5 week restriction period).

Behaviour frequency events • Positive comments/behaviours towards

restricted foods • Requests for restricted food or attempts to

gain access • Positive comments/behaviours about

restriction • Negative comments/behaviours about

restriction Outside of the experimental context • Forced-choice selection: child asked

choose between restricted and control foods for a snack. Restricted food chosen scored 1, not chosen scored 0.

• Forced-choice consumption: child consumption (grams) of restricted and control food free 2-choice sessions pre and post experiments.

Within testing context • Significantly increased behaviour response towards

restricted food in comparison to control food item following a 5 week period of restricted access to experimental food**.

• Difference in behaviour was greater for boys. Pre and post testing • No lasting effect of experimental restriction trials found

on children’s selection and intake of restricted and control foods 3 weeks after experiment.

• Consumption of both restricted and control food items significantly decreased between pre and post trial tests*.

Fisher & Birch, 1999a n=40 (3-6 years)

• Design: Within-subjects experimental (observed at regular school snack session)

• Experimental Foods: Control food (unsalted wheat crackers), Restricted foods (cheese fish-shaped crackers, pretzel fish-shaped crackers), one restricted food allocated according to child preference.

• Experiment Schedule: 8 X 15 minute sessions over 2 weeks − 4 unrestricted sessions (control and restricted

food freely available) − Followed by 4 restricted sessions (control food

freely available, restricted food available middle 5 minutes). The restricted food was visible to children throughout the experiment.

• Behaviour frequency: child behavioural events for restricted food (as above).

• Intake gram amount: during 5 minute non-restriction period and equivalent period of time for controls (15 minutes access/3).

• Selection: number of scoops taken of the restricted food.

Outside of the experimental context • Frequency of parent home purchase of

the 6 experimental foods. • 6-item questionnaire – extent to which

mothers and fathers typically restrict their child’s access to snack foods (e.g. Do you try to keep this food out of your child’s reach? Do you limit how often your child may have this food?)

Within testing context • Greater behavioural response***, selection*** and

intake** towards the ‘restricted’ food item during the mid 5 minutes of restricted sessions compared to the mid 5 minutes of the unrestricted sessions.

• Behaviour** and intake*** were also significantly higher in the non-restricted 5 minute period of the restricted sessions than the equivalent percentage of time in the total 15 minutes of the unrestricted sessions. Note. No measurement comparing total intake of control and restricted foods over the full duration (15 minutes).

Outside testing context • Less frequent purchase of experimental food at home

sig. associated with higher frequency child behaviour events towards experimental restricted food.

• Restriction of children’s access to experimental foods at home (6-item questionnaire) was associated with experimental child frequency of selection of the restricted food, as well as higher child weight for height, higher parent education and lower parent BMI.

Chapter 2: Literature Review 23

Author/Sample Experimental design Dependent variables Results Jansen et al., 2007 n=74 (5-6 years)

• Design: Between-subjects (primary school environment) • Random assignment to prohibition or no-prohibition

conditions (observed classroom) • Prohibited foods: Red M&M chocolates and crisps. Non-

prohibited foods: Yellow M&M chocolates and crisps. • Experiment Schedule: 10 minutes

− Phase 1: prohibition of one group, not the other (5 minutes). The restricted food was visible to children throughout the phase.

− Phase 2: Free access to all foods, both groups (5 minutes)

• CFQ restriction scale used to measure parents restrictive feeding at home.

• Food intake (kilojoules) • Desire to eat the restricted and control foods

was measured by Visual Analogue Scale (VAS) before and after phase 1. Scale ranged from no desire at all to a very large desire

• Visual Analogue Scale was also used to assess that taste ratings (not at all tasty to very tasty) and satiety ratings (tummy totally empty to tummy completely full) did not differ between groups.

• Desire for prohibited food significantly increased (during phase 1) for the experimental group*, whereas desire remained the same for the control group.

• Intake: experimental group consumed a larger proportion of prohibited food than controls* (kilojoules [kj]).

• Total intake: No sig. differences in absolute intake (kj) (over the full duration of the experiment) between groups.

• Restriction at home: CFQ high and low restriction associated with higher kj intake*** (R²= 0.21).

Jansen et al., 2008 n=70 (5-7 years)

• Design: Between-subjects (primary school environment) • Random assignment to 3 groups: No-prohibition, fruit-

prohibition, sweets-prohibition • Sweets foods: M&M chocolates and fruit gums. Fruit

foods: banana and pineapple. • Experiment Schedule: 10 minutes

− Phase 1: 5 minutes - prohibition of fruit (one group), sweets (one group), no prohibition (one group). The restricted food was visible to children throughout the phase.

− Phase 2: Free access to all foods all groups (5 minutes)

• CFQ restriction scale used to measure parents restrictive feeding at home.

• Fruit and sweet intake (grams) • ‘Desire’ for foods measured by Visual

Analogue Scale (VAS) before and after phase 1.

• No sig effect of prohibition on desire for fruit but sig. effect for desire for sweets in prohibition group*

• Fruit-prohibition group consumed more (grams) fruit in phase 2 (freely available) than the no-prohibition* and sweet-prohibition group**.

• Sweet-prohibition group consumed more (grams) sweets in phase 2 (freely available) than the no-prohibition* and fruit-prohibition group*.

• In phase 2 (5 min. period following restriction), the total energy intake (Kilocalories) for all foods offered was higher in both prohibition groups than the no-prohibition group*

• Restriction at home: no sig. effect CFQ restriction scale scores on energy intake (kilocalories) or total sweet intake (grams).

Rollins et al., 2014a n=37 (3-5 years)

• Design: Within-subjects (observed at regular preschool snack session 2.5-3 hrs > school-served lunch)

• Experimental Foods: Control food (Sweet Sponge Bob graham crackers, Kraft), Restricted foods (Sweet Scooby Doo graham crackers, Kelloggs), one restricted food allocated according to child preference.

• Experiment Schedule: Groups 4-7 children, 8 X 15 minute sessions over 2 weeks − 4 unrestricted sessions (control and restricted

food freely available) − Followed by 4 restricted sessions (control food

freely available 15 minutes, restricted food available middle 5 minutes). The restricted food was visible to children throughout the experiment.

• CFQ and KCFQ restriction scales used to measure parents restrictive feeding at home.

• Selection frequency: scoops of crackers • Intake: calories consumed for each 5 minute

interval by each child. • Behaviour: frequency of child vocalisations

and behaviours in response to the restricted food e.g. I want it or physical attempts to access the food.

• % RRV of food (Preference for restricted food)

• Inhibitory control and approach ( measured by CBQ)

• Restriction group sig. increased intake** and behavioural response’ ** (mid 5 mins of experiment) in comparison to non-restriction group (mid 5 mins of experiment).

• No sig. effect on selection • No sig. effect on eating responses 1 week later. Other Associations • Restriction at home: no sig. effect CFQ restriction scale

and KCFQ restriction scores on any child outcome measure.

• Intake sig. associated with low ‘inhibitory control’**, higher ‘approach’* and higher % RRV***

• No sig. effect on intake for children with high ‘inhibitory control’, low ‘approach’ and low % RRV.

• Higher child intake (grams) of experimental restricted foods associated with parents keeping all six experimental foods out of the child’s reach at home, as opposed to five or fewer of these foods*.

24 Chapter 2: Literature Review

Author/Sample Experimental design Dependent variables Results Ogden et al., 2013 n=53 (3 yrs [1-7 yr])

Study 1: Chocolate Coin Experiment • Design: Between-subjects, family home setting (2 days,

weekend) • Experiment Schedule: Parents randomly assigned to

restriction/non-restriction protocol for target food – chocolate coins. − Non-restricted protocol allow to eat when want. − Restricted protocol, keep out of reach in

cupboard, not give within 1 hr meal, only give one at a time, at least 30 mins between chocolates.

− Both groups show and give one chocolate at 10am Saturday.

− Parent recorded intake (grams) - chocolate coins & other sweet foods (not specified) separately

− Parent recorded child daily responses (demanding and eating behaviour)

Child Intake (grams) • restricted food • Other sugary foods Child preoccupation: mothers reports – 5-pt Likert scale (Never to Always) - start and end of experiment • demanding restricted food & other sweet

food: four items - demand, talk about, want to eat and ask for chocolate/sweet food items

• eating behavior towards restricted food & other sweet food: four items - eat, eat very fast, eat lots in one go, feel ill from eating chocolate/sweet food.

• Intake of restricted food 69% higher (mass consumed) in non-restriction group than restriction group.

• Non-restriction group had higher preoccupation (demanding and eating behaviour) for restricted food at start** but decreased more than restriction group, over period of experiment***.

• Non-restriction group showed a relatively lower preoccupation (demanding and eating behaviour) towards other sweet foods at the start* but the two groups were comparable at the end (p= 0.8), with restriction group showing no change over the experiment.

• At the end of the experiment, both groups had similar combined preoccupation mean scores (restricted chocolate + other sweet foods). (Demanding= 3.62, 3.64, Eating= 3.39, 3.41, Not reported in study)

Ogden et al., 2013 n=86 (7.5 yr [4-11 yr])

Study 2: Easter Egg Experiment • Design: Between subjects, family (2 weeks) • Experiment Schedule: Parents randomly assigned to

restriction/non-restriction protocol for target food – chocolate easter eggs. Protocols and recording same as above.

Same as above • Intake of restricted food 67% higher (mass consumed) in non-restriction group than restriction group.

• Demanding behaviour same for both groups at start but sig. greater in restriction group at end experiment*

• Eating behaviour sig. higher for non-restriction group at start*** but not sig. different at end experiment (p= 0.6).

• No sig. changes in preoccupation with other sweet foods but the trend indicated greater increase amongst non-restriction group. The mean for demanding other sweet foods increased by 33% for the non-restriction group but only 5% for restriction group.

• At the end of the experiment, the non-restriction group had slightly higher combined preoccupation mean scores (restricted chocolate + other sweet foods) than the restriction group (demanding means = 4.84, 4.64, eating means = 4.32, 4.18 respectively, not reported in study).

Note. CFQ = Child Feeding Questionnaire, restriction scale (Birch et al., 2001); KCFQ = Child version of the CFQ (Carper et al., 2000); CBQ = Children’s Behaviour Questionnaire (Rothbart, Ahadi, Hershey, & Fisher, 2001); RRV = Relative Reinforcing Value. a % RRV scored by number of responses made for restricted food divided by total behaviour events made for both foods (preference for restricted food) * p < .05. ** p < .01. *** p < .001.

Chapter 2: Literature Review 25

2.4 STUDIES OF RESTRICTIVE FEEDING USING COHORT DESIGNS 2.4.1 Introduction

This section reviews 33 cross-sectional and 12 longitudinal cohort studies.

All cross-sectional and longitudinal studies identified measured parent restrictive

feeding using a self-report questionnaire, with the CFQ 8-item restriction scale

(Birch et al., 2001) being most prominently used. These measures are outlined and

discussed in Section 2.4.2. Section 2.4.3 presents cross-sectional study findings in

groups based on the child outcome measure used. A range of child outcome

measures have been used in these studies but were categorised into four groups for

analysis: child weight status, child food intake, child eating behaviours and child

food preferences (or liking or wanting)8. Section 2.4.4 presents findings for

longitudinal studies. The majority of these studies have assessed child outcomes as

change in child weight status, with a few examining change in child eating

behaviours. Section 2.4.5 reports on potential effect modification by sample

characteristics across the studies reviewed. Further details of study variables and

findings, as well as covariates included in studies, are provided in Appendix B,

Tables B.1 and B.2.

Most studies had adjusted for a range of parent and child characteristic

covariates. Where covariates have been examined in a study, this is denoted by ^ in

tables summarising studies in Section 2.4.3 and 2.4.4. Differences in effect

associated with the use of covariates have been highlighted in the review where

relevant and specific covariates used in studies are outlined in Appendix B, Tables

B.1 and B.2. However, there is a lack of evidence clarifying whether maternal

characteristics (e.g. maternal education, maternal BMI) would potentially confound

child outcomes independently of their association with parents’ restrictive feeding

behaviour. Furthermore, other potential confounding from co-existing feeding

practices (e.g. pressure to eat or foods used as rewards) has not been included in

any of the cohort studies identified, with the exception of Campbell, Crawford, and

Ball’s (2006) study (see Section 2.4.3.2, Table 2.7)

8 This notation refers to child liking for or wanting to consume a food or drink.

26 Chapter 2: Literature Review

2.4.2 Measures of parent restrictive feeding used in cohort studies

As mentioned in Section 2.2, there is no universally agreed definition or

concept of the restrictive feeding phenomenon to guide development of a measure

of this phenomenon. Construct validation9 of instruments used to measure parent

restrictive feeding in cohort studies has been minimal, with the initial step of

determining whether items included in a questionnaire measure what they are

intended to measure having been largely overlooked. There has been a tendency to

focus more on statistical testing of reliability between scale items and determining

whether scales predict child weight status (i.e. criterion validity).

Table 2.3 outlines the main parent questionnaires that have been used in

cohort studies examining restrictive feeding. The most frequently used

questionnaire by far has been the CFQ restriction scale developed by Birch et al.

(2001), which claims to differentiate high and low restricting parents. Ogden et al.

(2006) subsequently developed two complementary scales to differentiate between

overt and covert controlling feeding. While these were not developed to specifically

measure restrictive feeding, the covert scale was later adapted by Jansen et al.

(2014) as a covert restriction scale within their Feeding Practices and Structure

Questionnaire (FPSQ). The FPSQ also included a complementary overt restriction

scale with selected items from the CFQ restriction scale. Musher–Eizenman and

Holub (2007) developed the Comprehensive Feeding Practices Questionnaire

(CFPQ), which included two complementary scales intended to differentiate

restriction for health from restriction for weight control. The restriction for health

scale consists of a selection of items from the CFQ restriction scale and the

restriction for weight control scale was based on items predominantly from the

Dutch Eating Behaviour Questionnaire (DEBQ) (Van Strein, Fritjers, Gerard,

Bergers, & Defares, 1986). These scales are discussed in more detail below but this

review suggests that these measures present three main groups of similar

questionnaire items.

• The CFQ restriction scale group - The CFQ restriction scale (Birch et al.,

2001) and modified versions of this scale, which includes Musher-

Eizenman and Holub’s (2007) CFPQ restriction for health scale and Jansen

et al.’s (2014) FPSQ overt restriction scale. 9 Construct validity is the degree to which a test measures what it claims, or purports, to be measuring. (Cronbach & Meehl,1955).

Chapter 2: Literature Review 27

• The covert restriction group - Ogden et al.’s (2006) covert control scale

and the modified version, Jansen et al.’s (2014) FPSQ covert restriction

scale.

• Restriction for weight control group - Musher-Eizenman and Holub’s

(2007) CFPQ restriction for weight control scale and a similar measure

used by Dev, McBride, Fiese, Jones, and Cho (2013).

In addition, the Restricted Access Questionnaire (RAQ), which was

developed by Fisher and Birch (1999b) prior to the CFQ scale (Birch et al., 2001),

has been applied to a couple of studies included in this review and Gubbels et al.

(2009) applied a measure that differentiated restriction of specific foods and drinks

in a single study. These measures are also discussed below.

2.4.2.1 The CFQ restriction scale (Birch et al., 2001)

The CFQ restriction scale is one of seven scales included in the broader

CFQ parent-reporting questionnaire (Birch et al., 2001). This questionnaire

examines a number of parental feeding attitudes, beliefs and practices proposed to

be associated with the development of childhood obesity. The impetus for

development of this scale was Costanzo and Woody’s (1985) qualitative study,

suggesting that parent’s attitudes, beliefs and use of controlling feeding practices

may be associated with children’s risk of obesity. Fisher and Birch (1999a, 1999b)

later distinguished between controlling feeding practices of pressure to eat and

restriction, proposing that restriction of children’s access to snack foods increased

their intake of restricted foods in the absence of parent monitoring. Scales for

restriction, pressure to eat and monitoring were subsequently identified as three

separate scales within the final version of the CFQ questionnaire (Birch et al.,

2001). Validation of the restriction scale has been limited to assessment of criterion

validity with prediction of child weight. However, the restriction scale part of the CFQ

did not show a significant association with child weight for the two child samples

tested and reliability of the scale was assessed as only acceptable (Cronbach α =

0.73) (Birch et al., 2001). The authors recognised that further work was required to

establish reliability and validity of the measure but no further evidence of construct

validation of this widely used scale was found in the literature. The items included in

this scale are shown in Table 2.3.

28 Chapter 2: Literature Review

Face validity10 of this instrument suggests a lack of clarity of the

phenomenon being measured. While the research community refers to restrictive

feeding as restrictive feeding practices, only 1 of 8 items in this scale (item 4 in

Table 2.3) refers to a restrictive feeding practice. This item refers to the practice of

keeping “some foods out of my child’s reach” but it is not clear that this practice

resembles a scenario of higher restrictive feeding as proposed by the authors. A

high score for this item may indicate that restricted foods are being kept in the

house, with children potentially having greater access than if they were not kept in

the house. The majority of items in this scale refer to a parent’s need “to be sure” or

“guide or regulate” their child from eating “too many” or “too much” “sweet”, “junk”,

“favourite” or “high fat” foods, without reference to the parent’s approach to dealing

with this observation (see Table 2.3, Items 1,2,3,7,8). Furthermore, another two

items in this scale relate to giving foods as a reward (see Table 2.3, Items 5 & 6),

which was identified by Wardle et al. (2002) as a separate controlling feeding

practice (see Chapter 1, Section 1.1). Corsini, Danthiir, Kettler, and Wilson (2008)

examined this scale by factor analysis and found these two food reward items had

low scale loadings with the other items, suggesting that they were distinct from the

other items in the scale. Both Jansen et al. (2014) and Musher–Eizenman and

Holub (2007) excluded these two items from their FPSQ overt restriction and CFPQ

restriction for health scales respectively, which are based on items from the CFQ

restriction scale (Birch et al., 2001) (see Table 2.3). Birch et al. (2001) propose that

high scores on this scale represent high parent restriction but face validity suggests

these items could reflect an environment where the child has frequent access to

restricted foods accompanied by the need to apply limitations via more frequent

parent restrictive feeding behaviours. As the scale does not include a measure of

children’s access to restricted foods, it is not possible to know whether high or low

responses to the questions posed are associated with high or low restriction of

access.

2.4.2.2 Ogden’s overt and covert control scales (Ogden et al., 2006) & FPSQ overt and covert restriction scales (Jansen et al., 2014).

As mentioned in Section 2.2, Ogden et al. (2006) introduced the idea that

overt and covert approaches to controlling feeding could have differing effects on

10 Face validity refers to the extent to which a measure appears to subjectively measure the concept it is proposing to measure (Gravetter & Forzano, 2011).

Chapter 2: Literature Review 29

child outcomes and developed separate overt and covert controlling feeding scales.

Subsequently, Jansen et al. (2014) proposed that a slightly modified version of

Ogden et al.’s covert scale represented covert restriction in their FPSQ (Cronbach α

= 0.84 good) (see Table 2.3). Studies using Ogden et al.’s covert control scale

have, therefore, been included in this review as representing covert restrictive

feeding as well (Cronbach α = 0.83 good). However, findings for Ogden et al.’s overt

control scale have been excluded because Ogden et al. found this scale to be more

highly correlated with another feeding practice, pressure to eat. Jansen et al. did not

use this scale to represent overt restriction in their FPSQ but instead proposed an

overt restriction scale consisting of a selection of items from the CFQ restriction

scale (Birch et al., 2001). However, these scales are not complementary or mutually

exclusive and face validity does not suggest they differentiate overt and covert

restriction (see Table 2.3).

Ogden et al. (2006) was the only author to specify that their scales were

derived from “the literature and through discussions with mothers of small children”

(p. 102), suggesting some attention to construct validity. However, no further

reference to validation that this scale measures the phenomenon it is intended to

measure was reported. Face validity of the covert control/restriction scales (Ogden

et al., 2006; Jansen et al., 2014) suggests that the items resemble parent restrictive

feeding behaviours of avoiding children’s access to “unhealthy” foods. The

accompanying response scales provide a subjective frequency (Never to Always) of

avoidance of access, which may also reflect lower child intake of restricted foods.

Therefore, while these scales may resemble covert approaches to restriction, they

may also reflect lower child access to restricted foods.

2.4.2.3 CFPQ restriction for health and restriction for weight control scales (Musher-Eizenman & Holub, 2007)

Musher-Eizenman and Holub’s (2007) CFPQ consists of two scales aiming

to distinguish between restriction for health and restriction for weight control. The

restriction for health scale includes four items from the CFQ restriction scale (Birch

et al., 2001). The restriction for weight control scale includes one item from the CFQ

restriction scale and seven items adapted for use with children from the Dutch

Eating Behaviour Questionnaire [DEBQ] (Van Strein et al., 1986) (see Table 2.3).

Items in this scale reflect a parent’s effort to control their child’s general overall

30 Chapter 2: Literature Review

calorific intake, with 6 of the 8 items referring to a concern for their child becoming

overweight.

However, these two scales do not appear to be complementary and

mutually exclusive. While face validity of the restriction for weight control scale

appears to reflect such a motivation, the restriction for health scale does not elicit a

specific parent motivation for parent behaviours. The assumption is made that

restriction of sweet and favourite foods are for health reasons rather than weight

when it might be either or both. Both scales were shown to be significantly positively

correlated with parent reported concern about child weight, although greater

correlation was indicated for the restriction for weight control scale (restriction for

health, r = .22, p < .05; restriction for weight control, r = .51, p < .05) (Musher-

Eizenman & Holub, 2007).

Chapter 2: Literature Review 31

Table 2.3

Comparison of Scale Items Included in the Main Questionnaires Used in Cohort Studies to Measure Parent Restrictive Feeding

Child Feeding Questionnaire (CFQ), Restriction Scale (Birch et al., 2001)

Overt/Covert Control Scale (Ogden et al., 2006)

Feeding Practices Structure Questionnaire (FSPQ), Overt/Covert Restriction Scale (Jansen et al., 2014)

Comprehensive Feeding Practices Questionnaire (CFPQ) (Musher-Eizenman & Holub, 2007)

1. I have to be sure that my child does not eat too many sweet foods (lollies, ice-cream, cake and pastries).

2. I have to be sure that my child does not eat too many high-fat foods.

3. I have to be sure that my child does not eat too much of his/her favourite foods.

4. I intentionally keep some foods out of my child’s reach.

5. I offer sweet foods (lollies, ice-cream, cake and pastries) to my child as a reward for good behaviour.

6. I offer my child his/her favourite foods in exchange for good behaviour.

7. If I did not guide or regulate my child’s eating, (s)he would eat too many junk foods.

8. If I did not guide or regulate my child’s eating, (s)he would eat too much of his/her favourite foods.

Overt Scale

1. How often are you firm about what your child should eat?

2. How often are you firm about when your child should eat?

3. How often are you firm about where your child should eat?

4. How often are you firm about how much your child should eat?

Overt Scale (CFQ restriction items 1,3,4 & 7) 1. I have to be sure that my child does not

eat too many sweet foods (lollies, ice-cream, cake and pastries).

2. I have to be sure that my child does not eat too much of his/her favourite foods.

3. I intentionally keep some foods out of my child’s reach.

4. If I did not guide or regulate my child’s eating, (s)he would eat too many junk foods.

Restriction for Health (CFQ restriction items 1,3, 7& 8) 1. I have to be sure that my child does not

eat too many sweet foods (lollies, ice-cream, cake and pastries).

2. I have to be sure that my child does not eat too much of his/her favourite foods.

3. If I did not guide or regulate my child’s eating, (s)he would eat too many junk foods.

4. If I did not guide or regulate my child’s eating, (s)he would eat too much of his/her favourite foods.

Covert Scale

1. How often do you avoid going with your child to cafes or restaurants which sell unhealthy foods?

2. How often do you avoid buying lollies and snacks eg. potato chips and bringing them into the house?

3. How often do you not buy foods that you would like because you do not want your children to have them?

4. How often do you try not to eat unhealthy foods when your child is around?

5. How often do you avoid buying biscuits and cakes and bringing them into the house?

Covert Scale (Ogden et al.’s Covert Scale items 1,2,3 & 5) 1. How often do you avoid going with your

child to cafes or restaurants which sell unhealthy foods?

2. How often do you avoid buying lollies and snacks eg. potato chips and bringing them into the house?

3. How often do you not buy foods that you would like because you do not want your children to have them?

4. How often do you avoid buying biscuits and cakes and bringing them into the house?

Restriction for Weight Control (CFQ restriction item 1 below [item 2 in CFQ], DEBQ, Van Strein et al., 1986 ) 1. I have to be sure that my child does not

eat too many high-fat foods. 2. I encourage my child to eat less so

he/she won’t get fat. 3. I give my child small helpings at meals to

control his/her weight 4. If my child eats more than usual at one

meal, I try to restrict his/her eating at the next meal.

5. I restrict the food my child eats that might make him/her fat.

6. There are certain foods my child shouldn’t eat because they will make him/her fat.

7. I don’t allow my child to eat between meals because I don’t want him/her to get fat.

8. I often put my child on a diet to control his/her weight.

5-point Likert scale: Disagree to Agree 5-point Likert scale: Never to Always 5-point Likert scales: Overt: Disagree to Agree Covert: Never to Always

5-point Likert scales: Disagree to Agree

Adapted for use with children

32 Chapter 2: Literature Review

2.4.2.4 The RAQ (Fisher & Birch, 1999b)

Prior to development of the CFQ (Birch et al., 2001), Fisher and Birch

(1999b) developed and applied the RAQ scale for use with an Eating in the Absence

of Hunger (EAH) protocol (see Table 2.4). This measure has only been used by

Fisher and Birch (1999b) and Rollins et al. (2014b). The scale was applied to each

of the seven individual snack foods included in the EAH experiment protocol

(popcorn, pretzels, chips, fruit-flavoured chewy candies, chocolate, chocolate chip

cookies, and ice cream) but composite scores were derived from mean responses.

While scale items 2 and 3 reflected frequencies of parent restricting activities, items

1 and 5 are yes/no answers, with no measure of how often the item might be

purchased or kept out of the child’s reach. This means that a response of rarely limit

to item 3 could be related to either infrequent purchase (i.e. high restriction) or

frequent purchase (i.e. low restriction). Potentially greater parent activity may be

required if the item is made available more frequently than if it was not available.

Therefore, the questions do not clearly distinguish between high and low restrictive

feeding.

Table 2.4

The Restricted Access Questionnaire (RAQ) (Fisher & Birch, 1999b)

Questions Response scales

1. Do you deliberately limit how often you buy these foods?

2. When do you allow your child to have these foods?

3. In general, do you limit how much of these foods your child is allowed to have?

4. Is your child allowed to have second helpings of these foods (if served at the house or outside the home)? (reverse coded)

5. Do you try to keep any of these foods out of your child’s reach?

Yes/No Anytime, snack, dessert, special occasion, don’t allow (0-4) Never, rarely, sometimes, usually, always (0-4) Always, usually, rarely, never (0-3) Yes/No

Note. Questions applied to each of seven snack food items (popcorn, pretzels, chips, fruit-flavoured chewy candies, chocolate, chocolate chip cookies, and ice cream)

2.4.2.5 Gubbels et al.’s (2009) restriction question

Gubbels et al. (2009) asked a single specific question: “Are there specific

foods that you do not allow your child to eat or drink?” (response options: yes/no). If

the response was “yes” respondents were asked to indicate which of the following

Chapter 2: Literature Review 33

foods their child was not allowed to eat: sweets [lollies], cookies, cake, soft drinks,

crisps [potato chips] and sugar. This was the only study identified that measured

specific responses to specific foods and drinks targeted for restriction without

combining them into a composite score for restricted foods and drinks. However, it

does not give any indication of the level of restriction of an item beyond no access

and does not measure how a parent might restrict an item.

2.4.3 Analysis of cross-sectional study findings

Thirty three cross-sectional studies were included in this review. Some

studies applied more than one measure of parent restrictive feeding and a number

of studies applied more than one child outcome measure. Study findings have been

grouped by child outcome measures: child weight, child intake, child eating

behaviours and child preferences (or liking or wanting), which have been presented

in Sections 2.4.3.1 to 2.4.3.4. These are summarised in Tables 2.5 to 2.9 and a

summary of findings is presented in Section 2.4.3.5. Further details are provided in

Appendix B, Table B.1.

2.4.3.1 Studies measuring child weight status as the outcome measure

The most common outcome measure used in cohort studies has been child

weight status, with child body mass index11 z-score (BMIz) being most predominant

but other measures including total fat mass (TFM) and weight for age z-scores.

Table 2.5 shows findings for cross-sectional studies examining associations

between parent restrictive feeding and child weight status. The first section of the

table shows findings for studies using the CFQ restriction scale (Birch et al., 2001)

or modified versions of this scale to measure parent restrictive feeding (see Section

2.4.2 for details of these scales). Nine studies showed a positive cross-sectional

association between higher parent restrictive feeding scores and heavier child

weight status (Cardel et al., 2012; Costa, Pino, & Friedman, 2011; Gray, Janicke,

Wistedt, & Dumont-Driscoll, 2010; Gubbels et al., 2011; Jansen et al., 2012; Lee,

Mitchell, Smiciklas-Wright, & Birch, 2001; Musher-Eizenman, Lauzon-Guillain,

Holub, Leporc, & Charles, 2009; Spruijt-Metz, Lindquist, Birch, Fisher, & Goran,

2002; Webber, Cooke, & Hill, 2010). However, six studies found no association

(Gregory, Paxton, & Brozovic, 2010b; Hennessy, Hughes, Goldberg, Hyatt, 11 Defined as an individual’s weight (kg)/ height (m)².

34 Chapter 2: Literature Review

& Economos, 2010; Jansen et al., 2014; Powers, Chamberlin, Van Schaick,

Sherman, & Whitaker, 2006; Shohaimi, Wei, & Shariff, 2014; Wehrly, Bonilla, Perez,

& Liew, 2014). In addition, one study found their results change from no association

to a positive association when the two food reward items (see Section 2.4.2, Table

2.3, Items 5 & 6) were removed from the CFQ restriction scale (Sud, Tamayo, Faith,

& Keller, 2010). Overall, these findings do not provide clear evidence of a cross-

sectional association between parent restrictive feeding and children’s weight,

although there was no evidence of higher parent restriction scores being associated

with a lower child weight status. Differences in study findings were also not clearly

explained by child age. Although three studies with the youngest child samples

showed no association (Gregory et al., 2010b [2-4 years]; Jansen et al., 2014 [2

years]; Powers et al., 2006 [2-5 years]), four studies with older children also showed

no association with child weight status (Hennessy et al., 2010 [9 years]; Shohaimi et

al., 2014 [7-9 years]; Sud et al., 2010 [4-6 years]; Wehrly et al., 2014 [4-6 years]).

Furthermore, Sud et al.’s (2010) findings, which showed a change from no

association to a positive association when two items from the CFQ restriction scale

were removed, also indicated that findings are likely to be sensitive to the construct

of the measurement scale.

Studies using the CFPQ restriction for weight control scale or similar

(Musher-Eizenman & Holub, 2007; Dev et al., 2013) showed predominantly positive

associations with higher parent scores on this scale and heavier child weight status

(see Table 2.5), although only three of these studies included a range of maternal

and child covariates (Dev et al., 2013; Blissett & Bennett, 2013; Taylor, Wilson,

Slater, & Mohr, 2011). While Blissett et al. (2013) only found a positive association

between higher parent use of restriction for weight control and higher child BMIz for

children of Afro-Caribbean ethnic origin, children in this subgroup were significantly

older and had higher BMIz scores than the other comparative ethnic group in the

sample. However, it would be expected that parents’ who are restricting their

children’s overall calorific intake, which the restriction for weight control scale

resembles (see Section 2.4.2, Table 2.3), are doing so to reduce the weight of a

heavier child. A number of authors have found an association between parent’s

concern about their child’s weight and higher parent restrictive feeding scores (Gray

et al., 2010; Gregory et al., 2010b; Mais, Warkentin, Latorre, Carnell, & Taddei,

2015; Spruijt-Metz et al., 2002; Warkentin, Mais, Latorre, Carnell, & Taddei, 2016;

Webber, Hill, Cooke, Carnell, & Wardle, 2010). In particular, Webber, Hill, et al.

(2010) found that concern about weight (measured by the CFQ, Birch et al., 2001)

Chapter 2: Literature Review 35

mediated the relationship between higher parent restrictive feeding scores (CFQ

restriction scale, Birch et al., 2001) and higher child BMIz, with the later association

becoming non-significant when concern about weight was added to the mediation

model (β = 0.04, p = 0.44).

The two studies that applied covert control/restriction scales did not find an

association between these measures of restriction and child weight (Brown et al.,

2008; Jansen et al., 2014). While conclusions cannot be drawn from just two

studies, face validity of these scales suggest they measure the frequency of parents’

actions taken to avoid children’s access to “unhealthy” foods. Therefore, high scores

for these scales may also reflect lower child intake of the target foods (see Section

2.4.2, Table 2.3). However, Jansen et al.’s (2014) sample was very young (2 years)

and this study also reported no association between child weight for age z-scores

and their overt restriction scale, a scale that comprises of a selection of items from

the CFQ restriction scale (Birch et al., 2001). Fisher and Birch’s (1999b) study, using

their own RAQ to measure parent restrictive feeding, also did not indicate an

association between this measure and child BMIz at 5 years.

Overall, these studies do not confirm an association between child weight

and parent restrictive feeding, using the CFQ restriction scale (Birch et al., 2001) or

modified versions of this scale to measure parent restrictive feeding. While an

association between heavier child weight and parents’ restriction for weight control

(CPFQ, Musher-Eizenman & Hobul, 2007) is apparent, evidence suggests that

heavier children may influence parents’ use of restriction for weight control, rather

than restrictive feeding resulting in heavier children (Webber, Hill, et al., 2010),

although cross-sectional studies cannot clarify the direction of associations.

However, child weight status may not be the most appropriate outcome measure to

assess the effects of restrictive feeding on children’s future risk of developing diet-

related diseases and/or obesity because it is difficult to control for variables beyond

food intake that might also influence weight, such as physical activity, metabolism

and inherited predispositions (Vos & Welsh, 2010). In addition, poor diet quality is

possible without impacting on child weight. Child intake of foods and drinks targeted

for restriction may provide a more appropriate direct measure of the effects of

restrictive feeding on child diet-related outcomes. Studies applying child food and

drink intake as the outcome measure are discussed in the next section.

36 Chapter 2: Literature Review

Table 2.5

Cross-Sectional Associations Between Parent Restrictive Feeding and Child Weight Status

Lead Author (Country) Year Sample size

Survey tool

Age (yrs)

Child BMIz

Findings

CFQ Restriction Scale (Birch et al., 2001) or modified versions

Jansen ^ (Netherlands) 2012 4987 CFQ 4 +ve β= 0.09*** Gubbels ^ (Netherlands) 2011 1819 CFQ 5 +ve β= 0.10*** Lee (USA) 2001 192 (girls) CFQ 5 +ve r = .20** Costa ^ (Brazil) 2011 109 CFQ 6-10 +ve OR = 1.36*** Webber, Hill ^ (UK) 2010 213 CFQ 7-9 +ve β= 0.16* Cardel ^ (USA) 2012 267 CFQ (3) 7-12 +ve β= 0.26*** Spruijt-Metz ^ (USA) 2002 120 CFQ 7-14 +ve ª r = .26*** Gray ^ (USA) 2010 191 CFQ 7-17 +ve r = .31*** Gregory ^ (Australia) 2010b 141 CFQ (6) 2-4 None Powers ^ (USA) 2006 296 CFQ 2-5 None Wehrly ^ (USA) 2014 243 CFQ 4-6 None ᵇ Sud ^ (USA) 2010 70 CFQ 4-6 None

CFQ (6) 4-6 +ve r = .3* Hennessy ^ (USA) 2010 99 CFQ 9 None Musher-Eizenman (USA/France) 2009 219 CFPQ (H) 5 +ve OR 1.7** Shohaimi (Malaysia) 2014 397 CFPQ (H) 7-9 None Jansen (Australia) 2014 462 FPSQ (O) 2 None CFPQ Restriction for weight control scale (Musher-Eizenman & Hobul, 2007) and similar

Musher-Eizenman (USA/France) 2009 219 CFPQ (W) 5 +ve OR 2.0** Shohaimi (Malaysia) 2014 397 CFPQ (W) 7-9 +ve r =0.38** Blissett ^ (UK) 2013 171 CFPQ (W) 5-7 +ve Afro-Caribbean

r = 0.52* None British/German

Taylor ^ (Australia) 2011 175 CFPQ (W) 7-11 +ve β = 0.29** Dev ^ (USA) 2013 329 Weight 2-5 +ve OR 1.75* Covert Control & Restriction Scales (Ogden et al. 2006 & FPSQ, Jansen et al., 2014)

Brown ^ (UK) 2008 518 Covert 4-7 None Jansen (Australia) 2014 462 FPSQ (C) 2 None RAQ (Fisher & Birch, 1999b)

Fisher ^ (USA) 1999b 42 RAQ 5 None Note. RAQ = Restricted Access Questionnaire. Developed by Fisher and Birch (1999b) pre-dating development of the CFQ. CFQ = CFQ 8-item restriction scale (Birch et al., 2001). CFQ (6) = 6-items of the CFQ restriction scale (Birch et al., 2001), excluding two food reward items (Section 2.4.2, Table 2.3, items 5 & 6). CFQ (3) = 3-items of the CFQ restriction scale (Birch et al., 2001), items 1-3 (Section 2.4.2, Table 2.3, items 1-3). CFPQ (H) = CFPQ Restriction for Health scale (Musher-Eizenman & Hobul, 2007). CFPQ (W) = CFPQ Restriction for Weight Control scale (Musher-Eizenman & Hobul, 2007). FPSQ (O) = FPSQ Overt restriction scale (Jansen et al., 2014). FPSQ (C) = FPSQ Covert restriction scale (Jansen et al., 2014). Covert = Covert control scale (Ogden et al., 2006). ^ Included covariates (see Appendix B, Table B.1 for details). ª Child weight measured by Fat Mass. Dual-energy X-ray absorptiometry (DEXA). ᵇ Child weight/fat mass assessed by BMI-for-age and percentage body fat. Weight for age z-score. Mean ages across ethnic groups (black Afro-Caribbean 7.1 yrs, white British 5.7 yrs, white German, 5.0

yrs). Used own restriction for weight control scale. Measure used not referenced. * p < 0.05. ** p < 0.01. *** p < 0.001.

2.4.3.2 Studies measuring child intake as the outcome measure

Table 2.6 shows findings for studies examining associations between

parents’ restrictive feeding and children’s total daily energy intake of foods and

drinks (kilojoules/kilogram of child body weight). All studies used the CFQ restriction

Chapter 2: Literature Review 37

scale (Birch et al., 2001) to measure parent restrictive feeding and consistently

found no association with children’s daily energy intake (Campbell et al., 2006;

Gubbels et al., 2011; Lee et al., 2001; Sud et al., 2010), even though two of these

studies had found a positive association with higher child BMIz (Lee et al., 2001;

Gubbels et al., 2011). This indicates that factors other than diet may be contributing

to associations found between parent restrictive feeding measured by the CFQ

restriction scale and child weight. Alternatively, these different findings may reflect

parents increasing their use of restrictive feeding in response to concerns about

their child’s weight, resulting in a lower subsequent daily energy intake. It is also

possible that the difficulties of accurately measuring children’s intake by parent

reports may have influenced findings.

Table 2.6

Cross-Sectional Associations Between Parent Restrictive Feeding and Child Total

Daily Energy Intake

Lead Author (Country)

Year Sample size Age (yrs)

Survey tool

Associations with daily energy intake (kj/day)

Sud ^ (USA) 2010 70 4-6 CFQ (6) None

Campbell ^ (Australia) 2006 560 5-6 CFQ None

Lee (USA) 2001 192 girls 5 CFQ None

Gubbels ^ (Netherlands) 2011 1819 5 CFQ None

Note. CFQ = CFQ 8-item restriction scale (Birch et al., 2001). CFQ (6) = 6-items of the CFQ restriction scale (Birch et al., 2001), excluding two food reward items (Section 2.4.2, Table 2.3, items 5 & 6). ^ = Included covariates (see Appendix B, Table B.1 for details). * p < 0.05. ** p < 0.01. *** p < 0.001.

However, if parents’ aim is to limit specific palatable foods and drinks, as

proposed by Fisher and Birch (1999a) (see Section 2.2), overall energy intake and

the potential association with child weight would not necessarily reflect restriction of

the specific foods and drinks targeted by parents. Some studies have measured

children’s intake of specific nutrients (e.g. high-fat or sugar) or specific foods

potentially targeted for restriction by parents. Studies measuring types of foods

potentially targeted for restriction have mostly measured these by a parent

completed food frequency survey or diary and then applied a portion gram amount

or kilojoules to produce a composite measure of intake of potentially restricted

foods. While measuring specific foods and drinks targeted for restriction appears

more sophisticated, there is little knowledge of which foods and drinks are targeted

by parents to inform the selection of items. As a consequence, studies have tended

38 Chapter 2: Literature Review

to develop their own lists of foods and categories of “healthy” and “unhealthy” foods,

resulting in an array of different foods being included in measures. Gubbels et al.’s

(2009) study was the only one found that actually asked parents which foods and

drinks they restrict.

Table 2.7 shows findings for studies examining associations between

parents’ restrictive feeding and children’s intake of specific nutrients or foods

potentially targeted for restriction. These studies used a range of measures of

parent restrictive feeding, as well as a range of different nutrients and foods to

assess children’s intake and showed mixed results. Positive associations between

parent restrictive feeding and higher child intake of “unhealthy” foods potentially

targeted for restriction were found by four of the nine studies using the CFQ

restriction scale (Birch et al., 2001) or modified versions to measure parent

restriction. Notably, two of these studies used Musher-Eizenman and Hobul’s (2007)

CFPQ restriction for health scale (Mais et al., 2015; Warkentin et al., 2016), which

may have contributed to differences in findings, although Boots, Tiggemann, Corsini,

& Mattiske (2015) and Lee et al. (2001) showed positive findings using the full CFQ

restriction scale. Another factor was that three of the four studies with positive

findings had not adjusted for covariates (Lee et al., 2001 [5 years]; Mais et al., 2015

[5-9 years]; Warkentin et al., 2016 [3 years]). It is possible that a child or parent

characteristic may explain these associations. Furthermore, while Durão et al.

(2015) and Ystrom, Barker, and Vollrath (2012) were the only studies to indicate an

association between higher parent restrictive feeding and lower child intake of foods

potentially targeted for restriction, these studies had very large samples and

controlled for a range of covariates. These larger samples may have provided more

power and, therefore, greater reliability of findings, although such very large

samples also provide a greater risk of type 1 errors i.e. false positive findings (Field,

2013). Alternatively, the mix of findings for studies using the CFQ restriction scale

may indicate a lack of sensitivity of this measure to children’s level of intake of

restricted foods and drinks, as discussed in Section 2.4.2. In addition, the different

foods included in outcome measures, without clear knowledge of the specific foods

and drinks targeted for restriction by parents, could also have contributed to

variations in these findings.

In contrast, studies using Ogden et al.’s (2006) covert control scale to

measure parent restrictive feeding consistently reported lower child consumption of

unhealthy snack foods associated with higher parent covert control scores, after

Chapter 2: Literature Review 39

adjusting for a range of maternal and child covariates (Boots et al., 2015; Brown et

al., 2008; Durao et al., 2015; Ogden et al., 2006;). While this scale may reflect a

covert approach to restricting foods it may also be measuring the level of children’s

restricted intake of target foods, as suggested in Section 2.4.2. In this case, it would

be expected that higher scores on this scale would be associated with lower child

access and hence lower intake of target foods. Interestingly, Boots et al.’s (2015)

findings contrasted with their findings using the CFQ restriction scale (Birch et al.,

2001) as the measure of parent restrictive feeding for the same sample of 3.9 year

olds (n = 611), but Durão et al.’s (2015) study showed consistent negative findings

for their sample of 4 year olds (n = 4122) using either the CFQ restriction scale or

Ogden et al.’s covert control scale. However, Boots et al. measured children’s intake

of unhealthy snack foods potentially targeted for restriction, whereas Durão et al.’s

measure encompassed a broader range of energy dense foods, which may be less

specifically related to parent restrictive feeding activities. As mentioned earlier,

Gubbels et al. (2009) was the only study that measured direct associations between

specific foods and drinks parents said they restricted with children’s intake of these

specific foods and drinks. This study predictably found that parent reports of not

allowing their child to consume a specific food or drink item (sweets [lollies],

chocolate, cookies and cake, soft drinks and crisps [potato chips]) was associated

with lower child consumption of the same item, amongst a large sample of 2 year

olds (n = 2578).

Some studies also examined associations between restrictive feeding and

children’s intake of healthy foods. The findings for these analyses, using either the

CFQ restriction scale (Birch et al., 2001) or Ogden et al.’s (2006) covert control

scale were mixed. Brown et al. (2008) and Ogden et al. found no association

between Ogden et al.’s covert control scale and children’s intake frequency of

healthy snacks for children aged 4 to 11 and 4 to 7 years respectively. However,

Boots et al. (2015) found a positive association with higher children’s intake of the

same healthy snack foods (fruit, vegetables, yoghurt, cheese) in their younger

sample (3.9 years). Boots et al. also examined associations between children’s

intake of the same group of snack foods and the CFQ restriction scale and reported

opposing findings of lower child intake frequency of these snacks for the same

sample (see Table 2.7). However, this contrasted with Ystrom et al.’s (2012) findings

of a positive association between child intake of a wholesome diet and higher parent

restrictive feeding using the CFQ restriction scale with a similar aged sample (3

years). Again, these discrepancies might be explained by differences in the foods

40 Chapter 2: Literature Review

included in measures. While Boots et al. specifically measured healthy snack foods,

Ystrom et al.’s measure represented a broader range of healthy non-dinner and

dinner foods.

Only one study used the CFPQ restriction for weight control scale (Musher-

Eizenman & Hobul, 2007) to examine associations with child intake of specific

foods. Taylor et al. (2011) found no association between parents’ scores on this

scale and child intake of a set of non-core foods, indicating that diet quality may not

be associated with restriction of child intake for weight control for children aged 7 to

11 years (see Table 2.7).

Overall, studies to date show inconsistent findings between child intake of

foods potentially targeted for restriction and parent restrictive feeding scores using

the CFQ restriction scale (Birch et al., 2001). In contrast, studies using Ogden et

al.’s (2006) covert control scale consistently showed higher parent scores

associated with lower child intake of foods potentially targeted for restriction. While

these findings may reflect differences in parents’ approaches to restrictive feeding,

they could reflect differences in the sensitivity of these two measures to the level of

restriction applied by parents, as discussed in Section 2.4.2. On the other hand,

neither scale appeared to be sensitive to children’s intake of healthy foods.

However, comparisons and clarification of these associations is not only hampered

by the measure of parent restrictive feeding but also the array of different foods and

drinks used to represent restricted foods in studies.

Furthermore, while measurement of child intake of restricted foods and

drinks might indicate children’s consumption of restricted items, young children’s

diets are heavily controlled by their parents. Therefore, children’s intake of specific

restricted foods and drinks may not reflect what they would choose to consume in

the absence of their parent’s control or their dietary selections when they become

independent. This is important because children’s food preferences established in

early life have been shown to track through into adulthood, bringing with them

associated risks of diet-related disease and obesity (see Chapter 1, Section 1.1).

Therefore, measurement of children’s preferences for (or liking or wanting) restricted

foods or drinks may be a better indicator of children’s future risk of diet-related

disease and/or obesity.

Chapter 2: Literature Review 41

Table 2.7

Cross-Sectional Associations Between Parent Restrictive Feeding and Child Intake of

Specific Nutrients or Foods Potentially Targeted for Restriction

Lead Author (Country)

Year Sample size

Age (yrs)

Survey tool

Associations with child intake Unhealthy foods (potentially restricted)

Healthy foods

CFQ Restriction Scale (Birch et al., 2001) or modified versions

Campbell ^ (Australia)

2006 560 5-6 CFQ (None) Savoury snacks (None) Sweet snacks (None) Sweet non-dairy drink (all kj/day)

Gubbels ^ (Netherlands)

2011 1819 5 CFQ (None) Daily Sugar Intake (kj/day)

Lee (USA)

2001 192 girls

5 CFQ (+ve) High Fat Diet r = .17**

Warkentin (Brazil)

2016 402 3 CFPQ (H) (+ve) Ultra processed foods ᵇ **

Mais (Brazil)

2015 659 5-9 CFPQ (H) (+ve) Ultra processed foods ᵇ **

Ystrom ^ (Norway)

2012 14122 3 CFQ (-ve) Unhealthy diet β= - 0.07**

(+ve) Wholesome diet β= 0.10**

Jani ^ (Australia)

2015 152 2.8 CFQ (None) Non-core foods ᶠ (None) Core foods ᶠ

Durão ^ (Portugal)

2015 4122 4 CFQ (-ve) Energy-dense food/drink (kj/day) ᵍ OR = 0.81 [0.72-0.93]

Boots ^ (Australia)

2015 611 3.9 CFQ (+ve) Unhealthy snacks β= 0.29***

(-ve) Healthy snacks β= -0.30**

Covert Control Scale (Ogden et al., 2006)

Boots ^ (Australia)

2015 611 3.9 Covert (-ve) Unhealthy snacks β= - 0.34***

(+ve) Healthy snacks β= 0.28***

Ogden ^ (UK)

2006 297 4-11

Covert (-ve) Unhealthy snacks β = - 0.36***

(None) Healthy snacks

Brown ^ (UK)

2008 518 4-7 Covert (-ve) Unhealthy snacks j β = -.27**

(None) Healthy snacks j (+ve) Fruit/veg at meals, β = .16*

Durao ^ (Portugal)

2015 4122 4 Covert (-ve) Energy-dense food/drink (kj/day) ᵍ OR = 0.80 [0.72-0.89]

Gubbels et al. (2009)

Gubbels (Netherlands)

2009 2578 2 Gubbels (-ve) Weekly Intake frequency of 6 items ᵏ β = - 0.08 to - 0.23

CFPQ Restriction for weight control scale (Musher-Eizenman & Holub, 2007)

Taylor ^ (Australia)

2011 175 7-11 CFPQ (W) (None) Non-core foods l

Note. CFQ = CFQ 8-item restriction scale (Birch et al., 2001). CFPQ (H) = CFPQ Restriction for health scale (Musher-Eizenman & Holub, 2007). Covert = Ogden et al.’s (2006) covert control scale. Gubbels = single question to parents: “Are there specific foods that you do not allow your child to eat or drink?” (response options: yes/no). If the response was ‘yes’ respondents were asked to indicate ‘which of the following foods their child was not allowed to eat: sweets [lollies], cookies, cake, soft drinks, crisps [potato chips] and sugar’ (Gubbels et al., 2009). CFPQ (W) = CFPQ Restriction for weight control scale (Musher-Eizenman & Holub, 2007). ^ Included covariates (see Appendix B, Table B.1 for details). > 30% of daily energy intake from fat. ᵇ Frequency of intake of: 13 ultra processed foods items (Fast food, instant noodles, soft drink, artificial juice, chips, sugared snacks, breakfast cereal, chocolate milk, crackers/biscuits/cakes, ice cream/popsicles, dairy desserts, processed meats) Mann-Whitney test between means: low and high intake ultra processed foods. 37-item food frequency questionnaire: non-dinner foods (never to 4 or > a day), dinner foods (≤1 X month to 5+ X week). Two dietary patterns (unhealthy and wholesome) identified by Exploratory Factor Analysis (EFA).

42 Chapter 2: Literature Review

Jani, Mallan, & Daniels (2015) ᶠ Number of items consumed in the past 24 hours, recorded by parents. Two item groups: non-core (unhealthy items) and core (healthy items). Non-core items: Indian - Samosa, Pav bhaji, Pakoda, Dhebra, Chevda, Bhel-puri, Pickles, Papad, Lassi, Indian sweets, Ghee. Non-Indian - Sweet biscuit, Savoury biscuits, Chocolates, Chips, Hot chips, Pizza, Noodles, Burger, Soft drink, Fruit juice, Flavoured milk, Milk with sugar, Ice-cream. Core items Indian – Rice, Idli, Chapatti, Dal, Paneer, Khadi, Butter milk. Non-Indian - White meat, Red meat, Fish, Egg, Baked beans, Nuts, Breakfast cereal, Bread, Muesli bars, Pasta, Raw vegetables, Cooked vegetables, Fruits, Water, Plain milk, Milk without sugar, Yoghurt, Cheese ᵍ Sugar sweetened beverages, crisps, pizza, burger, cakes, sweet pastry, chocolates and candies (dichotomised < & > 6 times/week) Composite scores for frequency of snacks consumed per day. Two groups: unhealthy (potato chips/crisps, salty/flavoured crackers, sweet biscuits, cakes and pastries, chocolate and lollies, sugar sweetened drinks, hot fried snacks) healthy (fruit, vegetables, yoghurt, cheese) Composite score of daily frequencies. Unhealthy snacks: chocolate, crisps, pastries, ice cream, sweets, cakes and biscuits. Healthy snacks: fruit, vegetables, yoghurt, cheese. j Composite score of daily frequencies. Unhealthy snacks: sugared cordial/soft drinks, sausages, pies, burgers, chips (hot), potato crisps, savoury snacks, ice cream, cakes/pastries, sweet biscuit. Healthy snacks: fruit, vegetables, yoghurt, cheese. ᵏ Sweets [lollies], chocolate, cookies and cake, soft drinks and crisps l CDQ (Magarey, Golley, Spurrier, Goodwin, & Ong, 2009) 13 non-core items selected to measure of frequency of intake over 24 hours, including soft drink, confectionery, and processed meats. * p < 0.05. ** p < 0.01. *** p < 0.001. 2.4.3.3 Studies measuring child eating behaviours as the outcome measure

Some cohort studies have measured observed child eating behaviour as

representing displays of child preferences (or liking or wanting) for restricted foods

as the outcome measure. A number of different child eating behaviours have been

included in studies examining feeding practices more broadly. However, only those

theoretically associated with child responses to restrictive feeding (Birch et al., 2003)

have been included in this review. This includes studies examining EAH, food

responsiveness or hungry eating styles. These behaviours generally represent

measures of higher child responsiveness to external food cues, which has been

associated with the development of obesity (Schachter, 1968).

• EAH - refers to eating beyond satiety in response to the presence of

palatable foods (Fisher & Birch, 2002). This has been measured in studies

by the EAH protocol (Birch et al., 2003).

• Food responsiveness - refers to over-responsiveness to external food

cues, such as taste and smell, as opposed to internal physiological satiety

cues (Schachter, 1968). Child food responsiveness has been measured in

studies by the food responsiveness scale within the parent-reported Child

Eating Behaviour Questionnaire [CEBQ] (Wardle, Guthrie, Sanderson, &

Rapoport, 2001).

Chapter 2: Literature Review 43

• Hungry eating style - has only been measured in one study using the

following single parent-reported question, ‘compared to peers, my child is

always hungry’ (Likert scale: 1 = completely disagree to 5 = completely

agree) (Gubbels et al., 2011).

Table 2.8 shows findings for studies examining associations between

parents restrictive feeding and selected eating behaviours. Studies measuring child

food responsiveness (CEBQ, Wardle, Guthrie, et al., 2001) and hungry eating style

(Gubbels et al., 2011) have unanimously found positive associations with higher

parent restrictive feeding scores, measured by the CFQ restriction scale (Birch et

al., 2001) or similar, for children aged between 2 to 9 years old (Carnell, Benson,

Driggin, & Kolbe, 2014; Gregory et al., 2010b; Gubbels et al., 2011; Jani, Mallan, &

Daniels, 2015; Jansen et al., 2014; Webber, Cooke, & Hill, 2010). While two of these

studies also found an association with child BMIz (Gubbels et al., 2011 [5 years];

Webber, Cooke, & Hill, 2010 [7-9 years]), Gregory et al.’s (2010b) younger sample

showed no association with child BMIz (2-4 years old). This suggests that child food

responsiveness behaviour may indicate obesity risk in younger children before it

manifests into weight gain and may explain why samples of younger children are

less likely to show positive findings of an association with child weight than samples

of older children (see Section 2.4.3.1). However, Jansen et al. (2014) found no

association between children’s food responsiveness and parent scores on their

covert restrictive feeding scale. This suggests that child food responsiveness may

be associated with higher parent scores on the CFQ restriction scale (or similar) but

not with Jansen et al.’s covert restriction scale, which may also reflect lower access

to restricted foods (see Section 2.4.2).

As these are cross-sectional studies it is unclear whether parents’ use of

restrictive feeding practices influence children’s eating behaviours or whether

children’s behaviour influences parents’ use of restrictive feeding. It is also possible

that a bi-directional relationship may develop over time. However, face validity of the

CFQ restriction scale (Birch et al., 2001) suggests that the majority of items in this

scale may reflect parents’ observations of children’s food responsive behaviour

towards restricted foods (see Section 2.4.2). This means that this scale may be

measuring similar child food responsive behaviours to the outcome measure used

and hence the positive associations found. Furthermore, Finlayson and Dalton

(2012) propose that non-specific measures of general wanting to consume foods

would not capture the difference in reinforcing value of restricted foods relative to

44 Chapter 2: Literature Review

those not restricted. Therefore, a general measure of food responsiveness or hungry

eating style may not be the most appropriate for assessing the effects of restrictive

feeding if parent restrictive feeding targets specific foods and drinks.

Table 2.8 also shows findings for studies examining associations with

children’s EAH. In contrast to studies examining children’s food responsiveness,

Birch et al. (2003) and Harris, Mallan, Nambiar, & Daniels (2014) found no cross-

sectional association with children’s EAH for 5 year old girls and 3.7 year old girls

and boys respectively, using the CFQ restriction scale (Birch et al., 2001) to

measure parent restrictive feeding. However, positive associations were found with

EAH for girls only by Fisher and Birch (1999b) and Rollins, Loken, Savage, & Birch

(2014c) when using the RAQ (Fisher & Birch, 1999b) to measure parent restrictive

feeding (see Table 2.8). While this discrepancy may be explained by different

measures of restrictive feeding, with the RAQ being a more specific measure of

parent restriction in relation to the specific foods used in the EAH protocol (see

Section 2.4.2), small sample sizes could also be a factor. Fisher and Birch’s total

sample (n = 42) showed no association between parent restrictive feeding and child

EAH. Findings only became significant for a very small sub-sample of girls (n = 22).

Rollins et al.’s overall sample was fairly large (n = 180), but the sub-sample of the

highest parent restricting profile group on which their findings were based was small

(n = 23).

Chapter 2: Literature Review 45

Table 2.8

Cross-Sectional Associations Between Parent Restrictive Feeding and Child Eating

Behaviours Potentially Related to Restrictive Feeding

Lead Author (Country)

Year Sample size

Survey tool

Age (yrs)

Child outcome Association Results

Studies examining effects on child food responsiveness

Jani ^ (Australia)

2015 152 CFQ 2.8 Food responsiveness +ve β= 0.31***

Gregory ^ (Australia)

2010b 141 CFQ (6) 3.3

Food responsiveness

+ve r = .32*

Carnell ^ (USA)

2014 432 CFQ 4.4 Food responsiveness +ve β= 0.25***

Webber ^ (UK)

2010 244 CFQ

8.3

Food responsiveness +ve β = .23***

Gubbels ^ (Netherlands)

2011 1819 CFQ 5 Hungry eating style ᵇ +ve β= .14***

Jansen (Australia) 2014 462 FPSQ (O) 2 Food responsiveness +ve r = 0.26***

FPSQ (C) Food responsiveness None Studies examining effects on child eating in the absence of hunger (EAH)

Fisher ^ (USA)

1999b 42 RAQ 5 EAH (total) None EAH (girls only) +ve r = 0.59***

Birch ^ (USA)

2003 140 (girls)

CFQ 5 EAH (girls) None

Harris ^ (Australia)

2014 180 CFQ 3.7 EAH (total) None EAH (by gender) None

Rollins (USA)

2014c 180 (girls)

RAQ

5 EAH +ve d = 0.75*

Note. CFQ = CFQ 8-item restriction scale (Birch et al., 2001). CFQ (6) = 6-items of the CFQ restriction scale (Birch et al., 2001), excluding two food reward items (Section 2.4.2, Table 2.3, items 5 & 6). FPSQ (O) = FPSQ Overt restriction Scale (Jansen et al., 2014). FPSQ (C) = FPSQ Covert restriction Scale (Jansen et al., 2014). EAH = Eating in the absence of hunger protocol (Fisher & Birch, 1999b). RAQ = Restricted Access Questionnaire. Developed by Fisher and Birch (1999b) pre-dating the CFQ they subsequently developed. ^ Included covariates (see Appendix B, Table B.1 for details). Measured by CEBQ Food Responsiveness Scale (Wardle, Guthrie, et al., 2001)

ᵇ Measured by parent-reported single question, ‘compared to peers, my child is always hungry’ (5-point Likert scale, completely disagree to completely agree); (Gubbels et al., 2011).

EAH protocol: 10-minute free access to toys and 10 sweet & savoury snack foods when ‘full’ (after lunch). Gram intake of snacks consumed measured (Fisher & Birch, 1999b).

Comparison of means between lowest and highest parent restricting profile groups of 4 parent restricting profiles (unadjusted). n = 23 in highest parent restricting profile group.

* p < 0.05. ** p < 0.01. *** p < 0.001.

2.4.3.4 Studies measuring child liking as the outcome measure

The present study suggests that measurement of child preferences (or

liking or wanting) for restricted foods are likely to be the most appropriate outcome

measures for assessing the effects of restrictive feeding practices on children’s

future diet-related outcomes. This is because child food preferences are

independent of parental control over child intake and child food preferences track

through to adulthood, bringing with them associated risks of diet-related disease and

obesity (see Chapter 1, Section 1.1). Child food preference has been assessed in

studies by asking participants to choose between food items, such as the forced

46 Chapter 2: Literature Review

choice selection methods used in the short-term experimental studies (see Section

2.3, Table 2.2). The difference between liking and wanting are described in Section

2.3.2. While experimental restriction studies have included measures that resemble

wanting to consume a food (see Section 2.3.1), only two cross-sectional cohort

studies claimed to measure child liking for foods potentially targeted for restriction

via mother or child reported Likert scales (see Table 2.9). These studies used the

CFPQ restriction scales (Musher-Eizenman & Holub, 2007) to measure parent

restrictive feeding. Both studies found no association between children’s liking for

foods potentially targeted for restriction and parents’ use of restriction for weight

control. This suggests that general restriction of calories does not influence

children’s liking for high-fat, high-sugar foods and drinks. In contrast, Vollmer and

Baietto (2017) found a positive association with children’s liking for high-fat, high-

sugar foods and parent restrictive feeding, using the CFPQ restriction for health

scale. This suggests that the items included in this scale, which consists of a

selection of items from the CFQ restriction scale (Birch et al., 2001), are associated

with higher child liking for foods potentially targeted for restriction. However, as

mentioned in Section 2.4.2, it is unclear whether this measure represents higher or

lower child access to target foods and drinks. Unfortunately, as these were the only

two studies identified, cohort studies provide limited information about associations

between parent restrictive feeding and child preferences (or liking or wanting) for

restricted foods.

Chapter 2: Literature Review 47

Table 2.9

Cross-Sectional Associations Between Parent Restrictive Feeding, Measured by the CFPQ

Restriction Scales (Musher-Eizenman & Holub, 2007), and Child Liking for Selected Foods

and Drinks

Lead Author (Country)

Year Sample size

Age (yrs)

Child outcome measure

Findings for CFPQ Scales

Restriction for health

Restriction for weight

Vollmer ^ (USA)

2017 148 4.5 Liking Scale High-fat, high-sugar foods

(+ve) β= 0.20* (None)

Taylor ^ (Australia)

2011 175 7-11 Liking Scale ᵇ Non-core foods

(None)

^ Included covariates (see Appendix B, Table B.1 for details). Preschool Adapted Food Liking Survey (PALS), parent-reported (Peracchio, Henebery, Sharafi, Hayes, & Duffy, 2012). A number of high-fat, high-sugar foods (not specified). Child response scale: Likert-scale – 7 face labels (‘hate it’ to ‘love it’). ᵇ Child liking scale (child-reported). 6-item scale developed for this specific study (e.g. “If I could. I would eat chips, lollies and chocolate all the time”). Response scale: 5-point Likert-scale – 1 (no, not at all) to 5 (yes, a lot). Note that while the authors refer to this scale as measuring food liking, face validity suggests it may bear a closer resemblance to wanting to consume a food. Child Dietary Questionnaire (CDQ), (Magarey et al., 2009). 13 non-core items selected to measure of frequency of intake over 24 hours. Study only specified that this included soft drink, confectionery and processed meats. * p < 0.05. ** p < 0.01. *** p < 0.001.

2.4.3.5 Summary of cross-sectional study findings

In summary, studies using the CFQ restriction scale (Birch et al., 2001) or

modified versions of this scale (i.e. Jansen et al. [2014] FPSQ overt restriction scale;

Musher-Eizenman & Holub [2007] CFPQ restriction for health scale) suggest a lack

of consistent association between parent restrictive feeding and child outcomes of

weight status or food intake, including intake of specific foods potentially targeted for

restriction. However, the child eating behaviour of food responsiveness was

consistently associated with high scores on these scales and one study suggested

that child liking for foods potentially targeted for restriction may also be associated

with the items presented in the CFQ restriction scale. This suggests that despite

parental control of child intake, children may still develop a liking for restricted foods.

However, this evidence is dependent on high scores for the CFQ restriction scale

representing higher parent restriction and hence lower child access to restricted

foods and drinks. As discussed in Section 2.4.2, this scale may instead resemble

parents’ observation of children’s food responsiveness or liking for restricted foods,

which could also be associated with greater child access to restricted foods. Covert

control/restriction scales (Ogden et al., 2006; Jansen et al., 2014) showed no

association with child weight or food responsiveness. Covert control measured by

Ogden et al.’s (2006) scale was also consistently associated with lower child intake

48 Chapter 2: Literature Review

of “unhealthy” foods potentially targeted for restriction. As discussed in Section

2.4.2, while these scales may reflect a covert approach to restrictive feeding, they

may also reflect reduced child access to restricted foods. In which case, it would be

expected that children would have a lower intake of restricted foods. Studies using

measures of parent restriction for weight control (Dev et al., 2013; Musher-

Eizenman & Holub, 2007) mostly showed an association between higher parent

scores for this type of restriction and heavier child weight but this did not translate

into children’s intake of or liking for foods potentially targeted for restriction (Taylor et

al., 2011; Vollmer & Baietto, 2017). This is suggestive of parents responding to a

heavier child with restriction rather than restrictive feeding leading to heavier

children. However, these are cross-sectional studies and cannot indicate the

direction of associations. A number of studies have examined the longitudinal

effects of parent restrictive feeding which are discussed in the next section.

2.4.4 Analysis of longitudinal study findings

Twelve longitudinal studies were identified. A summary of these studies is

provided in Table 2.10 with further details provided in Appendix B, Table B.2. Ten

studies identified used the CFQ restriction scale (Birch et al., 2001) to measure

parents’ restrictive feeding, with one study using the RAQ (Fisher & Birch, 1999b)

and one using the FPSQ (Jansen et al., 2014). Child outcome measures used in

these studies included child BMIz (or another child weight status measure) (N = 10),

child daily energy intake (N = 2) and child eating behaviours (food responsiveness

and EAH) (N = 4).

Nine of the studies that examined child weight status as the outcome

measure used the CFQ restriction scale (Birch et al., 2001) to measure parent

restrictive feeding and the tenth study, by Rollins, Loken, Savage, & Birch (2014c),

used the RAQ (Fisher & Birch, 1999b) (see Table 2.10). Eight studies found no

prospective association between parent restriction scores (measured by the CFQ

restriction scale) and change in child weight status during the follow-up period (1 to

3 years) (Campbell et al., 2010 child sample over 10 years only; Faith, Berkowitz, et

al., 2004; Gregory et al., 2010a; Gubbels et al., 2011; Montgomery et al., 2006;

Rollins et al., 2014c; Spruijt-Metz et al., 2006; Webber, Cooke, Hill, & Wardle, 2010).

These studies spanned a range of child ages, 3.3 years to 10-12 years at

commencement. However, two of these studies found a cross-sectional association

between higher parent restrictive feeding scores and higher child BMIz at baseline

Chapter 2: Literature Review 49

(Gubbels et al., 2011; Spruijt-Metz et al., 2006). These authors suggested their

findings indicate that parental restriction is influenced by child weight, rather than

parent restriction influencing child weight, which is consistent with Webber, Hill, et

al.’s (2010) mediation model findings discussed in Section 2.4.3.1. While three

studies found different associations between parent restrictive feeding and child

weight status or daily energy intake for sub-groups of their samples (Faith,

Berkowitz, et al., 2004; Montgomery et al., 2006; Rollins et al., 2014c), sub-samples

of children at risk of obesity measured by maternal obesity (Faith, Berkowitz, et al.,

2004) and children with low inhibitory control (Rollins et al., 2014c) may be

independently associated with heavier children. In addition, sub-sample sizes for all

three of these studies were very small (i.e. 22 to 24 participants), increasing the

potential for sampling error and limited generalisability.

However, the majority of these longitudinal studies used change in child

BMIz as the child outcome measure, which is problematic because BMIz is a

relative score. As children age, the scope for further relative increases in child BMIz

scores becomes more limited, with children’s weight relative to their peers becoming

established. This is because there is an association between heavier weight older

children and rapid weight gain between 1.5 to 3 years old (Nanri et al., 2015).

Therefore, if a child’s BMI z-score is on the 90th percentile when they are 3 years old

they may continue to gain weight in excess to their peers but show no change in

their relative z-score. This would be recorded as little or no change in BMIz, even

though the child would have continued eating habits that maintain a heavier weight

relative to their peers. A result of no change in BMIz can, therefore, be misleading

and increasingly so for older child samples. Farrow and Blissett’s (2008) study was

the only study that commenced when children were under 3 years old (commenced

at 1 year old) and showed a prospective association between higher parent

restriction scores (CFQ restriction scale, Birch et al., 2001) and lower follow-up child

BMIz. However, Campbell et al.’s (2010) study also showed the same prospective

association with a sample of children commencing the study at 5 to 6 years old. The

reason why this study also showed a prospective association may have been due to

the relatively younger child age combined with a longer follow-up period (3 years)

than other studies involving children of a similar age. Campbell et al.’s study also

included an older age group (baseline 10 to 12 years), for which no association was

found between parent restriction scores (CFQ restriction scale) and child BMIz

change. While Campbell et al. suggested these findings indicate that restriction may

be protective against excessive weight gain at an earlier age but ineffective as

50 Chapter 2: Literature Review

children become older, consideration also needs to be given to the reducing scope

for further relative changes in BMIz as children age.

Another measurement problem in these longitudinal studies is that all but

one study (Holland et al., 2014) only measured parents’ restrictive feeding at

baseline. For these studies, it is unclear whether parent restrictive feeding changed

over time and to what extent such changes may have contributed to the child

outcomes observed. While studies examining parents’ use of restrictive feeding for

children under 5 years suggest either consistency (Blissett & Farrow, 2007; Farrow

& Blissett, 2012) or progressively increasing use of restrictive feeding by parents

(Daniels et al., 2015), studies examining children over 7 years old suggest that

parents reduce their use of restrictive feeding beyond this age (Gray et al., 2010;

Webber, Cooke, Hill, & Wardle, 2010). Therefore, a reduction in parents’ use of

restrictive feeding as children get older may have contributed to different study

findings for older children.

Holland et al.’s (2014) study was the only study identified that measured

parent restrictive feeding at both time points. It evaluated a 16-week family-based

child weight loss program for overweight and obese children, aged 7 to 11 years (n

= 170). This study examined the relationship between changes in restrictive feeding

(measured by the CFQ restriction scale, Birch et al., 2001) and changes in children’s

intake and BMIz scores. Their evaluation showed that parents’ before and after

restrictive feeding scores reduced in line with a reduction in children’s BMIz. While

the authors concluded that the program reduced the negative effects of restriction

and subsequent child BMIz, the program protocol actually increased restriction by

removing energy-dense foods from the home and making nutrient-dense foods more

available. The reduction in restriction scores measured by the CFQ restriction scale

may therefore reflect less need for the parent to “have to be sure that my child does

not eat too many sweet... high fat foods”, as elicited by the CFQ restriction scale

(see Section 2.4.2, Table 2.3) because these foods were not available at home. This

alternative conclusion is supported by the study’s own report that the association

between reduction in restriction scores on the CFQ restriction scale and child BMIz

was mediated through a reduction in child daily energy intake (kilocalories) and a

reduction in the percentage of child intake of high-fat foods and foods with added

sugar. This study, therefore, indicates that higher restriction of target foods and

drinks is beneficial in terms of reducing child BMIz and that higher CFQ restriction

Chapter 2: Literature Review 51

scores may reflect increased parent activity associated with greater child access, at

least for this sample of older, overweight and obese children.

Table 2.10 also shows that four studies examined longitudinal associations

between parent restrictive feeding and children’s eating behaviours theoretically

associated with child responses to restrictive feeding (see Section 2.4.3.3). Gregory

et al. (2010a) and Jansen, Mallan, and Daniels (2015) both examined changes in

child food responsiveness scores (CEBQ, Wardle, Guthrie, et al., 2001) for 3 and 2

year old children over periods of 1 year and 1.7 years respectively. Gregory et al.

used the CFQ restriction scale (Birch et al., 2001) to measure parents’ restrictive

feeding and Jansen et al. (2015) used their own FPSQ overt and covert restriction

scales (Jansen et al., 2014) (See Section 2.4.2 for details). Both studies found no

association between parental restriction scores at baseline and changes in

children’s scores for food responsiveness for these samples young children. The

contrast of these findings with the consistent positive associations found by cross-

sectional studies (see Section 2.4.3.3, Table 2.8), suggests that child food

responsiveness may be an existing behaviour that influences parent feeding rather

than parent feeding influencing this child eating behaviour. These findings are

consistent with Llewellyn, Van Jaarsveld, Johnson, Carnell, and Wardle’s (2010)

findings that the appetitive trait of food responsiveness is moderately heritable

(59%). However, apart from questioning the suitability of this measure to capture the

effects of restrictive feeding (see Section 2.4.3.3), measuring change in food

responsiveness on a five point scale may create similar problems to measuring

change in BMIz. Studies have indicated that a high proportion of children are likely

to have already been introduced to foods potentially targeted for restriction by 1 year

(Koh et al., 2010) or 2 years of age (Gubbels et al., 2009). Therefore, if

environmental exposure to such foods influences children’s food responsiveness,

this may have already occurred prior to the commencement of these longitudinal

studies, hence limiting the scope for further increases in scale scores.

In contrast to longitudinal findings for food responsiveness, Birch et al.

(2003) and Rollins et al. (2014c) both reported positive prospective associations

between parent restrictive feeding and changes in girls’ EAH. These differences

may be due to children being older at commencement (5 years old) and longer

follow-up periods than studies examining food responsiveness. However, positive

findings for both of these studies are only apparent for sub-groups of their samples.

Birch et al.’s study shows that their significant findings are fully explained by the

52 Chapter 2: Literature Review

sub-group of overweight girls (see Birch et al., 2003, figure. 1, p. 218.). This study

also showed a significant association between high restrictive feeding scores and

mothers’ concern about child overweight for overweight girls. While this longitudinal

study showed no significant association with EAH and parent restrictive feeding

scores at commencement (see cross-sectional associations reported in Section

2.4.3.3), this does not discount the possibility that high parent restriction scores are

reflective of parents’ concern about their child being overweight and who

increasingly displays EAH. As mentioned earlier, Holland et al.’s (2014) study

suggested that higher scores on the CFQ restriction scale (Birch et al., 2001) may

reflect greater child access to restricted foods. The implication here is that

increasing EAH found amongst overweight girls in Birch et al.’s study may be related

to greater access to restricted foods rather than higher restriction.

Rollins et al.’s (2014c) findings of an association between parent restrictive

feeding (RAQ, Fisher & Birch, 1999b) and changes in girl’s EAH were also only

significant for a subgroup of girls who exhibited low inhibitory control, measured by

the Children’s Behavior Questionnaire (CBQ) (Rothbart, Ahadi, Hershey, & Fisher,

2001). This measure reflects children’s general lack of inhibition towards all activities

and not specifically towards food. Interestingly, Rollins et al.’s findings were the

opposite of their findings for child BMIz (see Table 2.10). This might suggest that

parents have been successful at maintaining a healthy weight for girls with low

inhibitory control by restricting access to these foods, measured by the RAQ.

However, measures of low inhibitory control and the EAH protocol (Fisher & Birch,

1999b) may resemble similar child behaviour. This means that a positive association

between these two measures may be reflecting parent responses to the same child

behaviour. Unfortunately, no longitudinal studies found had used child preferences

(or liking or wanting) for restricted foods as the outcome measure, which the present

study suggests would be most appropriate for assessing the effects of restrictive

feeding on children’s future risk of diet-related disease and/or obesity.

Chapter 2: Literature Review 53

Table 2.10

Longitudinal Studies Examining Associations Between Parent Restrictive Feeding and Child

Diet-Related Outcomes

Lead Author (Country)

Year Sample size

Survey tool

Base age

(year)

Period Outcome measure

Association Result

Studies examining effects on child weight

Farrow (UK)

2008 62 CFQ 1 1 yr BMIz -ve

b= -0.31*

Gregory (Australia)

2010a 106 CFQ (6) 3.3

1 yr BMIz None

Montgomery (UK)

2006 40 CFQ 4.6

2 yrs BMIz None

Rollins (USA)

2014c 180 (girls)

RAQ

5 2 yrs BMIz None Total sample -ve * low inhibitory

control (CBQ) Faith, Berkowitz (USA)

2004 57

CFQ 5 2yrs BMIz None Total sample +ve b=0.39* at risk

of obesity ᵇ Gubbels (Netherland)

2011 1819 CFQ 5 2 yrs BMIz None

Webber (UK)

2010 405 CFQ 7-9 3yr BMIz None

Holland (USA)

2014 170 CFQ change

7-11

16wk BMIz +ve

↓ restriction = ↓ BMIz *

Spruijt-Metz (USA)

2006 120 CFQ 7 -14 2.7 yrs Fat Mass (DEXA)

None

Campbell (Australia)

2010 204 CFQ 5-6 3 yrs BMIz -ve b= -0.014** 188 10-12 3 yrs BMIz None

Studies examining effects on child daily energy intake

Montgomery (UK)

2006 40 CFQ 4.6

2 yrs Daily energy intake (kj)

None Total sample +ve r = .35* boys

Holland (USA)

2014 170 CFQ change

7-11

16wk Daily energy intake (kj)

+ve ↓ restriction = ↓ BMIz* mediated by ↓ intake

Studies examining effects on child eating behaviour

Jansen (Australia)

2015 388 FPSQ

2 1.7 yr Food responsive

None Overt None Covert

Gregory (Australia)

2010a 106 CFQ (6) 3.3

1 yr Food responsive

None

Birch (USA)

2003 140 (girls)

CFQ 5 4 yrs EAH +ve 5-7 yrs*** 5-9 yrs**

Rollins (USA)

2014c 180 (girls)

RAQ

5 2 yrs EAH + inhibitory control

+ve

d = 1.10* subgroup: low Inhibitory Control, CBQ ᶠ

Note. All studies included covariates. See Appendix B, Table B.2 for details. Only Holland et al. (2014) measured the independent variable longitudinally. CFQ = Child Feeding Questionnaire: 8-item restriction scale (Birch et al., 2001). CFQ (6) = exclusion of 2 food reward items (Section 2.4.2, Table 2.3, Items 5 & 6) from the 8-item restriction scale (Birch et al., 2001). RAQ = Restricted Access Questionnaire pre-dating the CFQ (Fisher & Birch, 1999b). DEXA = Dual-Energy X-ray Absorptiometry. FPSQ = Feeding Practices and Structure Questionnaire (Jansen et al., 2014). EAH = Eating in the Absence of Hunger protocol (Fisher & Birch, 1999b). CBQ = Children’s Behaviour Questionnaire (Rothbart et al., 2001). 4-parent subgroup restricting profiles: lowest restricting parent subgroup, n= 51 (unlimited access to snacks) compared with two highest restricting parent profiles. Highest restricting group d = 0.60*, n = 23 (sets limits & restricts all snacks); second highest restricting group d = 0.80*, n = 64 (sets limits & restricts high fat/sugar snacks). ᵇ Measured by maternal obesity. Obese and overweight children only selected for sample and trial.

54 Chapter 2: Literature Review

Family-Based Behavioral Treatment program (FBT). Measures applied before and after 16-week child weight loss treatment program, which included no access to unhealthy foods at home. Child Eating Behaviour Questionnaire, food responsiveness scale (Wardle, Guthrie, et al., 2001). ᶠ 4-parent subgroup restricting profiles: comparison of children with high and low inhibitory control (using the CBQ) within the highest restricting parent subgroup (sets limits + restricts all snacks). Very small subgroup samples, n = 11 to12. * p < .05. ** p < .01. *** p < .001. 2.4.4.1 Summary of longitudinal study findings

In summary, longitudinal studies using the CFQ restriction scale (Birch et

al., 2001) to measure parent restrictive feeding mostly showed no prospective

association between restrictive feeding and child weight status, with a couple of

studies suggesting that restrictive feeding may be protective against unhealthy

weight gain for younger children. This suggests that positive cross-sectional findings

reflect child weight influencing parent restrictive feeding as children get older, rather

than the opposing direction. While this finding was consistent with suggested

associations reported in cross-sectional studies (see Section 2.4.3.2), the outcome

measure of change in BMIz used in longitudinal studies is problematic because it is

a relative score and scope for further changes in relative weight is likely to be more

limited as children age. Studies examining child food responsiveness as the

outcome measure found no prospective association with parent restrictive feeding

(using the CFQ restriction scale), which contrasted with the unanimous positive

associations shown for cross-sectional studies. These findings suggest that child

food responsiveness may influence parent restrictive feeding, which is consistent

with moderate heritability of this appetite trait (Llewellyn et al., 2010). However,

further consideration needs to be given to the sensitivity of this measure, children’s

environmental experiences with these foods prior to the commencement of studies

and the relatively short timeframes of studies. In contrast, Birch et al.’s (2003) and

Rollins et al.’s (2014c) studies showed increasing prospective scores for child EAH

associated with higher scores for parent restrictive feeding for slightly older child

samples. However, these findings were fully explained by sample sub-groups of

overweight girls and girls with low inhibitory control respectively. For Birch et al.’s

study, these associations may be related to greater child access to the types of

foods included in the EAH protocol associated with higher scores on the CFQ

restriction scale, which is suggested by Holland et al.’s (2014) study. For Rollins et

al.’s study, low inhibitory control may resemble child behaviour associated with EAH.

It is possible that a direct association between these two measures explains the

positive findings for this study.

Chapter 2: Literature Review 55

2.4.5 Effect modification by sample characteristics.

Studies were reviewed for potential effect modification by sample

characteristics. Effect modification occurs when the magnitude of the effect of the

association being observed differs depending on the level of a third variable within

the sample. Some studies have suggested that child gender (Fisher & Birch, 1999b),

child age (Campbell et al., 2010) or children at risk of obesity (measured by

maternal overweight/obesity (Faith, Berkowitz, et al., 2004; Powers et al., 2006) may

modify findings. However, overall evidence from the studies reviewed did not

support effect modification by these sample characteristics (see Appendix C). This

does not mean that these characteristics do not modify the effects of parent

restrictive feeding but that evidence from studies reviewed does not support these

claims. Studies also reported no effect modification by child weight for children of 5

years or younger (Birch et al., 2003; Faith, Berkowitz, et al., 2004; Farrow & Blissett,

2008; Gubbels et al., 2011). However, Birch et al.’s (2003) study suggested effect

modification by child weight for girls over 5 years when examining effects between

child EAH (using the EAH protocol, Fisher & Birch, 1999b) and parent restrictive

feeding, measured by the CFQ restriction scale (Birch et al., 2001). Overall, further

studies are required to clarify such effect modification for older children, as well as

whether these differences may reflect prior child eating experiences or inherited

predispositions. See Appendix C for further discussion of potential effect

modification by these sample characteristics.

2.5 OVERALL EVIDENCE OF EFFECTS OF PARENT RESTRICTIVE

FEEDING.

This section presents an analysis of the evidence of associations between

parent restrictive feeding and children’s diet-related outcomes suggested by

quantitative experimental (see Section 2.3) and cohort studies (see Section 2.4)

reviewed. Short-term experimental studies examining restrictive feeding have

consistently found greater child pre-occupation behaviours towards and greater child

intake of foods immediately following a period of restriction. However, it is not clear

how these findings relate to children’s restrictive feeding experiences in the natural

environment, when such responses may reflect natural variations in wanting to

consume a food related to immediate satiety and deprivation situations (Epstein et

al., 2011; Epstein et al., 2003; Raynor & Epstein, 2003; Rolls & Rolls, 1997; Temple,

2014; Vervoot et al., 2016) (see Section 2.3.2). Ogden et al.’s (2013) longer

56 Chapter 2: Literature Review

experimental studies suggested that the alternative of allowing free access can lead

to higher child intake of a restricted food. This finding also raises the possibility that

differences in behavioural responses observed between restricted and non-

restricted groups may be associated with differences in immediate satiety and

deprivation states related to different levels of consumption, rather than differences

in child liking of the restricted food. Despite author’s claims that their findings

provide evidence of negative implications of restrictive feeding, these studies and

animal studies cited by these studies, have not demonstrated associations between

experimental findings and (i) higher preference for the restricted food outside of the

experimental context, (ii) disruption to self-regulation of eating, or (iii) parents’ use of

restrictive feeding at home (Corwin et al., 1995; Files et al., 1994; Fisher & Birch,

1999a; Rollins et al., 2014a).

Cohort studies have attempted to examine the effect of parent restrictive

feeding on children’s diet-related outcomes within their natural environment but have

been hindered both by the measures of restrictive feeding used, as well as the child

outcome measures selected. With regard to measurement of restrictive feeding, this

has been hindered firstly by the lack of universally agreed definition or concept of

what constitutes restrictive feeding (see Section 2.2) and secondly, by the lack of

attention given to construct validity of measures (see Section 2.2). In particular,

measures of parent restrictive feeding used in cohort studies do not include

measurement of the level of restriction of foods and drinks applied to children.

Inclusion of this dimension of restrictive feeding would logically be required to

determine whether a child is experiencing high or low restriction of the target foods

and drinks. As mentioned in Chapter 1, Section 1.1, a substantial body of research

has examined the converse effects of not restricting foods and drinks and has

consistently suggested that early exposure or repeated exposure to a food or drink

encourages child liking for that food or drink (Addessi et al., 2005; Anez et al., 2013;

Beauchamp & Mennella, 1998; Birch, 1979a, 1979b, 1998; Birch & Marlin, 1982;

Breen et al., 2006; Cashden, 1994; Caton et al., 2013; Cooke et al., 2004; Cooke,

2007; Grimm et al., 2004; Hartvig et al., 2015; Liem & de Graaf, 2004; Mallan,

Fildes, Magarey, & Daniels, 2016; Mennella et al., 2001; Pliner, 1982; Schwartz et

al., 2011; Skinner et al., 2002; Sullivan & Birch, 1990, 1994; Wardle et al., 2003;

Wardle & Cooke, 2008). This body of evidence suggests that not restricting a food

or drink may enhance a child’s preference (or liking or wanting) for a food or drink.

However, the focus of this research has been on foods children are initially reluctant

to consume (e.g. vegetables). Only a small number of these studies have examined

Chapter 2: Literature Review 57

these effects for innately liked foods or drinks potentially targeted for restriction

(e.g. high-sugar, high-salt and energy dense foods), although findings have

indicated similar positive associations (Birch & Marlin, 1982; Grimm et al., 2004;

Hartvig et al., 2015; Liem & de Graaf, 2004; Mallan et al., 2016; Pliner, 1982;

Sullivan & Birch, 1990) (see Sections 2.6.3 & 2.6.6 for further discussion). This

evidence suggests that the level of restricted child access to restricted foods and

drinks achieved by parents may be an important dimension of restrictive feeding to

consider when assessing the effects of restrictive feeding on children’s diet-related

outcomes.

As a consequence of deficiencies in the measurement of parent restrictive

feeding, it is unclear whether current measures used in the cohort studies reflect

children’s restrictive feeding experiences within their natural environments. This

review differentiated measures of parent restrictive feeding used in cohort studies by

three main types, which are potentially measuring different phenomenon (see

Section 2.4.2). These are: the CFQ restriction scale (Birch et al., 2001) and modified

versions (Jansen et al., 2014; Musher-Eizenman & Holub, 2007); covert

restriction/control scales (Jansen et al., 2014; Ogden et al., 2006); and restriction for

weight control scales (Musher-Eizenman & Holub, 2007; Dev et al., 2013). Face

validity of the most commonly used measure, the CFQ restriction scale, suggests

that higher scores on this scale may represent parents’ observation of child

preferences for restricted foods and their need to limit child consumption, without

reference to the specific action taken by parents or the accompanying level of

restricted food access applied. It cannot, therefore, be established whether the

parents’ observations and subsequent undetermined behaviours are associated with

high or low restriction, which the scale claims to measure. In contrast, the covert

restriction/control scales (Jansen et al., 2014; Ogden et al., 2006) predominantly

resemble parent activities related to avoiding child access to foods potentially

targeted for restriction. While this measure may reflect a covert approach to

restrictive feeding, the subjective measurement of the level of restricted child access

(Never to Always), may also provide some differentiation between high and low

restriction. In fact, the combination of findings from cohort studies suggest that

higher scores on the covert control/restriction scales may reflect higher restricted

child intake, whereas the CFQ restriction scale (or modified versions) may be

associated with greater child access to restricted foods. The possibility that higher

scores on the CFQ restriction scale may be associated with greater child access to

restricted foods is supported by Holland et al.’s (2014) prospective trial, involving a

58 Chapter 2: Literature Review

sample of overweight and obese children aged 7 to 11 years old. This study showed

that restricting children’s access in the home was associated with a reduction in

parents’ scores on the CFQ restriction scale (see Section 2.4.4). High scores on the

CFQ restriction scale could, therefore, reflect parents’ behaviour of regular

management of access to restricted foods that are more frequently available to the

child, at least for older overweight children.

If the CFQ restriction scale (Birch et al., 2001) reflects a scenario of greater

child access to restricted foods, this may also explain why unanimous positive

cross-sectional associations were found between higher parent restrictive feeding

scores measured by this scale, and higher child food responsiveness (see Section

2.4.3.3), as well as greater child liking for foods potentially targeted for restriction

(Vollmer & Baietto, 2017). The lack of prospective association found for food

responsiveness may suggest that child food responsiveness influences parent

restrictive feeding behaviour rather than a relationship in the opposing direction (see

Section 2.4.4), although further consideration needs to be given to study designs,

the sensitivity of measures and bi-directionality influenced by children’s prior

environmental food experiences.

Another observation was that findings related to the use of covert

control/restriction scales (Ogden et al., 2006; Jansen et al., 2014) were consistent,

whereas findings for studies using the CFQ restriction scale (Birch et al., 2001) or

modified versions of this scale were mixed. This could be due to the CFQ restriction

scale being insensitive to the level of restricted access applied to children of

different ages and/or different characteristics (e.g. weight status), potentially

reflecting multiple scenarios of restrictive feeding. In particular, Birch et al.’s (2003)

prospective study suggests that this measure may be associated with different

scenarios for healthy weight and overweight children, with prospective associations

between higher parent scores on the CFQ restriction scale and EAH only being

apparent for overweight girls in their sample (see Section 2.4.4). A study by Temple

et al. (2009) also demonstrated potential differences in effect of exposure modified

by individual weight. This study found that responses to repeated exposure to a

highly palatable snack food varied between obese and healthy weight women, with

healthy weight women reaching satiety over time but obese women becoming more

sensitised with repeated exposure and wanting to consume more of the snack.

However, while it is possible that children with different weight and/or eating

behaviour characteristics may have different responses to parent restrictive feeding

Chapter 2: Literature Review 59

behaviour, it is also possible that such differences may have arisen from children’s

prior environmental eating experiences. Associations between parent restrictive

feeding behaviour and children’s eating behaviour may then become bi-directional,

with parents’ adjusting their restrictive feeding behaviours in response to children’s

developing food preferences and associated eating behaviours.

Musher-Eizenman and Holub’s (2007) restriction for weight control scale

presents a different concept or type of restrictive feeding. Face validity of this scale

predominantly reflects parent activities aimed at restricting overall calorie intake

motivated by a concern about their child being or becoming overweight (see Section

2.4.2). Studies using the CFPQ restriction for weight control scale (Musher-

Eizenman & Holub, 2007) showed no association with children’s intake of specific

palatable foods (Taylor et al., 2011) but as expected, this scale was consistently

associated with higher child BMIz (see Section 2.4.3.1). These findings suggest this

scale is measuring parents’ attempts to modify their children’s diets in response to

their heavier weight, which aligns with Webber, Hill et al.’s (2010) finding that

parents’ concern about child weight mediated the relationship between restrictive

feeding and child weight status (see Section 2.4.3.1). However, again, this scale

does not provide quantification of child intake or even frequency of parent restrictive

feeding activities (see Section 2.4.2 for details) and showed no association with

children’s intake of foods potentially targeted for restriction (Taylor et al., 2011).

This review also questioned the appropriateness of child outcome

measures commonly selected to assess the effects of parent restrictive feeding in

cohort studies. Child weight status has been the most common measure used but if

the primary aim of restrictive feeding is to limit children’s consumption of specific

palatable foods rather than control overall energy intake (see Section 2.2), child

weight or overall energy intake may not be the most representative outcome

measures. Measurement of child intake of foods and drinks specifically targeted for

restriction by parents is potentially a more appropriate measure but is complicated

by parents controlling child intake of these foods via their restriction practices. This

measure is likely to be more representative of parents’ success with restricting

young children’s access to target foods and drinks. If, as Fisher and Birch (1999a)

suggest, restriction of children’s intake of a food leads to a greater desire for the

food (see Section 2.2), then the most appropriate outcome measures would be

children’s preference (or liking or wanting) for specific restricted foods and drinks.

These measures would be better indicators of what children might choose to eat in

60 Chapter 2: Literature Review

the absence of parental control and hence better indicators of children’s future risk

of diet-related diseases and/or obesity (see Chapter 1, Section 1.1). However, only

two cross-sectional restrictive feeding studies examined child liking for groups of

potentially restricted foods. While desire for a restricted food may also be observed

by children’s eating behaviour, Finlayson and Dalton (2012) suggest that general

food responsiveness or EAH would not differentiate differences in desire between

target restricted foods and non-restricted foods in order to establish the effects of

restriction on these behaviours. Further research is required to establish appropriate

outcome measures for examining the effects of restrictive feeding on child diet-

related outcomes for use in cohort studies. Such measures need to be able to

measure children’s comparative preferences (or liking or wanting) for restricted and

non-restricted foods under the same access conditions. Potential options for

application are discussed further in Chapter 6, Section 6.6.2. Further work is also

required to identify the foods and drinks parents actually target for restriction to

improve the construct validity of measurement. An array of different foods and drinks

have been used in studies to represent restricted foods and drinks (see Section

2.4.3.2) but only one study identified had selected food and drink items based on

knowledge of what parents’ actually restrict (Gubbels et al., 2009).

Overall, findings of studies examining quantitative associations between

parent restrictive feeding and children’s diet-related outcomes do not provide clear

evidence of these relationships. This review argues that study designs, measures of

restrictive feeding and the use of different child outcome measures across studies

are likely to be contributing to different study conclusions. While the appropriateness

of different child outcome measures related to parent restrictive feeding needs

further consideration, study findings are dependent on the measure of parent

restrictive feeding being representative of this phenomenon. This study has

highlighted how measures of parent restrictive feeding used in cohort studies lack

evidence of construct validity (see Section 2.4.2). It is relatively unknown what

aspect of restrictive feeding the measures used in these studies reflect and how

these might relate to the entirety of this phenomenon in different contexts and over

time. In particular, measures of restrictive feeding have focused on parent

behaviours without the context of children’s level of restricted intake of target foods

and drinks imposed by their parents. This is a fundamental determinant of whether a

parent is high or low restricting, which current measures of parent restrictive feeding

used in cohort studies do not clearly measure. Likewise, the design of and selection

of variables included in experimental studies are unlikely to represent restrictive

Chapter 2: Literature Review 61

feeding in the natural world (see Section 2.3). In addition, conclusions from these

studies suggesting that restricting intake of a food increases a child’s preference for

that food are not consistent with another body of evidence suggesting that early and

repeated exposure is associated with greater child preferences for a food. Further

work is required to build knowledge of this complex social phenomenon in order to

inform more construct valid measurement of parent restrictive feeding before its

association with child outcomes can be examined. In response to this finding, the

potential dimensions of the restrictive feeding phenomenon are examined further

with evidence from both quantitative and qualitative studies in Section 2.6.

2.6 TOWARDS AN EVIDENCE BASED CONCEPTUAL FRAMEWORK FOR

THE RESTRICTIVE FEEDING PHENOMENON 2.6.1 Introduction

A major limitation of this area of research is the many gaps in our

understanding of how restrictive feeding is applied by parents in the natural

environment. Section 2.2 highlighted that there is no universally agreed definition

and concept of the restrictive feeding phenomenon. While measures of restrictive

feeding used in cohort studies claim to have been validated, none have

demonstrated that the measure developed is a good representation of the restrictive

feeding phenomenon i.e. construct validity (see Section 2.4.2). If the items proposed

to resemble a phenomenon do not represent that phenomenon, then regardless of

other psychometric properties of the scale (e.g. criterion validity or acceptable

reliability) the instrument will not be construct valid.

It appears that lack of construct validation of psychometric measures is not

unique to this area of research. Rowan and Wulff (2007) observed that within the

psychometric literature “little is reported about how items for instruments, checklists,

or inventories are generated” (p. 450). They also noted that attention has instead

focused on the later stages of instrument development with little consideration given

to the underlying dimensions of the phenomenon that scale items are intended to

measure. Rowan and Wulff suggested that, “From a quantitative or statistical point

of view, the origins of questionnaire items are not significant.” (pp. 450-451). A

number of authors have highlighted how a pre-development qualitative phase can

improve the validity of a measure of social phenomena (Faul & Van Zyl, 2004;

Nichter, Nichter, Thompson, Shiffman, & Moscicki, 2002; Rowan & Wulff, 2007).

62 Chapter 2: Literature Review

Faul and Van Zyl (2004) also suggest that, “This predevelopment work is crucial in

an effort to establish the theoretical framework” (p. 461) on which to base the

development of a scale.

Ogden et al. (2006) was the only author of a scale used in cohort studies

examining restrictive feeding that referred to a qualitative pre-development process

associated with the generation of items for their scales (see Section 2.4.2).

However, description of this phase suggested that development was limited to a

review of “the literature and through discussions with mothers with small children”

(Ogden et al., 2006, p. 102). No further details of this phase were presented.

Furthermore, a review of qualitative studies revealed that very little research

examining the nature of restrictive feeding has been undertaken in order to develop

a theoretical framework that could guide the development of related measures for

this phenomenon (see Appendix A, A.2 for the search strategy used to identify these

studies). Nine qualitative studies that included examination of some element of

restrictive feeding were identified (see Appendix D for details of these studies).

While these have included some exploration of restrictive feeding they have tended

to either include restrictive feeding as part of a broader analysis of parent

approaches to child feeding or examined very specific aspects of child feeding,

which would not encompass the potentially broader restrictive feeding phenomenon.

The information arising from these studies has generally been limited to describing

feeding practices in the form of parent behaviour or exploring parents’ beliefs and

motivations for using restrictive feeding practices. No studies had explored the lived

experiences of mothers in-depth and how the application of their intended or

reported restrictive feeding practices play out in the realities of everyday life.

However, none of the studies identified had intended to explore the restrictive

feeding phenomenon more broadly or had been undertaken for the purpose of

informing measurement of any aspect of child feeding. Further examination of the

nature and dimensions of the restrictive feeding phenomenon is, therefore, needed

to provide the first steps towards development of more appropriate measures.

Seibold (2002) proposed that a conceptual framework can be used to link

various concepts and serve as an impetus for the formulation of theory arising from

qualitative studies. The following sections present the potential dimensions that

might constitute the restrictive feeding phenomenon as a starting point for building

knowledge and developing a conceptual framework. The dimensions proposed are

based on and limited to analysis of existing quantitative and qualitative literature.

Chapter 2: Literature Review 63

These dimensions are, therefore, intended to provide sensitising concepts (Blumer,

1954)12 for further research but not limit research to this structure. In addition,

consideration has been given to evidence of associations between these potential

dimensions and children’s preferences (or liking or wanting) for restricted foods and

drinks. This group of measures were identified as the most appropriate for

examining the effects of this phenomenon on children’s diet-related outcomes (see

Section 2.5). Examination of such effects would inform which dimensions of this

phenomenon may be important to include in a measure of parent restrictive feeding

used to assess the effects of this phenomenon on children’s diet-related outcomes.

2.6.2 Parents’ motivation for restrictive feeding

Qualitative studies report that parents predominantly restrict young

children’s foods and drinks to achieve a healthy and varied diet rather than for

weight management (Alderson & Ogden, 1999; Carnell, Cooke, Cheng, Robbins, &

Wardle, 2011; Herman, Malhotra, Wright, Fisher, & Whitaker, 2012; Moore et al.,

2007; Sherry et al., 2004; Ventura et al., 2010). While some studies reported

mothers’ had concerns about their child’s weight (Sherry et al., 2004, 2-5 years;

Ventura et al., 2010, 3-5 years), Carnell et al. (2011, 3-5 years) found that concern

about weight gain was rarely sighted as a reason for restriction, although could be

implicit in concerns for long-term health. Carnell et al. goes on to suggest that these

two motivations (health and weight) may lead to different approaches to restrictive

feeding. Parent motivation may also be important for the selection of an appropriate

child outcome measure because if their motivation is to manage their child’s weight

this might involve general restriction of the child’s calorie intake, whereas motivation

to achieve a healthy diet is more likely to focus on restriction of specific “unhealthy”

foods rather than controlling overall intake.

However, while concern for child weight may be a secondary motivation,

the importance of this motivation may vary between different ethnic and socio-

economic groups of parents. Sherry et al. (2004, 2-5 years, USA) found that white

participants (low and middle income families) and some African American (low

income) participants were more likely to be partially motivated to control children’s

12 Sensitising concepts were defined by Blumer (1954). These concepts are not definitive or prescriptive but are intended to provide a general sense of reference and guidance, merely suggesting directions along which to look. Sensitising concepts are proposed as a starting point and an interpretive device for use in qualitative research (Glaser, 1978; Patton, 2002).

64 Chapter 2: Literature Review

food intake by a concern about their child becoming overweight than Hispanic

participants. However, most African American (low income) participants were

concerned about their child being underweight and associated heavier weight with

healthy children. They commonly believed that children would outgrow being

overweight. The prominence of child weight as a motivating factor may also vary by

child weight status (Musher-Eizenman & Holub, 2007; Wehrly et al., 2014) or other

factors such as child age or parents’ own weight status but no qualitative studies

examining these potential variations were identified.

Motivation for restrictive feeding may also vary by children’s eating

behaviours, as well as parents’ perception of their ability to influence their child’s

eating. Russell and Worsley (2013, n = 58, 2-5 years) and Ystrom et al., (2012, n =

14122, 3 years) found that parents who reported their children consumed relatively

“healthy diets” (as measured in these studies) believed they could influence their

child’s food preferences by controlling exposure, whereas parents who reported

their children consumed more “unhealthy” foods believed they had little influence

over their child’s food preferences. Moore, Tapper, and Murphy (2010) also found

that mothers’ feeding goals varied depending on whether they classified their child

as a “good” or “bad eater”13 (child age 3 to 5 years). While mothers of reportedly

“good eaters” spoke about long-term goals to establish a varied, well-balanced and

“healthy” diet, mothers of reportedly “bad eaters” focused on short-term goals on a

meal by meal basis, allowing the child to eat anything they were willing to consume.

Thus, parents’ motivations for using restrictive feeding with young children

appears to be predominantly for health reasons but concern about child weight may

be a secondary motivation for some. Parent motivations may also vary in

accordance with their child’s eating behaviour, as well as parents’ beliefs about their

ability to influence their child’s eating. Therefore, examining how mothers’ motivation

might influence their approach to restrictive feeding and hence children’s

experiences, may be an important dimension to consider in the measurement of the

restrictive feeding phenomenon.

13 These terms were reported as mothers’ spontaneous classification. Whilst no definition of these terms was given it may be presumed that these terms reflect the language commonly used by mothers.

Chapter 2: Literature Review 65

2.6.3 Levels of restriction and types of foods and drinks restricted

Section 2.4.2 highlights that measures of restrictive feeding used in cohort

studies have focused on parent restrictive feeding behaviours. Children’s level of

restricted intake of restricted foods and drinks imposed by parents is a fundamental

aspect of whether a parent is high or low restricting but has been largely ignored by

measures of restrictive feeding used in cohort studies. As mentioned in Chapter 1,

Section 1.1 and Section 2.5, a related body of evidence has examined associations

between children’s exposure to foods and their preferences for those foods. This

suggests that food preferences are modifiable through children’s food exposure

experiences and that higher intake (i.e. lower restriction) is associated with greater

child preferences for a food (Addessi et al., 2005; Birch et al., 1979a, 1979b, 1998;

Birch & Marlin, 1982; Breen et al., 2006; Caton et al., 2013; Cooke, 2007; Hartvig et

al., 2015; Liem & de Graaf, 2004; Mennella et al., 2001; Sullivan & Birch., 1990,

1994; Wardle et al., 2003; Wardle & Cooke, 2008; Zajonc, 1968).

However, the focus of this research has been on measuring responses to

“healthy” foods with very few studies examining exposure effects on child

preferences (or liking or wanting) for the high-sugar, high-salt and high energy

dense foods likely to be targeted for restriction. As previously explained, differences

in effects may occur due to children having innate taste preferences for high-sugar,

high-salt and energy dense foods (Beauchamp et al., 1986; Birch et al., 1990; Birch,

1992) and an innate tendency to reject sour and bitter tastes in the “healthy” foods

that have been the predominant focus of these studies e.g. vegetables (Birch et al.,

1990). However, the few studies that have examined whether repeat exposure

influences children’s preference for more palatable foods or drinks also indicated a

positive association between repeated exposure and higher child preference for the

item examined. Repeated exposures to fruit juices or carbonated sweet drinks have

been found to increase preferences (or liking or wanting) for the item amongst both

young children and adults (Birch & Marlin, 1982; Grimm et al., 2004; Hartvig et al.,

2015; Liem & de Graaf, 2004; Pliner, 1982). In addition, Sullivan and Birch (1990)

found that repeated exposure to either sweet, salty or plain flavoured tofu not only

increased children’s preferences for the flavour received but also resulted in

reduced preference for the alternative flavours of tofu over the course of the

experiment (n = 39, 4-5 years). No studies identified suggested that lower exposure

resulted in higher child preferences for a food or drink as proposed by the

experimental restriction studies (see Section 2.3). Furthermore, as highlighted in

66 Chapter 2: Literature Review

Section 2.3.2, there are two hedonic reward systems that may contribute to child

food preferences, liking and wanting (Berridge, 1996), and results observed in

studies may vary depending on the hedonic system being measured. A study by

Hartvig et al. (2015) showed that while liking for a juice drink stabilised with repeated

exposure, wanting to consume the drink (measured by quantity of intake when made

available) continued to increase with repeated exposure (n = 317, 9-11 years). This

suggests that wanting to consume a liked sweet tasting item may continue to

increase with repeated exposure independently of a child’s liking for the item.

At some point though, increasing the frequency of repeated exposure may

lead to a satiety response with a decline in the desire to consume a food (Epstein et

al., 2011; Epstein et al., 2015; Epstein et al., 2003; Mennella et al., 2001; Rolls &

Rolls, 1997; Rozin & Vollmecke, 1986; Temple, 2014). Such a phenomenon was

also suggested by Ogden et al.’s (2013) longer home-based experimental restriction

studies (see Section 2.3). However, responses to repeated exposure may vary

between obese and healthy weight individuals. Studies have found higher scores for

the relative reinforcing value (RRV)14 of foods (wanting to consume) associated with

higher BMI in both adults and children (Brignell, Griffiths, Bradley, & Mogg, 2009;

Finlayson, King, & Blundell, 2008; Hill, Saxton, Webber, Blundell, & Wardle, 2009).

In addition, Temple et al.’s (2009) study suggested that while normal weight

individuals may become satiated with frequent repeated exposure to the same food,

obese individuals may become sensitised to the food and want to consume it more

(see Section 2.5). This factor may have also contributed to the variance in

prospective development of EAH for overweight and healthy weight girls shown in

Birch et al.’s (2003) study (see Section 2.4.4). However, Temple (2014) also

suggests that such differences between obese and healthy weight individuals may

be due to neuro-adaptive changes occurring in response to environmental

experiences, indicating that restriction could potentially reduce the reinforcing value

of a highly palatable food. The suggestion of such environmental effects is also

consistent with Fildes et al.’s (2014) study, which showed that a relatively low

proportion of child liking for highly palatable snack foods15 is explained by genetics

(29%), with a much higher proportion attributed to shared environmental effects

(60%) (n = 2686 twins, 3 years). In addition, Breen et al. (2006) found relatively low 14 Relative reinforcing value (RRV) of a food is measured by how hard an individual is willing to work to gain access to a particular food compared with an alternative reward, which can be an alternative food or activity (Epstein, Leddy, Temple, & Faith, 2007). 15 Sweet buns, dessert mousse, sweets, chips, savoury snacks, cakes, ice lollies, plain biscuits, ice cream, crisps, chocolate biscuits and chocolate.

Chapter 2: Literature Review 67

heritability (20%) associated with children’s liking for dessert foods (n = 214 pairs

twins, 4-5 years old). This evidence suggests that satiety effects may vary by

individual characteristics but these associations may be influenced by environmental

food experiences.

Furthermore, a lack of attention has been given to identifying which specific

foods and drinks are targeted for restriction by parents. As mentioned in Section 2.5,

different authors have used different lists of foods and drinks to represent restricted

items, with only one study reviewed having asked parents which foods and drinks

they restrict (Gubbels et al., 2009). Overall, the level of restriction applied by parents

to foods and drinks may be an important dimension of the restrictive feeding

phenomenon and further knowledge of the specific foods and drinks targeted for

restriction by parents is required in order to measure this dimension effectively.

2.6.4 Restrictive feeding practices

Restrictive feeding practices is the term generally referred to in studies as

specific behaviours used by parents to restrict their child’s consumption of foods,

and it is the application of these behaviours that has generally been regarded as

resembling restrictive feeding by the research community. A number of qualitative

studies have revealed a range of practices use by parents with some commonality.

The range of practices presented in qualitative studies and those included in parent-

reporting scales used to measure restrictive feeding in cohort studies (see Section

2.4.2) are shown in Table 2.11. This shows that the range of practices presented in

current measures do not capture the variability and complexity of practices reported

in qualitative studies. In particular, the most common scale used in cohort studies,

the CFQ restriction scale (Birch et al., 2001), only includes reference to one

restrictive feeding practice, “I intentionally keep some foods out of my child’s reach”

(see Section 2.4.2, Table 2.3, Item 4.).

68 Chapter 2: Literature Review

Table 2.11

Parent Restrictive Feeding Practices Reported in Qualitative Studies or Included in

Restrictive Feeding Measurement Scales

Restrictive feeding practices. Qualitative studies (lead author, year)

Measurement scales (lead author, year)

Not buy /keep restricted foods in the home

Ventura, 2010; Moore, 2007; Sherry, 2004; Martinez, 2014ª.

Covert control scale (Ogden 2006) FPSQ covert restriction (Jansen, 2014)

Keep foods out of child’s reach at home Carnell, 2011 CFQ restriction scale (Birch, 2001) FPSQ overt restriction (Jansen, 2014)

Hide restricted foods from child Sherry, 2004 Negotiate or offer alternative healthy or healthier food

Moore, 2007; Carnell, 2011; Sherry, 2004

Avoid taking to fast food restaurant/restaurants with unhealthy foods

Moore, 2007. Covert control scale (Ogden 2006) FPSQ covert restriction (Jansen, 2014)

Avoid eating unhealthy foods when child around

Covert control scale (Ogden 2006)

Food rules (when, where, how much) Martinez, 2014; Herman, 2012

Situational flexibility to limit restricted food intake over period of time e.g. consider previous days intake.

Carnell, 2011

Limit when perceive eating too much Ventura, 2010 Buy/give small portions of restricted foods

Carnell, 2011

Restricted food only made available with parent permission

Carnell, 2011

Limit what restricted foods child allowed Martinez, 2014 Limit quantity or portion of a restricted food child allowed

Ventura, 2010; Carnell, 2011; Sherry, 2004; Martinez, 2014.

Give small helpings at meals to control weight

Restriction for weight (Musher-Eizenman, 2007)

Limit restricted food to certain times or special occasions

Moore, 2007; Carnell, 2011; Martinez, 2014;

Not allow child to consume restricted food at home.

Ventura, 2010

Verbal discouragement eg. tell stop eating, say ‘no’ to requests.

Carnell, 2011; Herman, 2012.

Encourage to eat less so won’t get fat Restriction for weight (Musher-Eizenman, 2007)

Do not allow child to eat between meals, so won’t get fat

Restriction for weight (Musher-Eizenman, 2007)

Restrict food at the next meal if consumed too much at the last meal

Restriction for weight (Musher-Eizenman, 2007)

ª Martinez, Rhee, Blanco, and Boutelle, 2014

Chapter 2: Literature Review 69

Qualitative studies reported that virtually all mothers in their samples used

restrictive feeding practices (Baughcum et al., 1998; Moore et al., 2007; Sherry et

al., 2004; Ventura et al., 2010). Authors also reported a tendency for mothers to use

multiple practices, with Ventura et al. (2010) reporting that parents used “a myriad of

feeding practices to accomplish child-feeding goals” (p. 242). Moore et al. (2007)

also reported that individual mothers used extensive repertoires of feeding, ranging

from 13 to 30 strategies per mother, with 126 different strategies identified and 51

being unique to a mother and child pairing. In addition, Carnell et al. (2011) and

Moore et al. (2010) made reference to mothers’ reports of striving for balance, rather

than abiding by rigid patterns of practices, suggesting that mothers tend to use a

range of practices in a flexible way. Furthermore, Ventura et al.’s qualitative study

reported parents using both overt and covert controlling feeding approaches,

suggesting that while Ogden et al. (2006) differentiated these approaches, they do

not necessarily delineate parents. In fact, Ogden et al.’s own study reported a

medium sized positive correlation (r= .3, p= .02) between overt and covert

controlling feeding practices.

These findings indicate a potential complexity of relating specific practices

to individual parents, let alone being able to differentiate wide arrays of practices

between parents. No study identified had explored how individual parents might use

a range of restrictive feeding practices and whether groups of practices could be

delineated between individual parents. This knowledge is potentially important to the

question of whether or how different restrictive feeding practices might influence

children’s restrictive feeding experiences and hence diet-related outcomes, beyond

the child’s level of restricted intake.

2.6.5 The way parents’ deliver restrictive feeding practices

Another dimension of the restrictive feeding phenomenon is the way in

which a practice is delivered by a parent. Hughes et al. (2005) highlighted that the

general parenting climate could moderate the effects of child feeding practices and

proposed that a parent’s feeding style16 may moderate the child’s outcome.

However, as mentioned in Section 2.2, a recent systematic review suggested only

16 Most measures of parent feeding styles were derived from Baumrind’s (1971) taxonomy of four parenting styles: Authoritarian, Authoritative, indulgent and uninvolved. These are derived from variations of two dimensions of parental behaviour: responsiveness/nurturance to demandingness/control.

70 Chapter 2: Literature Review

weak to moderate associations between parenting styles and various domains of

child feeding practices (Collins et al., 2014). The five studies examining associations

between parenting styles and restrictive feeding that met the review’s criteria were

inconsistent, suggesting a lack of evidence of an association between parenting

feeding styles and parents’ use of restrictive feeding practices using current

measures. Three found no association between restrictive feeding practices and

parenting styles (Blissett, Meyer, & Haycraft, 2011; Duke, Bryson, Hammer, &

Agras, 2004; McPhie et al., 2011), one found an association between higher

restrictive feeding scores and an authoritarian parenting style for children aged 6.7

years (n = 239, r = 0.25, p < 0.001) (Hubbs-Tait et al., 2008) and one found an

association between higher restrictive feeding scores and a permissive/indulgent

parent feeding style for younger children, aged 2 to 5 years (n = 48, r = 0.26, p <

0.05) (Blissett & Haycraft, 2008). Differences in findings between these studies were

not explained by differences in measures used or child age. All studies selected by

the review used the CFQ restriction scale (Birch et al., 2001) as the measure of

restrictive feeding practices. Furthermore, it is unclear how a measure based on

general parenting styles would contribute to identifying the effects of restrictive

feeding on child outcomes and potentially inform advice to parents on how to

change their practices. If a measure of a broad parent feeding style was found to

moderate the effects of a measure of restrictive feeding, this implies that the

measure of parent restrictive feeding is not differentiating important aspects of this

phenomenon.

Another taxonomy of parenting style that is potentially a more direct

measure is Ogden et al.’s (2006) proposal to differentiate between overt and covert

controlling feeding practices. However, Ogden et al. operationalised these concepts

as purely parent behaviours, without considering how a parent communicates with

their child about these restricted foods and drinks. Practices of avoiding or not

buying restricted items presented in Ogden et al.’s covert scale would not in

themselves determine whether they were delivered overtly or covertly.

Communication (verbal or non-verbal) with the child would theoretically determine

whether a practice is overt, whereas covert restriction would theoretically involve no

communication about the food being restricted. However, parent communication

associated with restrictive feeding practices is a dimension that has received very

little attention by studies to date, although it would theoretically be part of both the

parenting style and overt restrictive feeding practices. The only study identified

distinguished between positive and negative affective tones of mothers’ statements

Chapter 2: Literature Review 71

accompanying overt restriction of a palatable food (chocolate cup cakes) (Pesch,

Miller, Appugliese, Rosenblum, & Lumeng, 2016). This study found that mothers of

white ethnicity and of a lower education were more likely to display negative

affective tones to older and obese children. However, the study did not extend to

examination of potential effects on child diet-related outcomes.

2.6.6 The restrictive feeding phenomenon over time

How parents’ use of restrictive feeding might change over time and in

response to children’s cognitive development has also received little attention to

date. Such information was lacking from both qualitative and quantitative studies

identified. Only one qualitative study had considered this aspect of restrictive

feeding. Nielsen, Michaelsen, and Holm (2013) found that sugary and readymade

foods were highly restricted when children were 7 months old but most mothers

were already engaged in teaching rules about restricting the intake of confectionary,

fizzy drinks and cake by the time children were 13 months old (n = 45). This

suggests that parents may begin to reduce children’s level of restriction from a very

young age. These findings are also consistent with Koh et al.’s (2010) and Gubbels

et al.’s (2009) studies, which show that a high proportion of children have already

been introduced to high-sugar and energy dense foods before they reached 1 and 2

years old respectively (see Chapter 1, Section 1.1 and Section 2.4.3.2).

Only two quantitative studies examining changes in restrictive feeding over

time were identified. While Farrow et al.’s (2012) UK based study indicated

consistency in the use of parent restrictive feeding between 2 and 5 years old (n =

31), the larger Australian NOURISH RCT sample (n = 424), showed a significant

increase in parents’ restriction scores between 2 and 5 years old, predominantly

occurring between 2 to 3.7 years for control participants (Daniels et al., 2015). Other

quantitative studies involving children over 7 years reported lower parent restriction

scores amongst parents of older children (Gray et al., 2010, 7 to 17 years; Webber,

Cooke, Hill, & Wardle, 2010, 7 to 9 years), suggesting that parents reduce their use

of restriction after 7 years old. However, all of these studies used the CFQ restriction

scale (Birch et al., 2001) to measure parent restrictive feeding, which does not

measure the level of restriction applied and higher scores on this scale may be

associated with greater child access to restricted foods and drinks rather than higher

restriction (see Section 2.4.2 & Section 2.5). In addition, Campbell et al.’s (2010)

study suggested that the effects of restrictive feeding may vary by child age but as

72 Chapter 2: Literature Review

explained in Section 2.4.4, the outcome measure of change in BMIz may have

resulted in biased findings. Evidence from the combination of studies available to

date does not provide clear evidence of a differential effect of parent restrictive

feeding by child age (see Appendix C). However, it is feasible that the effectiveness

of restrictive feeding practices may vary with child age, as well as parents’

approaches to restrictive feeding changing in response children becoming more

independent.

Furthermore, as mentioned in Chapter 1, Section 1.1 and Section 2.5,

studies have generally concluded that children’s early exposure to a food enhances

their acceptance of and liking for that food (Anez et al., 2013; Beauchamp &

Mennella, 1998; Cashden, 1994; Cooke et al., 2004; Liem & de Graaf, 2004; Mallan

et al., 2016; Mennella et al., 2001; Schwartz et al., 2011; Skinner et al., 2002).

However, again studies have almost exclusively examined these effects in relation

to “healthy” foods that children may initially reject due to their sour or bitter tastes

(e.g. vegetables) (Birch et al., 1990; Birch, 1992). Such foods are also associated

with childhood neophobia, which is the fear of new or unfamiliar foods (Logue,

2004). Neophobia gradually increases from infancy to peak at around 3 to 4 years

old and then gradually decreases thereafter (Cooke, 2007). Therefore, early

exposure may be important to the development of child food preferences for

potentially neophobic foods. However, it may be of less importance to the

development of preferences for restricted foods and drinks due to children’s innate

preferences for the high-sugar, high-salt and energy dense foods that tend to be

targeted for restriction (Bellisle & Rolland-Cachera, 2000; Cooke & Wardle, 2005;

Cooke, Carnell, & Wardle, 2006; Howard, Mallan, Byrne, Magarey, & Daniels, 2012;

Russell & Worsley, 2008; Skinner et al., 2002; Wardle & Cooke, 2008). Furthermore,

genetic traits feature in relation to neophobia, picky eating17 and taste sensitivity for

bitterness18 (Looy & Weingarten, 1992). This may contribute to the relatively higher

heritability in child preferences found for healthier foods, such as vegetables (54%),

17 Picky eating (also known as fussy, faddy or choosy eating) is usually classified as part of a spectrum of feeding difficulties. It is characterised by an unwillingness to eat familiar foods or to try new foods, as well as strong food preferences (Taylor, Wernimont, Northstone, & Emmett, 2015). 18 Sensitivity to 6-n-propyl-thiouracil (PROP) bitter taste is inherited, with PROP tasters being more sensitive to bitter tastes in some fruits and vegetables than PROP non-tasters (Looy & Weingarten, 1992).

Chapter 2: Literature Review 73

fruit (53%), and protein foods (48%), in comparison to innately liked snack foods19

(29%) likely to be targeted for restriction (Fildes et al., 2014).

However, there is a distinct lack of studies examining the effects of early

exposure on children’s preferences for these highly palatable foods and drinks to

clarify whether early exposure might influence child preferences for them.

Beauchamp and Cowart (1985) found that very young infants showed a preference

for sweetened water as opposed to plain water but preference was only maintained

several months later for infants whose mothers continued to feed them sweetened

water (n = 140, child aged 6 months). Mallan et al. (2016) found a significant

correlation between child exposure by 14 months and child liking20 at 3.7 years for a

group of 17 non-core foods21, which included foods potentially targeted for

restriction. However, this study also found a significant correlation of greater

magnitude between child exposure by 14 months and higher child intake frequency

scores at 3.7 years for the same non-core foods (n = 340). It is, therefore, unclear

whether the association between early exposure and ongoing higher child intake

explains the associations observed for child liking in relation to these non-core

foods.

If early exposure and/or ongoing high availability of target restricted foods

in earlier years contribute to children learning to like restricted foods more, it is

possible that parents may later respond to child developed high liking for restricted

foods with greater use of restrictive feeding practices. Such a scenario might explain

why some studies using the CFQ restriction scale (Birch et al., 2001) to measure

parent restrictive feeding concluded that restrictive feeding is more likely to be used

in response to a concern about a child’s weight or eating behaviour rather than

children’s eating behaviours or weight gain resulting from use of restrictive feeding

(Gregory et al., 2010a, 2010b; Gubbels et al., 2011; Spruijt-Metz et al., 2006;

Webber, Hill, et al., 2010). Furthermore, parents using restrictive feeding practices

early on to reduce child exposure to restricted foods may be different parents from

those introducing restrictive feeding practices later in response to developed child

19 Sweet buns, dessert mousse, sweets, chips, savoury snacks, cakes, ice lollies, plain biscuits, ice cream, crisps, chocolate biscuits and chocolate. 20 Parent-rated questionnaire (Wardle, Sanderson, et al., 2001). Dichotomised score for each item (Liked: likes a little, likes a lot. Not liked: neither likes/dislikes, dislikes a little, dislikes a lot, never tried). Scored by the number of the 17 items liked. 21 Ice cream, chips/corn chips, fast foods, sweet biscuits, savoury biscuits, lollies, cake (doughnuts, buns, pastries), muesli bars, fruit sticks/straps, hot chips, chocolate spreads, honey/jam, vegemite, cheese spread/dip, peanut butter, fruit gel/jelly.

74 Chapter 2: Literature Review

preferences from early exposure and greater access to restricted foods. Further

research is required to establish whether early exposure directly influences higher

child liking for highly palatable foods likely to be targeted for restriction

independently from children’s ongoing intake. Overall, further consideration needs to

be given to how parents’ use of restrictive feeding might change over time in

response to children’s cognitive development and/or developed food preferences.

Children’s age of introduction to a restricted food or drink and patterns of exposure

over time may be an important dimension within the restrictive feeding phenomenon.

2.6.7 The restrictive feeding phenomenon and other control feeding practices

Another dimension that needs further consideration is how parents’ use of

other controlling feeding practices (e.g. pressure to eat, instrumental feeding) might

modify the child outcomes observed in relation to restrictive feeding. Carnell et al.’s

(2011) qualitative study found that mothers reported using both restrictive feeding

and pressure to eat to achieve a balanced diet (child age 3 to 5 years). Quantitative

studies have also reported significant correlations for parents scoring highly on both

the CFQ restriction and pressure to eat scales (Birch et al., 2001) (Ogden et al.,

2006; Spruijt-Metz et al., 2002; Wehrly et al., 2014). As quantitative studies

generally indicate an association between practices of pressure to eat and lower

child weight (Spruijt-Metz et al., 2002; Wardle & Carnell., 2007; Wehrly et al., 2014),

the opposite of what some studies are suggesting for restrictive feeding, this adds a

complexity to the restrictive feeding phenomenon requiring further exploration.

Furthermore, Campbell et al. (2006) was the only study identified that controlled for

other feeding practices when examining associations with restrictive feeding. This

study found within their sample of 5-6 year olds (n = 560) that parents’ use of

pressure to eat (measured with the CFQ scale, Birch et al.) was significantly

associated with children’s higher intake of sweet snack food (p = 0.006), savoury

snack food (p = 0.005) and high energy (non-dairy) drinks (p = 0.015), which are

items likely to be targeted for restriction. However, parents’ use of restrictive feeding

(measured with the CFQ scale, Birch et al.) was not found to be independently

associated with the intake of these foods and drinks. These findings suggest that

coincidental parent use of pressure to eat may influence the same child outcomes

being examined in relation to parents’ use of restrictive feeding and therefore may

be an important covariate.

Chapter 2: Literature Review 75

Likewise, how the foods parents use as rewards might align with the foods

they restrict is another important dimension to consider. This is because if restricted

foods are provided as rewards this is likely to increase children’s liking for these

foods (Birch et al., 1982; Mikula, 1989; Newman & Taylor, 1992), irrespective of

restrictive feeding practices. Interestingly, the most widely used tool (CFQ restriction

scale, Birch et al., 2001) conceptualised food rewards within the measure of

restrictive feeding, although other authors have challenged the inclusion of food

reward items in this scale (Corsini et al., 2008; Gregory et al., 2010b; Jansen et al.,

2014; Sud et al., 2010). However, Musher-Eizenman and Holub (2007) found that

parents practices of giving food as a reward positively correlated with higher scores

for parents’ use of restriction for weight control and restriction for health (p < 0.05)

using their CFPQ measure. Therefore, further exploration of how restrictive feeding

and the use of food rewards might be related is also required.

2.6.8 Summary

In summary, while there are many gaps in our knowledge of the restrictive

feeding phenomenon, current evidence from both qualitative and quantitative

studies suggests that the restrictive feeding phenomenon comprises a number of

dimensions, which may be interrelated but are not fully understood. There may also

be additional dimensions that have not yet been revealed by existing studies. In

addition, there is currently little knowledge of the contribution these different

dimensions might make to children’s future risks of developing diet-related diseases

or obesity.

2.7 GAPS IN KNOWLEDGE

The following gaps in knowledge of restrictive feeding were identified by

this literature review.

• There is no universally agreed definition or concept of what constitutes

restrictive feeding (see Section 2.2).

• The relevance of conclusions drawn from experimental studies to children’s

natural worlds is questioned. Observations made in these studies may

reflect natural fluctuations in wanting to consume a food under different

access conditions rather than a lasting change in child preference for a

restricted food (see Section 2.3).

76 Chapter 2: Literature Review

• Cohort studies have been hindered by the lack of construct valid measures

of restrictive feeding and selection of child outcome measures that do not

clearly relate to restrictive feeding. In addition, longitudinal studies have

used child outcome measures that may be biased towards showing no

change as children age and they have not recognised that parent’s

restrictive feeding may change over time (see Section 2.4).

• A substantial body of evidence suggests that there are positive

associations between early and repeated exposure to a food and the

development of child preferences for that food. However, there is a lack of

evidence for such associations related to the types of foods and drinks

likely to be targeted for restriction, for which children have innate

preferences (see Section 2.6.3 & 2.6.6).

• Qualitative studies provide limited knowledge of how this complex social

phenomenon is experienced in the natural world (see Section 2.6). As a

result, there is currently insufficient knowledge of this phenomenon to guide

development of a construct valid instrument to measure the effects of this

phenomenon on child diet-related outcomes.

A potential set of dimensions of this phenomenon, based on a review of

current literature, was presented in Section 2.6. It is argued that this highlights that a

major limitation of this area of research is the many gaps in our understanding of the

restrictive feeding phenomenon. In addition, there is a lack of knowledge of how

different potential dimensions of this phenomenon might independently influence

child preferences (or liking or wanting) for restricted foods and drinks and ultimately

children’s risk of diet-related disease and obesity. Further development of an

effective outcome measure reflecting child preferences (or liking or wanting) for

restricted foods and drinks is required (see Section 2.5). However, a better

understanding of the dimensions that constitute this phenomenon and the

interrelationship between them was identified as the priority before the effects of this

phenomenon on child outcomes can be effectively assessed.

2.8 AIM AND RESEARCH QUESTIONS

The overall aim of this thesis was to gain a more in-depth understanding of

the restrictive feeding phenomenon, with a particular focus on identifying the key

dimensions of this phenomenon that might influence child preferences (or liking or

wanting) for restricted foods and drinks. The potential dimensions presented in

Chapter 2: Literature Review 77

Section 2.6 was intended to provide a map of existing knowledge and highlight gaps

to guide subsequent research in this study. A sequential mixed methods design was

selected, commencing with a qualitative component followed by a quantitative

component. The overall study design and methodology is set out in Chapter 3.

The aim of the study and research questions is outlined below. The

research questions for the quantitative component of the study were posed following

completion and analysis of the qualitative component. The quantitative component

was intended to extend and complement the findings of the literature review and

qualitative component.

Aim

Gain an in-depth understanding of the restrictive feeding phenomenon and identify

the key dimensions of this phenomenon that may contribute to child preferences for

restricted foods and drinks.

Research Question for the Qualitative Component

1. What are the dimensions of the restrictive feeding phenomenon, how are these

interrelated and which dimensions might influence 5 to 6 year old children’s

preferences for restricted foods and drinks?

Research Questions for the Quantitative Component

2. What are the patterns of child intake frequencies of a selection of commonly

restricted foods and drinks at 5 years old and how do these patterns align with

children’s progressive introduction to and development of their liking for these

foods and drinks at ages 14 months, 2 years, 3.7 years and 5 years?

3. What are the unique associations between child intake frequency at 5 years,

child early exposure and mother’s own liking for a selection of commonly

restricted foods and drinks and child liking for the same items at 5 years old?

78 Chapter 2: Literature Review

Chapter 3: Methodology & Method 79

Chapter 3: Methodology & Method

3.1 INTRODUCTION

In Chapter 2, it was concluded that measures of restrictive feeding used in

experimental and cohort studies to date are unlikely to be valid representations of

restrictive feeding in the natural environment. Consequently, it is difficult to interpret

current literature that examines associations between parent restrictive feeding

using these measures and child diet-related outcomes (see Chapter 2, Section 2.7).

In addition, existing qualitative literature provided limited knowledge of the restrictive

feeding phenomenon on which to base a measure (see Chapter 2, Section 2.6).

Therefore, the aim of this study was to gain an in-depth understanding of the

restrictive feeding phenomenon and identify the key dimensions that may contribute

to relevant child diet-related outcomes e.g. child preferences (or liking or wanting)

for restricted foods and drinks (see Chapter 2, Section 2.5). The intention was to

provide the first steps towards developing an evidence-based conceptual framework

to inform future development of more construct valid measures of restrictive feeding.

This study does not extend to developing a specific measure.

As highlighted in Chapter 2, Section 2.6, a number of authors have

suggested that a pre-development qualitative phase can support development of a

theoretical framework on which to base valid measurement of social phenomena

(Faul & Van Zyl, 2004; Nichter et al., 2002; Rowan & Wulff, 2007). Furthermore,

Creswell and Plano Clark, (2011) suggest that, “...the use of quantitative and

qualitative approaches in combination provide a better understanding of research

problems than either approach alone.” (p. 5). They suggest that such an approach

provides the opportunity for both qualitative and quantitative data to contribute to the

story and Greene, Caracelli, and Graham (1989) describe the mixed methods

approach as providing, “multiple ways of seeing and hearing” (p. 20). A mixed

methods approach appears to be particularly suitable for developing a quantitative

measure to assess the effects of social phenomena on an outcome of interest. The

benefits of using both approaches is that qualitative research can provide the benefit

of an in-depth understanding of a problem with variables of interest emerging from

these rich, thick data. Quantitative analyses can then be used to objectively test

whether key variable associations suggested by qualitative data can be generalised

80 Chapter 3: Methodology & Method

to a larger number of people. Quantitative analyses can also be used to assess the

effects of different dimensions (variables) of a social phenomenon on outcomes of

interest. Such analyses could inform which dimensions of a phenomenon are

important to include in a measure aiming to assess the effects of the phenomenon

on an outcome of interest.

A sequential mixed methods design (Creswell & Plano Clark, 2011) with a

qualitative component followed by a quantitative component was selected to achieve

the aim of this study. The initial qualitative component to the study was intended to

enable inductive conceptualisation and identification of the dimensions that might

constitute the restrictive feeding phenomenon. Key dimensions emerging from the

qualitative component were intended to inform subsequent selection of variables to

quantitatively examine the dimensions of this phenomenon further and associations

with child preferences (or liking or wanting) for restricted foods and drinks.

This chapter is presented in two main sections. Section 3.2 outlines the

overall study design and participants. Section 3.3 presents the methodology and

method for the initial qualitative component of the study. The methodology and

method for the subsequent quantitative component of the study is presented in

Chapter 5. This is because the selected sequential mixed methods design of this

study required the selection of variables and method for the quantitative component

to be informed by the findings of the qualitative component, reported in Chapter 4.

3.2 OVERALL STUDY DESIGN AND PARTICIPANTS

3.2.1 Study design

As said, a sequential mixed methods design was selected for this study to

provide complementary qualitative and quantitative data analysis to further existing

knowledge of the restrictive feeding phenomenon and associated dimensions. This

sequential process commenced with an exploratory qualitative component. Findings

from this stage informed the design, data selection and analyses of the subsequent

quantitative component, to complement and extend the findings of the qualitative

component. However, the design of the quantitative component of the study was

constrained by the data available within a secondary source (NOURISH database,

Daniels et al., 2009). Findings from both sets of analyses were then interpreted

together in an integrated discussion (see Chapter 6, Section 6.2). This mixed

Chapter 3: Methodology & Method 81

methods study was symbolised as QUAL → quant, with the qualitative component

being the predominant component of the study.

Neuman and Benz (1998) and Creswell and Plano Clark (2011), highlight

that most research involves both inductive and deductive elements, with qualitative

and quantitative methodologies existing along a continuum rather than being

discrete. The qualitative component of the present study required a mix of inductive

and deductive questions. The quantitative component of the study also involved two

different levels of analysis. Part I involved the examination of patterns across and

between selected variables using descriptive quantitative data collected at four

different child age points. While the richness of these data was reduced to

standardised questionnaire responses, it provided a level of quantification that could

complement, confirm or dispute reports given in the qualitative data. It was also able

to provide a perspective of changes in variables of interest over time, which was

more trustworthy than mothers’ retrospective recollections via the qualitative data.

This analysis was intended to complement and extend the picture of the restrictive

feeding phenomenon presented by the qualitative data. However, this level of data

was not suitable for inferential statistics to clarify the probability of associations

between variables.

Assessment of the probability of associations between dimensions of this

phenomenon and child outcomes of interest is required to objectively clarify which

dimensions need to be included in a content valid22 but practical measure.

Therefore, Part II of the quantitative component of the study was intended to

examine cross-sectional associations between key dimensions of restrictive feeding

and child liking for restricted foods and drinks by inferential statistics. However,

ability to quantitatively examine the key dimensions identified was limited to

variables available within the secondary data source (NOURISH database, Daniels

et al., 2009) and data was required to be reduced further to enable assumptions to

be met for inferential statistical analysis.

22 Content validity is the extent to which a measure represents all facets of a given construct (Pennington, 2003).

82 Chapter 3: Methodology & Method

In summary, the study included the following two sequential components.

• Qualitative component - primary data collection by in-depth telephone

interviews with a sub-sample of control participants from the NOURISH

randomised control trial (RCT) (Daniels et al., 2009)23, who remained

actively enrolled in the study when children were 5 to 6 years old (n= 29).

• Quantitative component - secondary analysis of quantitative data for the

larger sample of control participants from the NOURISH randomised control

trial (RCT) (Daniels et al., 2009) who remained actively enrolled in the

study when children were 5 years old (n= 211). This component included

two parts.

− Part I - visual analysis of descriptive patterns of data for selected

variables of interest at four child age points (14 months, 2 years, 3.7

years, 5 years)

− Part II - statistical examination by binary logistic regression of cross-

sectional associations between selected variables of interest at child

aged 5 years.

Figure 3.1 outlines the key steps in the research design.

23 NH&MRC funded 426704 - Positive feeding practices and food preferences in very young children – an innovative approach to obesity prevention (1) (Ethics Approval: QUT HREC 00171 Protocol 0700000752)

Chapter 3: Methodology & Method 83

Overall Study Design

Sequential Mixed Methods

Qualitative Component

Primary data collection by telephone interviews with mothers of 5 to 6 year old children

NOURISH Active Controls Sub-sample (n = 29)

Interpretation of qualitative findings and identification of

research questions for quantitative analysis

Quantitative Component Part I

Patterns of descriptive data for variables of interest at child ages, 14 months, 2 years, 3.7 years, 5 years

Secondary Data Analysis NOURISH Active Control Participants (n = 211)

Quantitative Component Part II

Cross-sectional analysis of variables by binary logistic regression at child aged 5 years

Secondary Data Analysis NOURISH Active Control Participants (n = 211)

Interpretation of quantitative findings

Overall interpretation and discussion of qualitative and quantitative findings

Complementarity and Extend

Figure 3.1. Sequential mixed methods design

84 Chapter 3: Methodology & Method

3.2.2 Participants 3.2.2.1 Source of the sample

The sample for this study included participants enrolled in the control arm

of the NOURISH Randomised Controlled Trial (RCT)24 (Daniels et al., 2009), who

were still actively enrolled in the study at child age 5 years. The NOURISH RCT

recruited mothers in two cohorts25 during 2008 to 2009 from post-natal wards in

eight hospitals in Brisbane and Adelaide, Australia. Inclusion criteria were: English

speaking first-time mothers (≥ 18 years) with healthy term infants (> 35 weeks, >

2500 grams). The trial data collection method was via maternal-completed

questionnaire and researcher-measured mother and child length, height and weight

(using standard protocols) at five child age time points: 4 months (4.3 ± 1.0 months),

14 months (13.7 ± 1.3 months), 2 years (24.1 ± 0.7 months), 3.7 years (44.5 ± 3.1

months) and 5 years (60.0 ± 0.5 months). Questionnaires were mailed out and

contained a range of questions focusing on infant and child feeding. Questions

included study-specific items, as well as items from several widely used existing

questionnaires including the following.

• Longitudinal Study of Australian Children Questionnaire (AIHW, 2003)

• Child Feeding Questionnaire (Birch et al., 2001)

• Child Food Neophobia Scale (Cooke et al., 2006)

• Preschool-aged Children’s Physical Activity Questionnaire (Pre-PAQ, home

version) (Dwyer, Hardy, Peat, & Baur, 2011)

• Strengths and Difficulties Questionnaire (Goodman, 1997)

• Caregiver’s Feeding Styles Questionnaire (Hughes et al., 2005)

• Kessler Psychological Distress Scale (K10) (Kessler et al., 2002)

• Child Dietary Questionnaire (CDQ) (Magarey, Golley, Spurrier, Goodwin, &

Ong, 2009)

• Covert and overt controlling feeding scales (Ogden et al., 2006)

• Child Rearing Questionnaire (Paterson & Sanson, 1999)

• Child Eating Behaviour Questionnaire (Wardle, Guthrie, et al., 2001)

24 NH&MRC funded 426704 - Positive feeding practices and food preferences in very young children – an innovative approach to obesity prevention (1) (Ethics Approval: QUT HREC 00171 Protocol 0700000752) 25 Cohort 1 was recruited between February and June 2008 but only achieved 53% of the recruitment target. Therefore, a second cohort was recruited between September 2008 and March 2009 to increase the number of participants (Daniels, Wilson, et al., 2012).

Chapter 3: Methodology & Method 85

• Food Liking Questionnaire (Wardle, Sanderson, et al., 2001)

• Parental Feeding Style Questionnaire (Wardle et al., 2002)

Control participants received no intervention, only access to usual services,

which included access to child health clinic services (information and support for

child feeding, growth and development) and access to information via a telephone

helpline and website (Daniels et al., 2009; Daniels, Mallan, et al., 2012; Daniels et

al., 2015). Participants originally recruited to the trial (n = 698) were more likely to be

older, university educated, born in Australia or New Zealand, have a spouse, intend

to breast feed and not smoke during pregnancy than those who originally provided

baseline data but either became ineligible, declined to consent to the trial or could

not be re-contacted at child aged 4 months (n = 1396) (Daniels, Mallan, et al.,

2012).

3.2.2.2 Sample for the present study

Only NOURISH control participants still active at the child aged 5 years

time point were included in the present study. Controls only were selected because

exposure to the NOURISH intervention could influence mothers’ feeding practices

and may have impacted on the phenomenon of interest for this study (Daniels,

Wilson, et al., 2012). In addition, only participants remaining in the NOURISH trial at

the 5 year time point could be invited for interview and provided the full set of data

across all time points for quantitative analysis. Five potential participants who

indicated that their child had a professionally diagnosed food allergy or intolerance

at the child aged 5 years data collection point were excluded from the sample. The

remaining participants were included in the present study, which consisted of 211

mother and child dyads. All participants were included in the quantitative component

of the study (n = 211) and a subsample of these participants were included in the

qualitative component of the study (n = 29).

Table 3.1 shows characteristics of the sample in comparison with

NOURISH trial control participants lost to follow-up (n = 135). Participant

characteristics were compared using t-test or chi-squared analysis to identify and

report significant differences between these two samples. All variable

measurements used for comparison were recorded at the first time point of the

NOURISH trial (i.e. child aged 4 months). Overall, there was evidence of retention

bias related to maternal education, age at delivery, family income and partner

86 Chapter 3: Methodology & Method

status. This means that the sample was more representative of higher educated

mothers of an older age who have a partner and live in a household with a relatively

higher income than mothers who were lost to follow-up from the NOURISH trial. In

addition, the original NOURISH trial sample (n = 698) varied from those whose

baseline data was collected antenatally but subsequently did not consent or could

not be re-contacted to participate (n = 1396). The mothers who did not participate in

the trial were less likely to be university educated (27% as opposed to 36%),

married or in a de facto relationship (83% as opposed to 90%) and were slightly

younger (26.2 years as opposed to 28 years) than the mothers that consented to

participate in the trial (Daniels, Wilson, et al., 2012). Table 3.1

Characteristics of the Study Sample of Mother and Child Dyads in Comparison to Other

NOURISH Trial Control Participants Lost to Follow-Up

Variables (at child 4 months)

Active controls Lost to follow-up

n n (%) / M (SD) n n (%) / M (SD) pa

Maternal characteristics

University education (yes) 211 137 (65) 135 62 (46) .000

Born in Australia 211 164 (78) 135 106 (79) .862

Age at delivery (years) 211 31 (5) 135 29 (5) .006

Low family income (Gross < $50,001 pa)b

207 39 (19) 124 39 (32) .009

BMI (kg/m²)a 210 25.94 (5.53) 134 26.59 (5.34) .282

% overweight (BMI ≥ 25)c 210 104 (50) 134 75 (56) .978

% obese (BMI ≥ 30)c 210 41 (20) 134 26 (19) .243

Married/de facto (yes) 211 206 (98) 134 121 (90) .003

Child characteristics

Gender (male) 211 98 (46) 135 75 (56) .098

Child weight for age z score 211 -0.03 (.92) 135 -0.04 (.88) .983

Note. % (valid rounded) within group (count) reported for categorical variables; M (SD) reported for continuous variables. a For continuous variables, t-test p values sig. (2-tailed) equal variance assumed. For dichotomous variables, Pearson chi-squared test p value sig. (2-sided). b Original data groups split closest to the lowest quartile. c World Health Organization (WHO). (n.d.). Global Database on Body Mass Index. Retrieved 12th January, 2017, from: http://apps.who.int/bmi/index.jsp.

The sample for the qualitative component of the study comprised of a

subsample of 29 mothers from the sample of 211 mothers included in the

quantitative component of the study. At the time interviews commenced, NOURISH

children of mothers interviewed were a mean age of 6 years old [5.3-6.6 years] and

26 had siblings. Seventeen mothers interviewed were from Brisbane and 12 were

from Adelaide. Eleven mothers were not born in Australia. Overseas countries of

Chapter 3: Methodology & Method 87

birth included: New Zealand, USA, UK, Malaysia, South Africa, Philippines and

Slovakia. The sample included two mothers who had separated from their partners

and one mother who had a new partner since her first child was born. Other

characteristics of the interview sample and the sample of participants invited but not

interviewed are shown in Table 3.2. The sample of mothers interviewed varied from

the participants invited but not interviewed in terms of country of birth, length of

breast feeding and family income, with no representation in the interview sample

from the lowest family income group (< $20,001 pa). There was very little apparent

difference for mean child BMIz. However, the interview sample had lower

representation from the heaviest children, with only four overweight (> 1 SD) and

one obese (> 2SD) child amongst those interviewed. While representation from

overweight mothers was similar to the group invited but not interviewed, there was

lower representation of obese mothers amongst those interviewed. No statistical

testing was performed on this small sample. Comparison was intended to be

qualitative because findings are not generalisable.

Table 3.2

Characteristics of the Sample of Mother and Child Dyads Interviewed in Comparison to

Those Invited but not Interviewed

Variable Interviewed Invited not interviewed

n n (%) / M (SD) Range n n (%) / M (SD) Range Maternal characteristics

University education (yes) 29 15 (52) 120 60 (50) Born in Australia 29 18 (62) 120 96 (80) Age at delivery (years) 29 31 (5) 23,39 120 30 (5) 19,43 Low family income (Gross < $50,001 pa) ᵇ 29 3 (10) 120 34 (28)

BMI 28 24.8 (3.9) 18.3,31.7 120 26.2 (6.2) 16.9,45.9 % overweight (BMI ≥ 25) 28 14 (50) 120 60 (51) % obese (BMI ≥ 30) 28 4 (14) 120 27 (23)

Child characteristics Gender (male) 29 15 (52) 119 50 (42) Child BMIz 29 0.40 (.84) -1.41,2.08 119 0.42 (.92) -1.71,4.24 Breast fed (weeks) 29 46 (28) 9,95 120 32 (24) 0,104

Note. % (valid rounded) within group (count) reported for categorical variables; M (SD) reported for continuous variables. Measurement at child aged 4 months time point. ᵇ Original data groups split closest to the lowest quartile. WHO (n.d.). Global Database on Body Mass Index. Retrieved 12th January, 2017, from: http://apps.who.int/bmi/index.jsp. Measured at child 5 years time point. Reported at child 3.7 years time point.

Sequential mixed methods design usually involves two separate samples

for qualitative and quantitative stages to avoid bias in the quantitative stage caused

by participants experiencing the qualitative stage. However, data utilised in the

88 Chapter 3: Methodology & Method

quantitative stage of this study were accessed from a secondary source, so had

been collected independently from the candidate and prior to the qualitative phase

being conducted. Prior completion of the NOURISH survey may have introduced

some bias. However, bias was likely to be minimal because the survey is a broad,

comprehensive questionnaire without specifically focusing on the variables of

interest for this study. In addition, the sample only included study controls that had

not been exposed to the intervention.

3.3 QUALITATIVE COMPONENT OF THE STUDY 3.3.1 Introduction

Chapter 2 highlighted that the small number of qualitative studies exploring

parent’s approaches to restrictive feeding have been limited in depth and scope

(See Chapter 2, Section 2.6). While these qualitative studies have elicited a range of

practices parents report using to restrict foods, they have not provided an

understanding of the range of practices by individual mothers, how mothers utilise

these in specific contexts and how the use of these practices might vary between

mothers (See Chapter 2, Section 2.6.4). It was concluded that a major limitation of

this area of research is the many gaps in our understanding of the restrictive feeding

phenomenon. It was also proposed that a better understanding of the dimensions

that comprise this phenomenon and the interrelationship between them was a

priority for research before the effects of this phenomenon on child outcomes can be

effectively assessed.

The qualitative component of the present study was more inductive than

deductive (Patton, 2002), providing depth of understanding of the complexity and

diversity of the restrictive feeding phenomenon from the lived experience of

mothers. The preliminary conceptual framework presented in Chapter 2, Section 2.6

outlined the potential dimensions of this phenomenon, based on limited existing

knowledge from both qualitative and quantitative studies. This framework also

highlighted gaps in the extent of current knowledge of this phenomenon, which

includes the following.

• The specific foods and drinks parents restrict their children from

consuming.

• Parents’ motivation for restricting foods and drinks.

Chapter 3: Methodology & Method 89

• How individual parents restrict their children’s consumption of certain foods

and drinks, including in different contexts and at different times i.e.

restrictive feeding practices.

• Parent communication associated with restrictive feeding.

• How parents’ use of restrictive feeding might change over time as children

age.

• How parents’ feeding practices of pressure to eat and giving foods as

rewards might relate to restrictive feeding.

• Parents’ lived experiences with restrictive feeding and what these

experiences suggest about the nature of the restrictive feeding

phenomenon, as well as potential effects on child diet-related outcomes.

These known gaps were used as sensitising concepts26 (Blumer, 1954)

reflected in the interview questions and prompts but exploration was not limited to

these concepts.

3.3.2 Research question

What are the dimensions of the restrictive feeding phenomenon, how are these

interrelated and which dimensions might influence 5 to 6 year old children’s

preferences for restricted foods and drinks?

3.3.3 Methodology 3.3.3.1 Research paradigm and approach

The target audience for the present study was public health and nutrition

research communities. This study was intended to explore the restrictive feeding

phenomenon, as well as elicit specific information in relation to known gaps in our

understanding of this phenomenon outlined in Chapter 2, Section 2.6.

A range of qualitative methods and related theoretical frameworks have

been developed, underpinned by specific philosophies or worldviews, commonly

termed paradigms. While previously developed qualitative theoretical frameworks

26 Sensitising concepts are intended to provide a general sense of reference and guidance rather than be definitive or prescriptive (see Chapter 2, Section 2.6).

90 Chapter 3: Methodology & Method

may assist with the conduct of similar studies, there is no requirement for qualitative

research to be carried out as previously conducted; indeed these may not be the

best approach for all studies. It is preferable to select a method tailored to the

research question rather than trying to fit a research problem into a particular

method. As Richards and Morse (2007) highlight, “that’s where the danger lies – in a

topic shoehorned into a particular method” (p. 26).

Although qualitative research is primarily about words and themes and

drawing meaning from people’s experiences, Miles, Huberman, and Saldana (2014)

point out that there are likely to be elements of quantification in most qualitative

research, such as searching for common themes and coding to group qualitative

data elements.

Furthermore, the sensitising concepts (Blumer, 1954) proposed for use

within this study required a mix of deductive and inductive responses. A pragmatic

approach was selected as appropriate for this study, which is commonly associated

with mixed methods approaches. The pragmatic paradigm is characterised by the

following features drawn from Lincoln, Lynham, and Guba (2011) and Teddlie and

Tashakkori (2009).

• Ontology (the nature of reality). The world exists in a way that is

simultaneously independent of the individual (objective) and constructed by

the individual (subjective).

• Epistemology (the relationship between the researcher and that being

researched [i.e. how we understand the world]). Pragmatic research sees

this as a continuum rather than two opposing poles. It values interaction

with participants as well as working towards objectivity.

• Axiology (the role of values in research). Research is bound by values and

it is accepted that personal values and theoretical orientations guide

researchers.

• The purpose of research. Research is intended to solve practical

problems and answer the questions posed.

• Types of research conducted. Pragmatic research can use many

different methods to gain or construct knowledge. The methods chosen are

based on the purpose of research with no one approach suiting all

research. Both qualitative and quantitative approaches are useful and

chosen in accordance with the best method for the questions posed.

Chapter 3: Methodology & Method 91

• Generalisation of research. Generalisation is not emphasised but time

and context are important, as well as external validity and transferability.

A pragmatic approach means that there is no set method to follow, enabling

the researcher to design a method most suited to answer the research questions.

However, integral to the design of this approach is the need to build in methods that

demonstrate methodological trustworthiness, meaning that the report of findings and

interpretation accurately reflects the situation being described.

3.3.3.2 Demonstrating trustworthiness

The framework adopted for this study to demonstrate trustworthiness was

based on proposals by Lincoln and Guba (1985) and Lincoln et al. (2011). This

framework presents the following four trustworthiness criteria, which have arisen

from the contructivist27 perspective and are widely adopted by qualitative

researchers.

• Credibility - findings reported reflect realities described by participants

• Dependability - the research process is carried out with attention to

qualitative methodology

• Confirmability - minimising subjectivity and bias of the researcher

• Transferability - can the work be generalised to theoretical propositions.

Table 3.3 outlines the research methods that were included in this study to

support these four trustworthiness criteria.

27 Constructivist represents a qualitative research paradigm. This is generally underpinned by a belief that there are multiple realities and that we understand the world by the researcher inductively creating meaning from participant perspectives not an objective perspective.

92 Chapter 3: Methodology & Method

Table 3.3 Methods Included in the Study to Support Trustworthiness Criteria Method Procedures included in the study

Credibility Findings reported reflect realities described by participants.

Member Checks (Wolcott, 2005)

• Clarification of meaning was sought with participants during the interviews. • Summaries of the interviews were sent to participants for review. • Recorded and transcribed interviews were reviewed several times to check accuracy of interpretation.

Findings grounded in narrative data (rich thick descriptions, Lincoln & Guba, 1985)

• Illustrative verbatim quotes were included in the text of findings with transcript references. • Additional supporting verbatim quotes were provided as evidence for key emerging and complex

themes with transcript references. • An analysis process that stayed close to the raw data was maintained for as long as possible. • Language used by participants utilised as much as possible in reporting the findings (In-vivo).

Interpretation into professional language was avoided to minimise potential for misinterpretation. Data Display ᵇ (Miles et al., 2014)

• Illustrative quotes were provided in the text to highlight meaning. • A table of supporting quotes displayed additional supporting raw data (see Addendum 4.1). • A summary table of notations against transcripts provided a visual display used to check that analysis

represented the range of responses and repetitiveness. (see example Appendix J). Re-examining transcripts going against the common grain and seeking rival explanations

• Where patterns varied for a participant, transcripts were re-examined. Some variance was explained by variations in other Sections of the transcript. Explanations or outstanding variations and dissent were included in the supporting quotes table (see Addendum 4.1).

Dependability The research process is carried out with attention to qualitative methodology.

Research questions were congruent with the study

• The interview schedule reflected the research questions and findings were reported in a structure that resembled the original research questions.

• The commencing interview schedule was reviewed for face validity to elicit responses that addressed the research questions, as well as encourage participants to raise additional aspects they felt were important to the topic.

A conceptual framework underpinned the study

• A conceptual framework based on a review of relevant literature and identification of gaps in knowledge underpinned the study and research questions posed (see Chapter 2, Section 2.6).

Designed with an iterative process • Each interview recording was reviewed and summarised as the interviews progressed. • The interview schedule and technique were reviewed after each interview and revised to improve data

collection and accommodate emerging and unexpected themes. Method repeatable • An audit trail was maintained to keep a record of the methods followed and decisions made.

• The method and procedures could be repeated from the description provided in the methods Section. Sample range • The sample was drawn from participants recruited to another study (Daniels et al., 2009) and can,

therefore, only be representative of mothers based in Brisbane or Adelaide whose eldest child was 5 to 6 years old at the time of interview.

• To improve diversity, equal numbers of university and non-university educated mothers, as well as, child gender were recruited to the study.

• Volunteers only included mothers who believed they avoided or limited some food or drink items even though the invitation letter encouraged participation from all mothers. It is unknown whether this is because all mothers limit some foods or mothers who do not limit any foods did not volunteer.

Peer review • Two supervising researchers of different backgrounds (nursing, psychology) reviewed the supporting quotes and provided feedback on congruence with findings presented.

Chapter 3: Methodology & Method 93

Criteria Method Procedures included in the study

Confirmability Minimising subjectivity and bias of the researcher.

The researcher’s potential biases are highlighted

• It was recognised that the researcher’s experience and theoretical orientations associated with the discipline of public health, other career experiences and experience as a mother creates potential biases associated with this study (see Section 3.3.3.3).

• The researcher’s experience of parenthood and health visiting may also contribute to greater insight and deeper meaningful analysis for this study.

The researcher has tried to minimise the influence of subjectivity

• Interviews were recorded and transcribed rather than relying on note taking, which may have introduced selection bias.

• A summary table was used to reduce data selection bias during analysis. • Illustrative and supporting quotes were included in the documentation to provide evidence of support

for analysis conclusions. • Reductionist coding was avoided so the researcher stayed close to the original data for as long as

possible in the analysis process. • Verbatim quotes and original transcripts were reviewed several times to check meaning. • Two supervising researchers of different backgrounds (nursing, psychology) reviewed the illustrative

and supporting quotes and provided feedback on congruence with the findings presented. • Member checks were in place at multiple levels. • Findings were reported in participants own language as much as possible to avoid misinterpretation

into professional language. • An audit trail of decisions made and conceptual thoughts was kept throughout the research process

Transferability Can the work be generalised to theoretical propositions.

The characteristics of the participants are described

• Characteristics of the participants potentially likely to influence findings are highlighted in Section 3.2.2.2.

• This sample only included representation from children whose mother’s said their child was not overweight. As perceived child weight may influence mother’s restrictive feeding practices, this was a key aspect that could not be explored with this sample.

• Novel findings cannot be assumed beyond this small sample. Similarities with other study findings • The findings have similarities with reports from other qualitative studies examining mother’s restrictive

feeding practices. Some findings were novel but not contradictory to other published studies (see Discussion in Chapter 6, Section 6.2).

Member refers to participants in the study. ᵇ The human brain has limited capacity to process large amounts of information and may overweight responses that are vivid or of personal interest (Miles et al., 2014)

94 Chapter 3: Methodology & Method

3.3.3.3 Reflexivity

As a researcher, I acknowledge that I bring my values, interests,

experiences and potential biases (Creswell & Plano Clark, 2011) to this study. A

tension exists between considering these attributes as bias and recognising that I,

as the researcher, influence the process of enquiry. However, this study includes

features that enable demonstration of findings beyond my interpretation such as: the

provision of ‘many-voiced’ accounts (Koch & Harrington, 1998) as supporting data;

retention of original data for as long as possible during the coding process; and

displays of data to assist with reducing potential interpretation bias (Miles et al.,

2014).

My discipline is predominantly public health. The public health issue of

childhood obesity was an area of interest and I sought to find a specific area of this

topic where I could make a contribution to knowledge. In discussion with Professor

Lynne Daniels (associate supervisor), the topic of restrictive feeding in relation to

childhood obesity arose. I selected this area of research because my initial review of

studies highlighted conflicting findings and sparked my interest to investigate why

this was the case.

The experiences that influence my worldview in relation to this study are

mixed. While my experience as a mother potentially enables me to empathise with

other mothers’, I only have the experience of my child, who may be different from

other children. However, my experience as a health visitor has also provided me

with insight into parenting and child feeding experiences, across a range of families

with children, from birth to 5 years old. For the 28 years prior to commencing this

study, I worked in the fields of public health, policy and strategic health planning.

This type of work required analysis of a range of quantitative and qualitative

information and often included interviews and group conversations to gather views

and information from personnel and customers to inform decision-making. These

experiences have given me a natural leaning towards mixed methods and an

understanding that quantitative and qualitative data can be complementary. I

understand that both my life and working experiences will not only influence my

selection of research questions and my approach to research but also my

interpretation and decisions of what to include in reported findings. However, these

same factors may also bring insightful understanding and empathy with participants,

as well as a broader perspective to this field of nutrition research.

Chapter 3: Methodology & Method 95

3.3.3.4 Ethical approval

This study was approved by QUT Human Research Ethics Committee and

on 19th June 2014 (approval number 1400000397, 19-6-2014).

3.3.4 Research method 3.3.4.1 Data collection methods

A research instrument involving a qualitative conversation with mothers

was sought to address the research question for this study. An open and

comprehensive discussion about the full range of individual mothers’ restrictive

feeding experiences was desired and the method of individual interviews was

considered most appropriate. While focus groups offer the benefit of stimulating

ideas amongst participants, this was of less relevance to this study than gathering

data about individual approaches and experiences. It was also considered that

participants may be more reluctant to share their negative as well as positive

experiences in a focus group setting than in an individual interview situation.

Consideration was also given to face-to-face interviews versus telephone interviews.

Telephone interviews were considered preferable because they offered more

anonymity to participants, hopefully encouraging them to feel more able to present

frank and comprehensive accounts of their practices. Participant facial expressions

and body language offered by face-to-face interviews were also of less relevance to

the research questions in this study.

A one-off telephone interview was selected as the data collection method to

gain the information sought by the research questions. From the practical point of

view, telephone interviews also offered greater flexibility for busy mothers and were

more suitable for a novice researcher to manage. It was also less costly and time

consuming for the researcher and provided the opportunity for greater geographical

reach, enabling inclusion of mothers based interstate to increase the chance of

obtaining sufficient volunteers.

An initial interview protocol provided a mix of semi-structured and open

questions, with optional prompts. The interview questions provided sensitising

concepts (Blumer, 1954) as a starting point for conversations, which were related to

gaps in knowledge of the potential dimensions of this phenomenon identified in the

96 Chapter 3: Methodology & Method

literature review (see Chapter 2, Section 2.6). Some questions required fairly

specific responses, such as ascertaining the foods and drinks parents targeted for

restriction, whereas other questions required a more open approach, such as how

parents restrict foods and drinks in the natural setting. This meant that a mix of

different types of questions, varying by deductive and inductive approaches, were

required.

To improve face validity of the commencing interview schedule it was

reviewed and refined with supervisors, other colleagues and four mothers known to

the researcher with parenting experience of six year old children.

3.3.4.2 Interview participants

Selection of participants

A convenience sample of NOURISH control participants (Daniels et al.,

2009) who were still active when children were 5 years old, were the sample

population for this study (n = 211) (See Section 3.2.2.2). Previous experience of

recruiting participants for an observational study (Harris et al., 2014) from the

NOURISH sample suggested a response rate of around 20%, although that study

involved home visits. As the NOURISH study had been ongoing for some time and

nearing completion, volunteer numbers were expected to fall further for this current

study. In addition, the NOURISH sample included fewer non-university educated

mothers than university educated (see Section 3.2.2) and the aforementioned

observational study (Harris et al.) only received five percent non-university educated

volunteers. Based on past experience, this current study aimed to increase potential

recruits from non-university educated backgrounds to potentially increase the

diversity of views and practices reported.

This study aimed to recruit 20-30 participants in total, in line with Hesse-

Biber (2010)28 and Hennink, Kaiser, and Marconi’s (2016) suggested number of

interviews to reach saturation points with similar studies. Hennink et al. (2016)

differentiated between saturation of codes and saturation of meaning, suggesting

that saturation of codes might be achieved after nine interviews but 16 to 24

28 Hesse-Biber (2010) proposes that participants are interviewed until very limited additional information is arising with each additional interview.

Chapter 3: Methodology & Method 97

interviews are likely to be required to reach saturation of meaning29. Recruitment

was planned in two phases, so that a second group of participants could be

recruited at a later date if saturation had not been reached in the first phase. The

first phase of invitations were sent to all NOURISH cohort 1 participants and just the

non-university educated participants in NOURISH cohort 2. This included 100

participants based in Brisbane and 50 participants based in Adelaide, with 57% of

this sample being non-university educated. Cohort 2 university educated NOURISH

participants were reserved for the second phase but were not required.

Recruitment and information provided

Invitations to participate in this study were sent to the 150 mother and child

dyads (see Appendix E for invitation letter and enclosures). Volunteering to

participate was made as easy as possible, providing email or post response options

to encourage a good response rate. Forty-two mothers volunteered (28% response

rate) and the first 30 to volunteer were recruited into the study. Respondents were

selected on the basis of the order they responded, the date sent by post or date of

email received. Participants selected were telephoned promptly and interviews were

organised at a time and day that suited participants. Initial contact provided the

opportunity to develop a friendly rapport with participants and encourage them to

feel comfortable with the researcher and committed to the study. By chance, this

sample included even numbers of university and non-university educated

participants and even numbers of child gender. Twenty-nine mothers were

successfully interviewed, with one mother (non-university educated, female child)

being unable to be re-contacted subsequently. She was not replaced because it was

already evident that saturation had been reached, with diminishing additional

meaning arising with each successive interview.

Details of the interview date and time were sent to participants by email

along with further information about the interview and a list of questions that were

used as a guide for the conversation. A list of foods and drinks (included in the

NOURISH survey, G2, p. 15) was included as a memory aide for the first question,

which was recommended by the four mothers who assisted with reviewing the draft

interview schedule (see Appendix F for interview participant information).

29 Hennink et al. (2016) referred to coding saturation as heard it all and meaning saturation as understand it all.

98 Chapter 3: Methodology & Method

Participants were also sent reminder emails and texts a few days prior to their

interview day, as well as given the opportunity to reschedule. Interview times were

reorganised for four participants.

3.3.4.3 Data collection Telephone interviews

All interviews were recorded so that records of interviews were available for

in-depth review and re-analysis as required. Recordings were stored on a password

protected computer, referenced with the participant ID number.

Verbal consent for the recorded interview was confirmed with participants

prior to commencing the interview and again at the beginning of the recording.

Participants were also informed that they could choose not to answer any questions

or terminate the interview at any time. Participants were given the option for their

own first names or alias names to be used during the interview for both themselves

and their children before recording commenced. All participants selected to use their

own first names and the first names of their children.

One recording was lost due to technical errors but notes had been taken

and were included in the analyses (summary table only, see Section 3.3.4.4). The

first recording was transcribed verbatim by the researcher, with the remaining

recordings being professionally transcribed verbatim. This was with the exception of

one recording where the interviewee had limited spoken English and the recording

was mostly difficult to interpret. However, comprehensible parts of the recording

were summarised, forwarded to the participant for confirmation and included in the

analyses (summary table only, see Section 3.3.4.4).

Interviewees were initially advised that interviews would be of

approximately 30 minutes duration. However, the length of interviews expanded in

line with improvements to the interview technique, with later interviews being mostly

of 60 minutes duration. As a result, later participants were asked whether they would

like to stop at 30 minutes or continue. All chose to continue but a target maximum of

one hour was sought by the interviewer to respect the interviewee’s time. Interviews

lasted 26 to 68 minutes with an average of 49 minutes.

Chapter 3: Methodology & Method 99

All interviewees were asked the eight main questions on the interview

schedule, with prompts and additional questions used only if required. The interview

schedule and interview technique were reviewed further after each interview, with

successive adjustments made to improve questioning and further explore emerging

themes. The final interview schedule reflects all the changes made following review

after each interview (See Appendix G for commencing and final interview

schedules). A summary of key responses from participants were reflected back to

interviewees for confirmation of their meaning at the end of a scheduled question

and/or at other relevant points throughout the interview. This was intended to assist

with confirmation of meaning and intent of responses given by interviewees (i.e.

member checks).

Two to four page summaries of the interviews were prepared from the

recordings and emailed to participants shortly after the interview. Participants were

invited to comment on any discrepancies or provide any further feedback within two

weeks. While all participants acknowledged the receipt of these summaries, only

seven provided a subsequent comment. Five said that the summary was a true

reflection of the conversation, including the participant whose recording was lost due

to a technical error. Two participants added additional information that was included

with their interview responses. No participants indicated that any part of the

summary was not a reflection of the conversation.

$25 retail vouchers were sent to the 29 participants completing the

interview with a thank you letter. A brief two page summary of the overall findings

was also forwarded to participants for information following final analysis of data.

Interviewing technique

It was recognised that data arising from interviews are constructed by

participants based on their experiences, selective memories and what they chose to

portray to the interviewer (Patton, 2002). It was also considered that mothers are

likely to have strong feelings of wanting to do the best for their child, so actions that

do not reflect this ideal may be difficult for them to confront or even recall. The

interview technique needed to recognise these factors and attempt to encourage

mothers to feel comfortable enough with the interview setting and interviewer to

reveal a more candid picture of their practices and experiences from their

perspective.

100 Chapter 3: Methodology & Method

The interview technique was characterised by the responsive interviewing

model (Rubin & Rubin, 2012), also recognising that the most effective approach

might vary during an interview and between participants to achieve a flowing

conversation. The interviewer contributed more to the conversation at the beginning

of interviews until participants engaged in flowing conversation. The approach was

supported by starting the interview with the most structured and easy to answer

questions. Other aspects of the interviewing technique are shown in Table 3.4.

Table 3.4

Key Elements of the Interview Technique

Relaxed approach

Developing a relaxed approach was important to enabling participants to feel comfortable to share their experiences. Volunteers were contacted by phone to make arrangements for the interview, which provided an initial opportunity to build a friendly, non-threatening rapport with them. When contacted again for the interview a friendly conversation was instigated to develop a relaxed style before commencing the interview. The decision to ask for verbal rather than written consent also contributed to building a relaxed approach.

Active listening

Participants were encouraged to lead the conversation with issues or experiences they wanted to raise about the topic and the order of interview questions was flexible to their conversation.

Clear communication

Reflection on the effectiveness of interview questions, based on participant responses, led to refinement of questions as the interviews progressed. This lead to improved clarity of questioning and more focused participant responses. Probing aimed to reflect the words participants used and the language of questions was adjusted to suit the language of individual participants to improve understanding.

Qualified naivety

The interviewer emphasised that there were no right or wrong answers and we wanted to learn from participants. This was conveyed in the information sent out to participants and again at the start of the interview. The interviewer also explained that she was not a professional nutritionist but was a mother herself.

Non-judgmental empathy and respect.

Care was taken not to make judgmental comments during conversations. A keen interest to learn from what participants were saying and encouragement to tell more was conveyed. Accuracy of what participants were saying was not questioned and care was taken not to highlight contradictions when probing further into the meaning of what participants were saying. This meant that at times contradictory statements were not clarified.

Informed by: Patton (2002), Rubin and Rubin (2012), Kvale (2007) and Gillham (2005)

The reflection process continued throughout the interviewing period, with

improvements being made to the technique and phrasing of questions, as well as

adjustments for individuals. Improvements were assessed to result in: longer

Chapter 3: Methodology & Method 101

interviews, less talking by the interviewer, more free flowing responses from

participants, and fewer opportunities for probing being missed. However,

participants continued to vary and flexibility in language continued to be required to

achieve free flowing conversations with the different participants.

3.3.4.4 Analysis of data

As there is no specific method applied in the pragmatic approach, the

method of analysis has been provided in detail for transparency. In addition, this

detail is provided to meet the criteria of method repeatable within the trustworthiness

criteria of dependability (see Section 3.3.3.2, Table 3.3). The description of method

and procedures is provided in sufficient detail to enable them to be repeated.

Overall approach to data management and analysis

Interview recordings were professionally transcribed to provide an accurate

record for analysis, quote extraction and reference. The analysis method was

designed to accommodate the different demands of the various dimensions of the

phenomenon being studied, reflecting the selected pragmatic approach. It was

designed to meet the specific identified needs of this project, informed by broad

reading of relevant analytical methods (Bruce, 2007; Creswell & Plano-Clark, 2011;

Fram, 2013; Hesse-Biber, 2010; Merriam, 2009; Miles et al., 2014; Patton, 2002;

Plano-Clark & Creswell, 2008; Saldana, 2013; Wolcott, 2005). The general

approach to data analysis was mostly informed by methods presented in Miles et al.

(2014) and Saldana (2013). The approach was predominantly inductive with

sensitising concepts (Blumer, 1954). This provided some guidance to investigation,

to assist with the study aim to progress development of a conceptual framework of

the restrictive feeding phenomenon (see Chapter 2, Section 2.6). Data analysis was

an iterative process with summaries of interviews being completed and recordings

reviewed after each interview (Patton, 2002). This supported a reflexive process

leading to adjustment of the interview schedule and questioning approach in light of

knowledge revealed by each subsequent interview (Bruce, 2007).

The approach to coding was predominantly informed by Saldana (2013).

Data were manually coded and analysed using Microsoft Word files and tables to

sort and group data. Data retained from transcripts were organised in files as

deemed to be appropriate on review with consideration to the sensitising concepts

102 Chapter 3: Methodology & Method

(see Section 3.3.1). The analysis process and organisation of data elements were

developed in an iterative way, so that the process made sense for the data

emerging from the interviews. However, a structured process of grouping (coding)

and display assisted with analysis and a reflexive process.

Analysis during the interview phase

Recordings were reviewed for initial themes emerging and summaries of

interviews were completed between interviews. Questions were added to the

schedule for emerging themes and questions eliciting minimal responses or lacking

clarity for participants were reviewed and changed. Changes made to the schedule

are outlined in Appendix H.

After the fifteenth interview, summaries of the interviews were reviewed

together to get a better overall feel for the themes emerging at that point. This was

intended to increase awareness of the common patterns and themes emerging and

inform the line of questioning for the remaining interviews. Initial main group codes

were developed in order to group key elements of data to aid analysis in relation to

each of the main interview questions (see Appendix I, Table I.1 for main group

codes).

Overall analysis

The sensitising concepts were used as a starting template for analysis.

Transcripts were divided into the sensitising concepts and other comments, with

each section of speech numbered so that quotes could be referenced back to the

transcript source. These were transferred to a table with a blank right hand column

for notes. This table was intended to provide a preliminary framework as a starting

point for analysis in workable chunks. Where participants took the conversation in a

different direction these chunks of conversation were re-allocated to the relevant

sensitising concept or emerging theme at the next stage of analysis.

The approach to analysis was reviewed and adapted as it progressed

rather than utilising a pre-determined method that may not have provided an

adaptable approach once the researcher could see how the data were presenting. In

line with Saldana’s (2013) philosophy, the term coding has been used in a broad

Chapter 3: Methodology & Method 103

sense to describe analysis of groups or chunks of data, rather than reducing data to

a label. Saldana advocates customising coding schemes to the specific context of a

study and states that “coding is just one way of analysing qualitative data, not the

way. There are times when coding the data is absolutely necessary and times when

it is most inappropriate for the study at hand.” (p. 40.). Transcripts were initially

reviewed and short notes of participant responses recorded in the right hand

column, with coding of supporting quotes. In order to stay close to the raw data for

as long as possible, coding by short notes was preferred to coding by phrases or

single words. Part of the intention of the study was to identify the range of practices

and differences between participants, so reduction of data to single words or

phrases did not make sense for this study.

Consideration was given to analysis of participant responses both across

interview questions and relationships between questions and data within cases. The

initial analysis focused on coding across-interview descriptive reports. Further

consideration was given to within case data (up and down) during the second cycle

of coding, in relation to emerging patterns and themes. The short notes recorded on

the transcripts were reviewed and re-reviewed and a preliminary list of first cycle

main group and sub-group codes developed. Thirteen main group codes and many

more subgroup codes represented data related to the interview questions, as well as

unexpected and emerging themes (see Appendix I). There was some overlap

between groups and sub-groups at this stage. A summary table was developed

using these codes and the short notes recorded in the interview transcript tables

were copied across to the table under the relevant group or sub-group code for each

participant. Some notes were put into more than one group or sub-group in the

summary table (see Appendix J for sample of summary table). The table was

intended to provide a display of the main essence and range of what participants

were saying to give an overview of the breadth and common themes and elements

of data arising. This table also provided simple descriptive reports of foods and

drinks restricted, as well as mothers’ motivations and types of restrictive feeding

practices they used.

Supporting quotes highlighted in the transcripts were then organised by

group codes in another document and were listed by participant. A number of

quotes appeared in more than one group, where they were relevant to more than

one. Each group was then reviewed further to re-examine emerging second cycle

sub-group codes, reflecting possible patterns and themes. This was done using

104 Chapter 3: Methodology & Method

multiple tactics noting: themes, patterns, contrasts, comparisons and clusters (Miles

et al., 2014). Quotes were re-reviewed several times and second cycle sub-group

codes revised several times. Quotes considered relevant to emerging themes were

highlighted, with duplication of quotes from the same participant consolidated.

Again, some quotes appeared under more than one sub-group code. The summary

table display was then used as a check for trustworthiness (Miles et al., 2014) to

ensure that key elements of data had not been overlooked and the commonality of

the elements of data extracted. In some instances this highlighted an overlooked

code, which was then included in the analysis. It also highlighted some differences

between perceptions of commonality and the data displayed, resulting in a re-

consideration of the importance of different codes.

In the second cycle coding, quotes were organised by group and second

cycle sub-group code rather than by participant. These were then reviewed by

groups and further adjustment to the main groups and sub-groups were made as

further insight and depth of meaning were realised by examining groups of data

more closely together. Further analysis focused on potential patterns and overlaps

between groups as well as sub-groups, with some groups and their meanings being

revised or amalgamated. This was integrated with frequent re-examination of

themes, patterns and concepts thought to be emerging, as well as consideration of

alternative meanings.

The original transcripts were then re-read to consolidate findings and reveal

further emerging insights. Experiences reported that appeared to dissent from

common themes were re-examined. In some instances, apparent dissent was

explained by variation in the pattern of events in another section of the transcript.

However, there were also discrepancies that could not be fully explained by the data

collected in the interviews and these were highlighted with the supporting quotes in

Addendum 4.1. Two supervising researchers of different backgrounds (nursing,

psychology) reviewed the supporting quotes and provided feedback on congruence

with findings presented. Dissenting quotes were also reviewed with a supervising

researcher.

New insights arose at every step of the analysis, with multiple re-reading of

quotes, transcripts and the summary table. This continued until it was believed that

the identified broad patterns represented the story of the raw data with no new

meanings emerging with further review. Relevant first cycle codes were retained

Chapter 3: Methodology & Method 105

along with additional complex sub-group codes emerging in the second cycle (see

Appendix K for second cycle complex codes). Further critical analysis of the broad

patterns presented by the data led to refinement into six conceptually congruent

broad themes. This included integration of mothers’ experiences into the themes, a

separate theme for mothers’ own preferences for restricted foods and drinks and

division of how mothers restrict foods and drinks into two sub-themes: restrictive

feeding behaviours and restrictive feeding communication. The final themes are

present in Chapter 4.

3.3.4.5 Reporting findings

The report of findings was organised by sensitising concepts (Blumer,

1954) and emerging themes, in order to stay true to the language and meanings

presented by the participants, rather than overlay any pre-determined perspective.

The reporting text has used the common words and terminology used by

participants wherever relevant. The use of professional terms has been avoided

because these may not directly translate into the meanings presented by

participants. Illustrative verbatim words and participant quotes were included in the

report of findings where they added meaning and depth to the descriptive text. Other

supporting verbatim quotes, representing the more complex elements of data or key

themes emerging, have been included in Addendum 4.1 to provide additional

evidence of reported findings.

Early questions, about what and why of food restriction, were more

deductive and some level of quantification made sense for these questions and the

target audience (public health and nutrition research communities). Latter questions

were more open with participants reporting various approaches and emphasising

different aspects of their experiences. While common themes could be highlighted,

quantification was not relevant where alternative approaches might render irrelevant

some aspects of participants practice e.g. how the supermarket context is managed

is irrelevant if the participant avoids taking their child to the supermarket. Reports of

findings were therefore approached on the basis of what made sense for the data

emerging and every attempt was made to stay true to the descriptions as they were

presented by the participants.

106 Chapter 3: Methodology & Method

The next chapter (Chapter 4) presents the findings for the qualitative

component of this study, which are subsequently discussed in Chapter 6 as part of

an integrated discussion with findings from the quantitative component of the study.

Chapter 4: Qualitative Findings 107

Chapter 4: Qualitative Findings

4.1 INTRODUCTION

This chapter reports the findings of the qualitative component of the study

as described in Chapter 3. To reiterate, the aim of this component of the study was

to gain a greater understanding of the dimensions of the restrictive feeding

phenomenon by interviewing a sample of 29 mothers with first born child aged 5 to 6

years old. This was facilitated by sensitising concepts (Blumer, 1954) reflecting gaps

in knowledge of this phenomenon revealed by the review of literature (see Chapter

3, Section 3.3.1). Commencing and final interview protocols are outlined in Appendix

G. The characteristics of this sample are reported in Chapter 3, Section 3.2.2.2,

Table 3.2.

This Chapter provides a summary of findings, with further supporting

quotes provided in Addendum 4.1. This report reflects the common language and

terminology used by mothers interviewed as much as possible. For quotations, the

number noted after a participants’ name refers to the transcript section and line of

speech. Findings have been presented in Sections 4.2 to 4.7 under the following six

main themes that emerged from the data.

1. Foods and drinks restricted and level of restriction.

2. Mothers’ motivation for restricting foods and drinks.

3. How mothers restrict foods and drinks: restrictive feeding practices.

Sub-theme 3a: Mothers’ restrictive feeding behaviours.

Sub-theme 3b: Mothers’ restrictive feeding communication.

4. Patterns of restrictive feeding over time.

5. Associations with other controlling feeding practices.

6. The influence of mothers’ own preferences.

Section 4.8 provides a summary of the findings for this component of the study.

108 Chapter 4: Qualitative Findings

4.2 THEME 1: FOODS AND DRINKS RESTRICTED AND LEVEL OF RESTRICTION

4.2.1 Foods and drinks targeted for restriction

Mothers made a clear distinction between foods and drinks they did not let

their child have “at all” (totally restricted) and those they limited or allowed “in

moderation”. Only two items were totally restricted, soft drinks and some fast food

outlets. A larger range of foods and drinks were restricted “in moderation” and all

mothers restricted some foods or drinks “in moderation”. Furthermore, variation in

foods and drinks least and most targeted for restriction appeared to vary more by

different foods and drinks than between mothers in this sample, with much

commonality in the differential targeting of items. The following list represents the

order of restricted foods and drinks that most commonly arose in conversation and

were emphasised by mothers.

• Soft drinks were restricted “in moderation” or totally restricted by all

mothers and usually mentioned first. (13/29 mothers totally restricted soft

drinks and a further 6/29 totally restricted cola or sports drinks only).

• Lollies and chocolates (26/29 mothers) and other sweet drinks (21/29

mothers) were commonly mentioned second and were the second most

common items restricted “in moderation”.

• Most mothers also stated that they generally restricted sugary foods “in

moderation” (17/29 mothers) but cakes, biscuits and sweet snack bars were emphasised less than the sweet items mentioned above and tended

to be raised later in conversations (14/29 mothers).

• Consumption of foods from fast food outlets (e.g. McDonalds, KFC and

Hungry Jacks) were commonly restricted “in moderation” (15/29 mothers),

with McDonalds being most highly targeted and featuring most frequently in

conversations. 4/29 mothers totally restricted visits to these outlets. More

traditional fast foods such as fish and chips were rarely mentioned.

• 16/29 mothers restricted chips (crisps) and savoury biscuits “in moderation”

but these tended to be mentioned later in conversations and with less

emphasis.

• Limiting highly processed foods including preservatives and additives

was very important for a few but mothers tended to mention this later in

Chapter 4: Qualitative Findings 109

conversations (11/29 mothers). However, the processing of foods may be

part of the reason behind restriction of the items mentioned above.

Meal items of ice cream and sweetened yoghurt were rarely mentioned in

relation to the initial question of which foods and drinks were restricted but arose as

foods restricted “in moderation” during subsequent conversations, with ice cream

being the most commonly limited dessert item.

4.2.2 Child preferences for restricted foods and drinks

Mothers reported higher levels of child interest in foods or drinks that were

restricted “in moderation” and familiar to them than for those totally restricted or

unfamiliar. Heidi’s quote reflects the general finding that children like what is familiar,

“...and sometimes he’ll come just looking for the food that he’s kind of used to.”

(Heidi, 3:54). Joanne also describes how her son’s frequent exposure to biscuits

appears to have influenced his strong preference for them, “they get hooked yeah I

think… and then they keep nagging you know wanting them all the time. He really

likes the biscuits so he’ll keep asking me if I brought them in the shopping.” (Joanne,

2:34-53). (See Addendum 4.1, Box 1 for additional quotes).

The pattern of higher familiarity associated with greater child interest in

foods and drinks was also demonstrated by the same child showing different

responses to different foods in accordance with their familiarity. Lilly was exposed to

high sugar foods a couple of times a week but had little exposure to chips. “They

might see them [chips] at parties and stuff but they’ll go past the bowl of chips

usually to the bowl of lollies.” (Victoria, 3:14). Sean had the opposite experience,

where he had been exposed to biscuits and chips on a regular basis but there was

very little mention of lollies in the interview, “...he’s not one to pig out on lollies or go

crazy... they might grab the bowl and be silly with like a bowl of chips...” (Joanne,

3:75-82).

In contrast, mothers also gave numerous examples of restricted foods or

drinks that their child had little or no exposure to being of little interest or even

disliked by their child. Soft drinks and fast foods featured strongly in these examples,

which were the only items mothers reported still totally restricting at 5 to 6 years old

(see Addendum 4.1, box 2 for additional quotes).

110 Chapter 4: Qualitative Findings

So even soft drinks, we don’t even have in the house, and it’s just not a habit that

we have, and she has actually, she’s tried soft drinks but she didn’t like the

fizziness of it. (Margot, 8:12)

...she’s been to two birthday parties at McDonalds... she’s never asked to go back.

I don’t think she particularly enjoyed what she ate... (Mhari, 3:54-58).

4.3 THEME 2: MOTHERS’ MOTIVATION FOR RESTRICTING FOODS AND DRINKS

4.3.1 Mothers’ motivation, beliefs and perceptions

Nearly all mothers emphasised that they restricted foods and drinks to

achieve a healthy diet for their child (27/29 mothers). Motivation to prevent child

weight gain was only mentioned as a secondary reason for restriction by some

mothers (see Section 4.3.3). However, most mothers elaborated that they were not

just motivated by child health but were seeking a “balance” between consumption of

“healthy” items and “unhealthy” items restricted “in moderation” (21/29 mothers).

Mothers accepted that their child would have or even wanted their child to have

some restricted “unhealthy” items “in moderation”, so they could enjoy the taste of

these foods and/or join in socially (see Appendix 4.1, Box 3 for quotes). Some also

expressed the belief that it was preferable for their child to have these items

sometimes, otherwise they were likely to desire them more (Appendix 4.1, Box 4 for

additional quotes).

I want him to be able to have them occasionally, so he feels balanced. I don’t want

him to get to the stage later in life where he says, “Oh my god, I’m not allowed to

ever have anything at home, so I’m going to binge and go crazy when I have the

chance” I think if he has a more balanced upbringing, where he has occasional

treats as well as the healthy food, I think he’ll have a healthier relationship with

food, rather than if I say, “No treats at all, ever, ever, ever.” (Tara, 2:9).

However, the desire for “balance” created a dilemma for mothers. This was

apparent in mothers’ frequent reference to their child not “missing out” or being

“deprived”, but also repeated emphasise on restricted foods only being given

infrequently and in “minimal” or “little” amounts. “But it’s quite a small, it’s quite a

miserable little piece of ice cream really” (Pip, 3:56). The emphasis on “little” also

extended to occasions, “just little occasions” (Jasmyn, 3:15), “a little side reward”

Chapter 4: Qualitative Findings 111

(Narina, 8:4). Lisa’s quote highlights this dilemma for mothers in one sentence with

reference to her child having not “missed out” but qualifying this with reference to

“minimal” amounts, “I believe everything is in moderation. She certainly hasn’t

missed out on having lollies, or having potato chips or anything. But they are so

minimal...” (Lisa, 1:6). This suggested that mothers wanted to believe that the

amount of “unhealthy” foods they allowed to prevent children “missing out” was so

small that it would not harm their child’s health. However, not “missing out” was

expanded by some mothers to include a desire for their child to experience

“overindulging” or a “sugar hit” sometimes, so that they are, “not completely

deprived from the odd sugar rush” (Natalie, 3:7). This suggested that some mothers

believed that over-consuming restricted foods is a desirable experience for their

child.

Expanding on achieving a “balance”, mothers commonly talked about the

desire to form lifelong habits (13/29 mothers) but the habits they aimed to achieve

differed for foods and drinks they totally restricted as opposed to those they

restricted “in moderation”. Mothers commonly referred to there being no “need” for

their child to have the items they totally restricted and a few wanted their child to

develop a dislike or lack preference for these items, “[fast food] ‘I’m actually very anti

that food. I’m hoping that I’ll get him to an age where the first time that he walks into

one of those places he finds the whole thing really disgusting and not want to go

back...” (Carolyn, 2:2). In contrast, mothers talked about the desire for their child to

get used to consuming restricted foods “in moderation” to achieve a ‘“balance” (see

Appendix 4.1, Box 5 for additional quotes). Carolyn’s quotes demonstrate how the

same mother might have a different aim for totally restricted foods (see quote

above) and foods restricted “in moderation”, in terms of lifelong habits.

...there have been some things which from the beginning I’ve just said “Look” yeah,

in my own head “There’s not a need for him to have this. We don’t need to

introduce it to him”... and then there are some things, you know, like the not too

much is more of a, you know, it’s okay to have a treat occasionally... (Carolyn, 2:2).

In addition to the findings related to “balance”, a number of mothers

referred to restriction being applied to prevent undesirable behaviour changes

(hyperactive, aggressive, emotionally upset), which they believed to be associated

with excessive consumption of high sugar foods (13/29 mothers). This belief

contributed to restriction decisions cited by the two mothers who did not mention

112 Chapter 4: Qualitative Findings

child health as a reason for restriction. Just over half of the mothers also mentioned

prevention of children’s teeth “rotting” as an additional reason contributing to

restricting high sugar foods and drinks.

4.3.2 Relative “nutritional values”

Mothers commonly referred to their perception of relative “nutritional

values” between foods and drinks contributing to their restriction decisions. While

there was a range of individual perceptions, there appeared to be three main

“nutritional value” comparisons (see Addendum 4.1, Box 6 for additional quotes).

• High sugar foods with “healthy” nutrients better than “just sugar”. Soft drinks were cited as having “no nutritional value” or “got absolutely

nothing”, with other high sugar items referred to as preferable because they

contained “something else” e.g. flavoured milk or a cupcake. This

assessment even extended to chocolates being preferable to lollies, due to

the milk or calcium contained in chocolate. “...a sweet treat maybe a

Freddo Frog or an Anzac biscuit or something that’s got the sugar but also

has a little bit of something else about it. As opposed to lollies and things

like that.” (Joanne J, 3:21)

• Savoury better than sweet foods. Savoury foods were commonly cited as preferable to sweet foods, although

this was sometimes influenced by mother’s belief that undesirable

behaviour changes were associated with excessive consumption of high

sugar foods. “I would say, “Please just make sure you have a sausage roll

or a sandwich or you know a little pie or whatever before you go for cake”...

even if I had a party here I wouldn’t buy sweets, I try to make it more as a

savoury.” (Joanne J, 3:67 & 2:21).

• Homemade better than bought processed foods. Bought items were commonly regarded as more highly processed and less

preferable to homemade versions of the same foods. “So any high, any

processed food at all, it doesn’t matter if it’s high sugar but really processed

foods we tend to limit severely... I’ll often make pizza myself rather than

buying pizza.” (Victoria, 1:18 & 3:104).

Chapter 4: Qualitative Findings 113

However, inconsistencies in assessment of “nutritional values” applied to

restriction decisions suggested that factors other than mothers’ assessment of

“nutritional values” must influence their restriction decisions. For example, mothers

commonly stated that they totally restricted soft drink because it was “just sugar”

and offered “no nutritional value” but there were no mothers that totally restricted

lollies, which they also suggested had “no nutritional value”. 4.3.3 Child weight and gender

Concern about child weight was not a prominent reason for restriction

raised by mothers but none reported a perceived problem with their child’s weight.

Two-thirds of mothers needed to be prompted to discuss child weight as a potential

reason for restriction, with “no” and “not at all” being common responses. Only two

of the mothers prompted to discuss child weight suggested that consideration of

future weight gain contributed to their restriction decisions. Another ten mothers

mentioned child weight gain as a future consideration contributing to their restriction

decisions unprompted, but only three of these mothers emphasised child weight as

a prominent reason along with child health. In addition, half of the mothers who

mentioned child weight as contributing to their reasons for restriction unprompted

also referred to either themselves or a close relative having a weight problem,

“…I’ve struggled with my weight my whole life, so I don’t want her to really... I’d

rather teach her better lessons than I did” (Melanie, 2:2,4). Such issues were not

raised during conversations with mothers who needed to be prompted to talk about

weight. While seven of the ten mothers who mentioned child weight as a reason for

restriction unprompted were mothers of girls, this imbalance could be explained by

the majority of mothers who referred to either themselves or the child’s father as

having a weight issue being mothers of girls. However, one mother did specifically

referred to her child’s gender as a factor related to the desire to prevent future

weight problems (see Addendum 4.1, Box 7 for additional quotes).

4.4 THEME 3: HOW MOTHERS RESTRICT FOODS AND DRINKS:

RESTRICTIVE FEEDING PRACTICES. How mothers restrict foods and drink was considered from two main

contexts, family-controlled environments and managing social influences. Mothers

commonly referred to “controlling” what they offered to their child at home and

contrasted this with social situations where they felt they had little or no control. “I do

114 Chapter 4: Qualitative Findings

all the grocery shopping, I cook all the food, I make her lunch. I have, at the

moment, with her only being six, I have full control over every single thing that goes

into her mouth... the kids have stuff out, but never at our place” (Lisa, 3:5,33). Most

mothers stated that they had a fairly consistent approach to restricting foods with

their partners, with the exception of two mothers who had separated from their

partners.

As mentioned in Theme 2 (see Section 4.3), two characteristically different

restriction intentions, total restriction or restriction “in moderation”, were commonly

applied to different restricted foods and drinks by the same mother. Mothers

operationalised these restrictive feeding intentions by applying a mix of different

restrictive feeding practices. Restrictive feeding practices involved mothers

restrictive feeding behaviours (actions) and their associated communication

(restrictive feeding communication), as reported in Sections 4.4.1 and 4.4.2

respectively. While mothers were not all the same, individual mothers generally

reported using a mix of restrictive feeding practices. There was no clear distinction

in application of practices between specific groups of mothers. The same mother

often reported applying different restrictive feeding practices, including both overt

and covert, to different restricted items in different contexts and at different times.

Variation in practices appeared to be related more to specific restricted items than

between mothers and particularly in relation to whether an item was totally restricted

or restricted “in moderation”. In addition, some mothers reported what might be

regarded as inadvertent restriction. This was where mothers stated an intention to

restrict an item at the beginning of the interview but subsequently said they did not

take any deliberate action to restrict the item because their child rarely had access

to it. However, these reports were rare in this sample of mothers and only related to

chips and cake. In these situations, children tended to only access the inadvertently

restricted item at social occasions and this situation was commonly associated with

a lack of either parent having a preference for the item (see Section 4.7).

Chapter 4: Qualitative Findings 115

4.4.1 Sub-theme 3a: Mothers’ restrictive feeding behaviours

4.4.1.1 Restrictive feeding behaviours within family controlled environments “Don’t Buy”

When mothers were asked how they restrict foods and drinks, the most

common initial response was that they “don’t buy” or bring these foods and drinks

into their home. However, subsequent conversations revealed that this usually

meant they “don’t buy” these foods and drinks “often” or they buy limited amounts.

Some mothers also elaborated that this practice was intended to help them avoid

“giving in” to their child’s demands for these foods at home, “I don’t have it in the

house. So they can whinge and cry all they want, it’s like well, ‘It’s not there, so what

are you going to do about it?’” (Heidi, 5:5) (see Addendum 4.1, Box 8 for additional

quotes).

Some mothers avoided taking their child down the supermarket aisles

containing restricted items so that their child did not ask for them. “…there’s always

something in every aisle that he asks for that I don’t particularly want to buy, or it’s

something that I would normally limit...” (Kate, 3:72). Mothers spoke about feeling

“bad” if they refused their child’s request for restricted items, so it was preferable to

avoid these items. Penny elaborated on why she avoided the aisles with restricted

items. “…if I don’t give it to them they’re upset. So, yeah, and then if I give it to them

I’m giving in. So I just don’t bother with that situation.” (Penny, 3:138). Other mothers

emphasised the need to be “firm” and say “no” to requests in the supermarket, but

also commonly referred to “giving in” to their child’s requests on occasions. “I just

say no... But Lily she’ll try it on and she’ll try and ask me and she’ll badger me you

know and occasionally I give in like okay yeah.” (Victoria, 3:112 &114). In addition,

some mothers avoided taking their child to the supermarket altogether but commonly

still bought a limited amount of restricted items and presented them to their child at

home (see Addendum 4.1, Box 9 for additional quotes). However, the majority of

mothers who took their child to the supermarket or shops also reported that they

commonly gave them a food they restricted “in moderation” as a “treat”. This was

often explained in relation to the child having to endure the visit or encouraging them

to behave well and that visits were infrequent, so the “treat” was infrequent. “And

yeah because it is only occasionally he often, he usually does get a treat like a little

chocolate when we go to the supermarket… and it’s usually only yeah once a

116 Chapter 4: Qualitative Findings

fortnight or once a month. I wouldn’t do it if it was like you know once or twice a

week.” (Melissa, 3:55).

Mothers’ Restrictive Feeding Behaviours

Mothers reported restrictive feeding behaviours involving a mixture of set

“rules”, flexible judgement of limits and avoiding access.

“Rules” and flexible judgement

“Rules” and flexible judgement used in family-controlled environments

predominantly reflected mothers’ motivation for “balance” between “unhealthy” foods

restricted “in moderation” and unrestricted “healthy” foods. They commonly ensured

that their child had sufficient good nutrition before giving a restricted food “in

moderation” or they compensated at home for excess amounts of restricted foods

given “in moderation” or likely to be consumed during outings or social events. They

flexibly judged the “balance” of foods restricted “in moderation” and unrestricted

“healthy” foods over the day or week as a deliberate strategy (see Addendum 4.1,

Box 10 for further quotes). Mothers said they restricted amounts consumed “in

moderation” by: limiting the number, portion or packet size of an item, diluting juice

or just saying “that’s enough” when a certain limit had been reached. So amounts

were sometimes predetermined and sometimes gauged by the mother during a

situation, with children asking for or taking repeated amounts until their mother said

“no”.

Mothers also emphasised the importance of setting consistent “rules” or a

“routine” at home, about when and where their child had access to restricted foods

or drinks “in moderation” including: specific times of the day, after a meal, certain

times of the week or on special or traditional occasions such as: birthdays,

Christmas, Easter or for special achievements (see Addendum 4.1, Box 11 for

additional quotes). However, the most common “rule” mothers mentioned was

related to children needing to eat their dinner before accessing dessert, which was

also linked to mother’s desire for “balance” (see Section 4.6.2). In contrast, one

mother rejected the use of “rules” for restriction “in moderation”. She believed that it

would lead to an expectation and preferred to give unexpected “surprises” (Karren,

2:8). Another mother took a similar approach suggesting that, “…it’s not a special

treat anymore if every time we go to the supermarket you get an ice block or a

Chapter 4: Qualitative Findings 117

chocolate bar...” (Victoria, 3:114). While these two mothers only used flexible

judgement, most mothers combined flexible judgement with some “rules” or routines

to achieve a “balance” between restricted foods given “in moderation” and

consumption of “healthy” foods.

...only allowed to have dessert every second night … lollies and chocolate is not

sort of a fixed rules... sometimes just as an after school snack, sometimes as an

after dinner. Probably more on the weekends… than during the week. And it’s you

know it’s not all the time that we have them. (Melissa, 1:8 & 3:4).

But it’s not set in... we go with the flow in terms of that, and it’s whatever David and

I feel... you’ve been pretty good and you know, you’ve eaten your fruit and you’ve

had this and that, and yes you can have something out of the box”. So it’s not set

in stone... The only sort of regimented time that they know that the can choose

something out of the box and put in their bag is for after Jiu Jitsu. (Carolyn, 3:

14,22).

Avoiding Access

While a few mothers mentioned that they communicated “rules” to their

child about a food or drink that was totally restricted, avoiding access was the

restrictive feeding behaviour most commonly used for items that were totally

restricted. Mothers also commonly avoided child interest in items they restricted “in

moderation” by keeping them out of sight or by offering alternative “healthy” options.

They commonly said that if their child cannot see the restricted items they do not

tend to ask for them or they forget about them, “out of sight, out of mind” (Kate,

3:52). Lolly bags brought home from parties or given as gifts were commonly treated

in this way. Mothers exclaimed that party bags and gifts from relatives were the

main origin of lollies getting into the house, which were subsequently given as

“treats” at home. They commonly reported initially throwing out some of the items

based on their perceived relative “nutritional values”. They subsequently allowed

their child to have some lollies as limited “treats” but then threw away the remaining

items when their child forgot about them (see Addendum 4.1, Box 12 for additional

quotes). Mothers also reported avoiding taking their children to specific fast food

outlets. Some avoided these outlets altogether (i.e. totally restricted), with one

mother even turning down invitations to parties to avoid the food outlet. Where visits

were avoided “in moderation”, mothers imposed limitations on the frequency of visits

118 Chapter 4: Qualitative Findings

(e.g. once a month) and access was commonly presented as a “treat” or reward

(see Section 4.4.2.1).

With regard to the practice of offering alternative “healthy” options, fruit was

commonly referred to as the alternative snack and water as the alternative to

sweetened drinks, which were the same items mothers commonly encouraged their

child to consume i.e. pressure to eat (see Section 4.6.1) (see Addendum 4.1, Box

13 for additional quotes). However, alternative “healthy” options sometimes involved

making healthier homemade versions of restricted foods their child liked, such as

pizzas, hamburgers, cakes and slices (see Section 4.4.2.1 for quotes). Tara also

suggested that such practices would be, “making them feel like they’re indulging

sometimes...” (Tara, 3:2). Mothers also used a practice of requiring their child to eat

a “healthy” or savoury food first before accessing restricted foods, which was also

commonly used with the intention of reducing children’s consumption of restricted

foods or to achieve a “balance”.

Family Outings

Greater access to items restricted “in moderation” was commonly

associated with family outings such as: visits to shopping malls, long car journeys,

eating out and holidays. Mothers reported being unconcerned about access to foods

restricted “in moderation” on these family occasions due to their infrequency.

4.4.1.2 Managing social influences

Mothers commonly found children’s parties, the school environment and

visits to grandparents challenged their approach to restriction and they often spoke

about their lack of “control” in relation to these social influences. “Whatever goes

into your child’s mouth at home is to do with the parents. It is a parental issue, it’s

not a child issue. I think outside of the home it is much, much harder... I don’t know

what the secret is, yet...” (Tara, 5:2).

Children’s parties and other social occasions

All mothers said they were more lenient at children’s parties than at home,

with most saying that they did not put any restrictions on what their child ate. They

justified their leniency by the infrequency of parties being unlikely to have an impact

Chapter 4: Qualitative Findings 119

on their child’s overall health, “…if he binges at a party, it’s a once off... it’s not

detrimental to his health in the long term, whereas if we were doing that every day,

and that was part of our home life then perhaps it would be” (Kate, 3:30).

However, most mothers also said they did or would intervene if they saw

their child having an excessive amount of items they restricted “in moderation”. They

commonly reported directing them towards “healthier” or “savoury” food options or

other party activities. A few purposely let their child “overindulge” and experience a

“sore tummy” or feeling “sick” to teach them the consequences of their actions.

Mothers said that the intention of this approach was that their child would not

overeat next time. “Look, you see, this is what happens if you have too much of it.

You can have some of it, but you’re not allowed to have a lot of it, you know?

Because it does make you a bit sick” (Melanie, 3:26). Others that said they did not

intervene elaborated that their child’s consumption was never a problem and some

said that their child was not that interested in party food so they did not need to

intervene. Erin also suggested a potential association between her daughter’s lack

of regular access to the types of foods served at parties with her daughter’s lack of

interest in such foods, as well as her own lack of interest in these foods.

I’ve never been a big soft drink drinker or never a big sweets eater so I just tend

not to buy it. I tend not to buy biscuits and that sort of thing either… I’m not sure if

it’s affected anything but I’ve noticed at parties that... she’ll have a little bit, and

then she moves on. You know she might eat half a piece of cake and give it over to

me, and say you know ‘I’ve had enough’... (Erin, 3:4,8).

Mothers also pre-empted the potential excess consumption of restricted

foods at parties and attempted to limit this by: talking to their child before the party

about eating savoury or “healthy” foods as well; feeding their child “healthy” foods

immediately before the party so they ate less of the party food; or compensating by

providing more “healthy” foods at home during the day or week before or after the

party. Concern about over eating at parties was also related to mothers’ beliefs

about the association between excess high sugar foods and undesirable behaviour.

And for some, limitations were related to sharing and manners; not wanting their

child to be the one at the party table eating all the food. “...it’s not only health, but it’s

also sharing... So it’s not my children hovering over the brownies at church,

preventing anybody else from having one. Because that has happened...” (Pip,

3:16).

120 Chapter 4: Qualitative Findings

Mothers talked about wanting to let their child join in with peers and made

references to not wanting to be a “mean mummy”, “bad guy”, “nasty parent” or “party

pooper” in relation to restricting foods in social situations. Some mothers referred to

a past experience of intervening, ruining the enjoyment of the party for their child

(see Addendum 4.1, Box 14 for additional quotes).

...at first I was, you know, trying to be very strict about limiting that, and you know,

‘One cookie, and have one bit of chocolate, and one bit of this’ and it just made me

feel like I was the bad guy throughout the whole party... it wasn’t fun for them, and

it wasn’t fun for me... (Tara, 3:4).

Mothers reported being more restrictive during other social occasions (such

as getting together with a group of friends or extended family) than at children’s

parties, although less restrictive than at home. They commonly said that other social

occasions did not tend to create the same issues as children’s parties because the

food was usually healthier and quantities of restricted foods more limited. In these

situations, mothers reported practices of: limiting the amount of snacks eaten before

a meal served at these occasions; cutting cakes into small pieces; and emphasising

to their child to share limited amounts of restricted foods with others. The school environment

Lessons taught in school about healthy eating and healthy lunchbox

policies at schools were regarded as supportive by mothers. However, they often

reported dissatisfaction with the limited time allowed for their child to eat, causing

them to revert to providing less “healthy” foods or tuckshop/canteen30 lunches to

“bribe” them to eat or get them to eat something (see Addendum 4.1, Box 15 for

additional quotes). It was common for mothers to include an item they said they

restricted “in moderation” in their child’s lunchbox, either on a daily basis or a

number of times a week, with some highlighting that this was included as a “treat”

(see Addendum 4.1, Box 16 for additional quotes). However, mothers also reported

children asking for both “healthy” and “unhealthy” foods that they had seen in other

children’s lunch boxes.

30 Referred to as “tuckshops” in Queensland and “canteens” in South Australia.

Chapter 4: Qualitative Findings 121

The integration of healthy eating policies across school environments

seemed to vary. Some mothers reported social cultures of children wanting to join in

with ordering “unhealthy” tuckshop/canteen meals or queuing at the

tuckshop/canteen to purchase commonly restricted foods and drinks after their lunch

(see Addendum 4.1, Box 17 for additional quotes).

“...he was originally getting a wrap and he’s worn me down to now getting a hot

dog or chicken nuggets” (Kate, 3:60).

“...she just wants to buy what the other kids have” (Melanie, 4:22,28).

At some schools, teachers were also providing lollies and other commonly

restricted foods and drinks as rewards or “treats”. However, these descriptions

contrasted with other reports, where healthy foods where emphasised across the

whole school environment. One mother reported that, “...because he’s seeing other

kids eating the healthy stuff, he’ll, he’s actually trying more healthy stuff than he

would have.” (Natalie 3:154,156).

Grandparents and relatives

All mothers reported that their child had more of the food they restricted “in

moderation” when visiting grandparents and relatives. Some mothers reported

conflict, with grandparents believing they had a “right to spoil” their grandchildren.

This commonly resulted in mothers giving in to or compromising with the

grandparents or relatives, “...my mum keeps saying ‘But I’m allowed to spoil them’...

Yeah we indulge her rather than the children.” (Natalie, 3:98,100). Other mothers

were neutral or even positive about grandparents giving their child “extra treats”,

either relating it to their beliefs about a traditional role of grandparents or their own

memories of childhood. “I grew up with my grandparents you know always, I always

felt like I had some little treat that they’ve given me... and I thought that was quite

lovely and I certainly don't want to take that away from them.” (Veronika, 3:158)

(see Addendum 4.1, Box 18 for additional quotes).

122 Chapter 4: Qualitative Findings

4.4.1.3 Mothers’ experiences of restrictive feeding Realities of everyday life and guilt

Mothers reflected on how their good intentions of feeding “healthy” foods to

their child had been harder to achieve in reality and some mothers openly

expressed “guilt” or “disappointment” with themselves for not achieving the dietary

standards they had hoped for their child (see Addendum 4.1, Box 19 for additional

quotes).

…they’re born and they’re perfect, and you know, it just seems like a lot of the time

it’s just downhill from there... And I want to keep as much perfection as possible.

(Carolyn, 2:8,10).

...you have a philosophy about how you’re going to parent, and the reality is once

the child comes... you’re not just dealing with an idealism, you’re dealing with a

human being with absolute human emotions and their own mindset, and you think

“I’m going to feed my child carrots and pumpkin, and they’re going to eat meat and

all this stuff” and then all of a sudden the child only likes, like, two vegetables... I

know a lot of parents fall into the trap of succumbing to the want of the child...

because I did. (Karren, 4:10).

Mothers’ desire for “balance” also appeared to be associated with “guilt”

about providing “unhealthy” foods, which was evident in a number of uncanvassed

aspects of conversation. Mothers counter-balanced conversations about giving

restricted items by subsequently emphasising the “healthy” foods they also give to

their child, “I should list the vegetables they eat just to make myself feel better.” (Pip,

3:38). In addition, mothers’ descriptive language often did not reflect the frequency

of child access they later revealed. As mentioned in Section 4.4.1.1, they often

referred to not buying restricted foods but subsequently described buying limited

amounts. In addition, mothers frequently referred to giving “minimal” amounts (see

Section 4.3.1), as well as emphasising that they “don’t” give or do “not often” give

restricted foods and drinks, which was sometimes revealed to mean several times a

week.

…they don't get any really high sugar things. Like processed sugar foods like

chocolate or biscuits, they get that well a couple of times a week maximum.

(Victoria, 1:18).

Chapter 4: Qualitative Findings 123

...we don’t tend to have dessert as a family. We might have it two or three times a

week, if that. (Pip, 3:20,40,42).

It was also common for mothers to make reference to their child’s desire for

these restricted foods being in line with social norms and hence deflecting from their

individual parenting decisions, with comments such as, “like all children”, “she’s like

every other kid”, “they’re normal kids”, “we’re all the same”, “we all do it”. (see

Addendum 4.1, Box 20 for additional quotes).

Feelings of “guilt” associated with mothers’ dilemma of “balancing”

enjoyment of restricted foods and children’s health may also have influenced the

constructed realities presented by mothers in interviews. The versions of restrictive

feeding presented in the first part of interviews tended to emphasise the positive

aspects of the mothers’ intentions or experiences with restrictive feeding but when

asked to reflect on their past experiences some revealed less positive experiences,

“And it doesn’t mean that we’ve never broken a rule, we’ve broken rules... when my

third one was born... I needed a little bit more quiet so they’ve got a little bit more of

what they wanted.” (Veronika, 5:2). These reported experiences suggest that

restrictive feeding is not only inherently inconsistent as mothers’ deliberately adjust

their practices to achieve a “balance”, but that the realities of everyday life are likely

to challenge their abilities to achieve their intentions. Feelings of “guilt” and self-

disappointment may also have resulted in selective reporting towards more positive

experiences and intentions rather than reflecting the range of mothers’ experiences.

Firmness and consistency

Despite the realities revealed, mothers’ emphasised the importance of

being “firm” and consistent about children’s access to foods or drinks restricted “in

moderation”. They generally reported what they regarded as desirable child

behaviour when access to restricted foods was associated with a consistent “rule” or

regular routine. However, some mothers perceived that such a routine had become

an undesirable “habit” or “expectation”, associated with places, times or occasions

(see Addendum 4.1, Box 21 for additional quotes).

124 Chapter 4: Qualitative Findings

So when I get the petrol I’ll say oh do you guys want a Kit Kat or get one but then

you’re sort of starting every time you go to the petrol station they’re expecting it. So

maybe yeah things like that you shouldn’t start because then you fight a battle

every time you… oh a petrol station there, almost a given that you’re going to get

the Kit Kat or a packet of chips. (Joanne, 6:4).

Such conditioning or “expectations” were also evident when a regular “rule”

or “habit” was not followed. Carolyn reflected on how her children became confused

when she veered away from a “rule” regarding access to restricted foods, “‘No, look,

you’re not having something out of the box today. I’ve got these really nice bananas’

or whatever here, that’s what we’ll pack instead. That usually causes a little bit of

consternation...” (Carolyn, 3:24). These findings suggest that while “rules” and

consistency may achieve a consistent child response, whether this is regarded as a

desirable situation depends on the mothers’ perception.

Furthermore, while mothers commonly referred to being “firm” about

restricting foods the same mothers also cited incidents of “giving in”. Lisa even

referred to being firm about their approach to “giving in”, “...my word is law, so once

I’ve said no, that’s the end of it. I mean, she can keep asking if she wants... my

husband and I are very, we’re very firm... if we’re going to back down, we need to

both agree on it.” (Lisa, 3:5,11). Other mothers reflected that “giving in” to their

child’s requests had led to subsequent adverse child responses of “whinging”,

“complaining” or “persistently asking” for the item in subsequent situations (see

Addendum 4.1, Box 22 for additional quotes).

I will say no to something, no, no, no and one day I’ll accidentally say yes. Oh my

God try to go back to no after that. You know it’s definitely challenging... and before

you know it they get to the age of five and six and you, as the parent, are more

conditioned than the child. (Veronika, 5:2-10).

He kicks up a bit more of a fuss about not being allowed to have lollies...

sometimes I say no then it will be you know moaning and complaining... every now

and then I’ll surprise them by saying yes. I think most of the time they expect me to

say no. (Tegan,3:4 & 8:2).

Two mothers also reported deliberately giving inconsistent “surprises” to

avoid “expectations” but reported similar adverse child responses.

Chapter 4: Qualitative Findings 125

4.4.1.4 Summary of mothers’ restrictive feeding behaviours. Table 4.1 summarises the range of restrictive feeding behaviours reported

by mothers in this study.

Table 4.1

Restrictive Feeding Behaviours Commonly Used by Mothers in Different Contexts

Family-controlled environment Managing social influences

At home Children’s parties Rules • Limit when offered by “rules” or “routine” eg. time of day,

day of week, after meal, special occasions. • Must eat dinner before dessert. • Child not allowed to have restricted food eaten by

parents, ”mummy’s and daddy’s food” e.g. chips. • Limit number, portion or packet size of restricted item. Flexible judgement • Flexibly judge the amount of restricted food consumed

over the day or week to achieve a “balance”. • Give “healthy” foods prior to accessing “unhealthy” foods. • Limit when offered by “surprises”. • Compensate with “healthy” foods at home for “unhealthy”

foods at parties and social events. • Amount gauged by mother by saying: “no”, or “that’s

enough” after a certain amount consumed. Avoiding access • Avoid access at home: don’t buy often, buy limited

amount, don’t buy at all. • Keep restricted items out of sight e.g. lolly bags. • Throw some gifted lollies away. • Offer healthy options instead of restricted items e.g. fruit. • Offer homemade healthy versions of restricted foods e.g.

pizza, cake. • Mother avoid negative modelling by consuming restricted

food out of child’s sight. • Avoid (or limit) visits to fast food outlets. • Diluting juice or soft drink. Visits to the shops • Avoid taking child to supermarket. • Avoid supermarket aisles containing restricted items. • Say “no” and do not “give in” when child asks for

restricted item.

• Not put any restrictions on what child eats.

• Give meal of “healthy” foods before going to party so full.

• Tell child to eat a “healthy” or “savoury” food before sweet foods.

• Direct towards healthier or savoury foods.

• Direct away from food to party activities.

• Let child overindulge until they feel sick to teach consequences.

• Child not interested in party food, not need to intervene.

Other social occasions • More restrictive than at parties

but less than at home. • Limit amount of snacks

consumed before a meal is served.

• Emphasise sharing to their child • Cut cake into small pieces. School environment • Include a limited amount of

restricted item in lunchbox. • Limit the frequency of tuckshop

meals. • Limit money for tuckshop

purchases. • Teachers providing lollies and

other restricted items. Grandparents and relatives • More restricted food accessed

when visiting grandparents. • Grandparents feeling they have

a right to “spoil” their grandchild with restricted foods.

• Tell grandparents to limit restricted foods.

• Allow child to have whatever grandparents want to give.

Eating out • Choose restaurants with healthier foods. • Feed healthy food before go out to eat. • Compensate for restricted food consumed when out with

healthy food given at home over day or week. • Avoid specific fast food outlet (either totally or limited

visits). • Turn down party invitations at fast food outlet. Other family outings • Limit specific restricted foods to when on holidays or

away. • Limit specific restricted foods to long car journeys.

126 Chapter 4: Qualitative Findings

4.4.2 Sub-theme 3b: Mothers’ restrictive feeding communication 4.4.2.1 Mothers’ verbal communication

All mothers said they spoke overtly to their child about foods and drinks

they restricted “in moderation”. The majority said they told their child that these

foods or drinks were “unhealthy” and not good for their bodies, with some explaining

consequences such as: a “sore tummy”, “feeling sick” or becoming “fat”. However,

when describing conversations with their child about the foods they restricted “in

moderation”, mothers commonly also used language with positive connotations

about the restricted food such as, “treats” (23/2931 mothers), “special occasion”

(7/29 mothers) or “party” (3/29 mothers) foods, along with reference to them tasting

good. In contrast, mothers described conversations with their child about

unrestricted foods using more factual language such as, “healthy” or “good for your

body”. Lisa highlights this contrast, “She understands that fruit and vegetables are

good... and ice creams and ice blocks in summer are for a special treat.” (Lisa, 3:91)

(see Addendum 4.1, Box 23 for additional quotes). One mother also reflected that

her reference to “healthy” and “strong” didn’t mean much to her child at this age.

“…‘You know, you need to eat healthy to grow up big and strong’... Look it doesn’t

really seem to mean much to her, being six.” (Jasmyn, 3:2,4).

One of the most dominant features of conversation arising from these

interviews was mothers reference to giving the foods they restrict “in moderation” as

“treats”32, which was uncanvassed and repetitive. “Treats” were also commonly

described by mothers as high in sugar, highly processed and “unhealthy”, although

some processed savoury foods and fast foods were also mentioned (see Addendum

4.1, Box 24 for additional quotes). A couple of mothers highlighted the significance to

their child of labeling foods as “treats” or “special occasion” foods, “...if you call it

that, call it a treat, they’re perfectly happy to have strawberries instead of a Mars

bar.” (Pip, 3:34). However, there were few reports of healthier foods being presented

as a “treat” or referred to as tasting good. Examples included rarely given or

expensive items, such as strawberries or sushi, as well as favourite meals.

Furthermore, some mothers used negative language to talk down the desirability of

31 Denotes number of participants to use this word. 32 This includes similar terms used by mothers such as “special occasion” or “party” foods. These terms were commonly used interchangeably by mothers. The word ‘treat’ was selected to represent this group of terms because it was most commonly mentioned.

Chapter 4: Qualitative Findings 127

these healthier “treats”, “...he still thinks milk is, like plain milk is like a treat... my

poor, sad son...” (Heidi, 2:10). Other mothers described the desirability of healthy

“treats” in terms of their resemblance to a restricted food.

...So it’s all homemade, and healthy, but for them it’s a treat because it’s, oh hamburgers. (Natalie, 3:9). ...they love making, like, homemade pizza... they think of that as fast food I suppose. (Lisa, C:4). ... and telling them also that you know, “This is a healthier version of that food that

you really like”... So making them feel like they’re indulging sometimes... (Tara,

3:2).

One mother reflected that her children had learnt that her reference to

“treats” was synonymous with “unhealthy” foods. “...I do call sushi a treat, even

though it’s a healthy food... and my boys pull me up on that. Because they say,

‘That’s not a treat, that’s healthy’... So I think when they hear the word treat, they

think of something that might not be so healthy for you.” (Tara, 3:54).

Discussion of food and drink items mothers totally restricted (fast foods and

soft drinks) tended to be different. Mothers commonly reported using negative

language when conversing with their child about totally restricted fast foods, such as

“fat shop” or “bad foods”. Reference to soft drinks was more commonly about there

being “no need” for their child to have these drinks at their age, supported by

negative statements about these drinks such as: “no nutritional value”, “not good for

you”, “full of sugar” or “rots teeth”. Alternatively, they reported minimal conversations

with the child about these items.

The impact of mothers’ language was highlighted by Carolyn, a linguist,

who specifically mentioned that without a label her child still had no concept of a fast

food outlet that she totally restricted.

...early on I made a decision that if something doesn’t have a name, it doesn’t

really exist in a child’s mind. So as an example the McDonalds thing. We never

talked about it, we never pointed it out. We just never really referred to it... my

children never talk about McDonalds, Hungry Jacks, KFC... and I think it’s worked

for me. (Carolyn, 5:4).

128 Chapter 4: Qualitative Findings

In contrast, Carolyn labelled the high sugar foods she restricted “in

moderation” as a “treat”. “...we label it as a sometimes food or a special treat, we

talk about things being high in sugar, and that, that’s not healthy for you.” (Carolyn,

3:2). This demonstrates that the same mother might use a covert approach for foods

she totally restricts but overt communication with positive connotations about a food

she restricts “in moderation”.

Different patterns of communication were also associated with the

application of the three different groups of restrictive feeding behaviours, “rules” and

flexible judgement or avoiding access (see Section 4.4.1.1). “Rules” and flexible

judgement were generally conveyed by overt communication and predominantly

with positive connotations about the items that were restricted “in moderation”. The

few examples of overt “rules” conveyed with negative connotations tended to relate

to items that were totally restricted. However, behaviours of avoiding access were

used for both totally restricted items and items restricted “in moderation” and were

applied either covertly or with overt communication. Examples of covert

communication (i.e. no communication) associated with either total restriction or

restriction “in moderation”, included avoidance of supermarket aisles containing

restricted foods or not taking the child to the supermarket at all (see Section

4.4.1.1). However, where items were restricted “in moderation” the practice of

avoiding the supermarket tended to be combined with overt communication about

the restricted items when later presented to the child at home. Furthermore,

examples of avoidance of access to fast food outlets included both total restriction

and restriction “in moderation”. Where avoidance was associated with total

restriction, mothers tended to either not talk to their child about these foods or make

negative references to the outlet (see Section 4.4.1.1). Where visits were avoided

“in moderation”, mothers were more likely to report overt conversations about the

limitations, as well as limited visits commonly being presented as a “treat” or reward.

You know they’ll be just little occasions where I might be “Alright, you know, have a

treat” ...like to go to McDonalds for a play, and then get a happy meal and stuff,

which I’m fine with, like as long as it’s not too often. (Jasmyn, 3:16).

4.4.2.2 Mothers’ non-verbal communication (modelling eating behaviour)

The most common practice mothers reported in relation to non-verbal

communication was to avoid negatively modelling the consumption of restricted

Chapter 4: Qualitative Findings 129

foods to their child. However, mothers’ reported consuming restricted foods and

drinks out of their child’s sight, suggesting that they are less strict with themselves

but also expressing “guilt” associated with these dual standards (see Addendum 4.1,

Box 25 for further quotes).

I have a little spot where I have chocolate that they don’t know about... Or when

they’re looking the other way, if I need a piece of chocolate to revive me after work.

Yeah. So I’m yeah, less strict with me than I am with them. (Pip, 5:5).

I know it sounds really terrible, we’re the parents that only do it when they’re not

watching us. We like, hide. It’s terrible... we’re both terrible parents, that actually

eat it, like after they go to bed. So that they don’t see us. (Melanie, 3:58, 60).

In relation to this, mothers commonly cited incidences of being “caught” by

their child and sharing the restricted food with them. This suggests that their

intentions of not negatively modelling the consumption of restricted foods and drinks

are not always achieved, “...when you get caught and feel obliged not be hypocritical

and let them have it...” (Narina, 3:26). In contrast, a few mothers said they

consumed totally restricted items in front of their child without letting them have any.

They generally told their child that this was “adult” or “mummy and daddy’s” food or

drink and Lisa’s quote reflects the essence of mothers’ reports.

kids don’t have to do it just because parents are. It is ok for kids to grow up seeing

mum and dad drink Coke or fizzy drink or cordial if that’s what they want to. But it

doesn’t mean the kids are allowed. (Lisa, 5:4).

Interestingly, these mothers also mentioned that their child showed little

interest in the items associated with this practice, at least at this age. “We’re lucky

they haven’t shown much interest in them and we’ve never offered them, they’ve

only had milk and water... But they can see us having a drink of Coke...” (Joanne,

5:4,12).

In addition, some mothers reported that they modelled and reinforced

consumption of restricted foods “in moderation”. “...I just explain to him that they’re a

treat so, that chocolate... it’s not something that mummy and daddy would eat all the

time because that’s not good for our bodies, so you know, you don’t eat them all the

time either.” (Kate, 3:14).

130 Chapter 4: Qualitative Findings

4.5 THEME 4: PATTERNS OF RESTRICTIVE FEEDING OVER TIME

4.5.1 Changes in restrictive feeding over time

Most mothers reported that they had become more lenient with restriction

of foods and drinks as their child got older. They commonly said they had avoided

introducing restricted foods for as long as possible, with many reporting that their

child had not accessed these foods at all up until about 2 to 3 years old. Mothers

described how it was easier to restrict foods when their child was younger because

they had “no concept” of restricted foods, they “didn’t know” about them and “didn’t

ask” for them (see Addendum 4.1, Box 26 for additional quotes). They referred to

their child’s expanding social world and their growing awareness of what others and

peers ate as they matured, which had influenced mothers to become less restrictive,

at least in social circumstances. They also reported parties, social events and gifts

from relatives proliferating when their child was around 3 years old, with

consequential greater access to associated foods such as lollies and chips. Claire’s

quotes capture the common essence of what mothers reported (see Addendum 4.1,

Box 27 for additional quotes).

...as a 2 or 3 year old he really had no concept of it because it was just never there

for him... I just wouldn’t even give them any sort of junk food and if people try and

offer it to them usually you’re there at that age, just say ‘no thank you. (Claire, 4:20

& 5.14)

...as his world expanded – going to Kindy and getting friends and all the rest of it

then yeah I guess his food did as well... the peer group sort of comes into it and the

social thing... you know they’re... only kids once and you’re at a party I say sort of

let them go with the group. (Claire, 4:20 & 5.16)

One mother provided a different perspective on the transition to restricting

“in moderation”. She elaborated that restricting foods “in moderation” was not a

feasible option when her child was very young because she didn’t understand the

concept of limits, only “yes or no”, but as her child became older she could introduce

restricted foods “in moderation” without adverse behaviour responses.

…she’s old enough to get it, that if I give her some, then that’s it. Whereas, when

you’re, like I said when you’re littler, you don’t really understand that there’s a limit.

You know it tastes good, you just want to eat it... (Helen, 4:2).

Chapter 4: Qualitative Findings 131

In contrast, to the common trend of becoming more lenient, some mothers

reported a different pattern of restrictive feeding over time. Three mothers said their

approach to restricting items had not changed but the amount their child consumed

had increased as they aged. Five mothers said that they had allowed restricted

foods to be introduced but reverted to greater restriction again when their child was

older. Three of these mothers stated that the reason for this change was related to

an increase in their own understanding about nutrition and/or changing dietary

needs of another family member (see Addendum 4.1, Box 28 for additional quotes).

The other two mothers described how earlier introduction of restricted items had led

to adverse child eating behaviour, which they redressed with greater restriction as

their child became older.

When she was little, she enjoyed sweets, but because I’d, I would only offer it to

her out of the blue, she appreciated it. But as she’s got older... it became quite

obsessive. I had to control her spending her pocket money to once a month...

(Karren, 8:16).

...when we do go to a birthday party she does tend to over indulge... she has been

definitely becoming more persistent in asking for it [sugary foods] and things, I

have had to become more strict about it. So that’s been my reaction to it, to limit it

even further rather than give in. (Victoria, 3:64 & 4:4,6).

4.5.2 Experiences of restrictive feeding over time

Mothers were invited to reflect back on their experiences over time and give

examples of what they believed worked well and not so well. This question was

phrased in terms of advice they would give to a new mother. The most prominent

piece of advice mothers said they would give to a new mother was to avoid

introducing (totally restrict) foods and drinks you do not want your child to have for

as long as possible. They reflected that once their child had been introduced to a

restricted food or drink item they wanted it more and it was hard to change (see

Addendum 4.1, Box 29 for additional quotes).

132 Chapter 4: Qualitative Findings

...if you give in once and you start buying like LCM’s and that sort of stuff it’s very

hard to break the pattern... I once bought I don’t know, these Scooby Doo snacks

and you know, from then on, you know, I always get asked for those... once it’s

introduced and they know what it is and they know that they like it then you’re sort

of increasing the pressure to keep buying it because they recognise the packets on

the shelf. (Claire, 6:2,4).

...people would always say to us, like “How come she doesn’t ask for it?”... and I

said to them “it’s because she doesn’t know what’s in the packet... when she knew

what was inside, then she started asking”... once she tasted sugar, that was it for

us... once she knew about it, then we did have to speak to her about it... let her

know that she wasn’t allowed to have a lot of it. (Melanie, 4:2,10 & 5:14)

In addition, a number of mothers provided uncanvassed reports comparing

responses to restricted foods between the study child and younger siblings. These

reports indicated a pattern of greater child interest associated with earlier exposure to foods restricted “in moderation”. While the most common pattern reported was of

younger siblings being exposed to restricted foods earlier than the study child, there

were a few examples where the younger siblings had been exposed later and the

same pattern of earlier exposure and comparative higher interest was reported in

relation to the older study child (see Addendum 4.1, Box 30 for additional quotes).

Pip describes the behaviour of her study child at a party in comparison to her

younger daughter who was exposed to restricted foods earlier.

...he’s not the sort of child who would rush off at a party and secretly grab a handful

of snakes, and eat in a corner somewhere. My daughter is, but he’s not... my littler

one is more in sort of the “Pleeeeeeeeeeease” like... she is probably the one that

demands things more than Miles... the minute he had chocolate at three, she was

only eighteen months, so she had all these things way before he did. (Pip,

3:60,88,90 & 4:10)

Margot and Natalie also provided examples of how earlier introduction to

healthier options positively influenced their child’s food preferences away from

restricted foods.

Chapter 4: Qualitative Findings 133

...she wasn’t ever introduced to cakes or biscuits and chocolates until she was, say,

two, and because she ate the other stuff, she kept eating it... she’s not actually a

big cakey person. So even though I made all these muffins, and say “You can have

them for recess and lunch”. She’s like “I’d rather just have apple slices”. (Margot,

5:2 & C:10).

...if we do go out and we’re having, say lunch in a mall... he was only allowed

Subway, and now he chooses it. Yeah, so when he’s confronted with, you know, all

those bright lights, like you know, in the candy shop in a mall sort of setting, he

wants Subway... (Natalie, 3:166,168).

However, while mothers reports appeared to suggest that children’s early

exposure and familiarity with restricted foods and drinks was associated with the

development of their preferences for them (also see Section 4.2.2), some of the

same mothers subsequently stated a belief that giving a food “in moderation” is

preferable to totally restricting it, otherwise children will want it more (see Section

4.3.1). A few mothers clarified that their apparent contradictory comments referred

to different points in time, with a change to giving “in moderation” being influenced

by their child’s developmental awareness and socialisation (see Addendum 4.1, Box

31 for additional quotes). However, a number of the mothers who stated this belief

also reported that they still totally restricted soft drinks.

Furthermore, reports of an association between high restriction and

children’s over indulging eating behaviour were only based on mothers’

observations of other children, “...I think that it’s important that they do get to have

treats... I’ve seen other children who are really restricted... can’t control themselves

when it’s available to them... they’d be the one that was like scoffing their face with

cake.” (Tegan, 5:2). This association was not supported by any examples of

mother’s own experiences, so it is unclear what scenarios these reported

observations may reflect or whether such perceptions and beliefs relate to mothers’

own feelings of “guilt”. Mothers’ reports of their own children suggested opposing

associations when children were faced with restricted foods at parties (see Section

4.2.2 & 4.4.1.2). However, as mentioned earlier, a few mothers described how

earlier introduction of restricted items had led to adverse child eating behaviour,

which they redressed with greater restriction at a later age (see Section 4.5.1).

These examples could reflect a possible scenario linked to these observations by

other mothers.

134 Chapter 4: Qualitative Findings

4.6 THEME 5: ASSOCIATIONS WITH OTHER CONTROLLING FEEDING PRACTICES

This section outlines mothers’ reports on how they use controlling feeding

practices of pressure to eat and instrumental feeding in conjunction with restrictive

feeding within the natural setting.

4.6.1 Pressure and encouragement to eat

The most common items mothers reported encouraging their child to

consume were fruit and vegetables (24/29 mothers) and water (15/29 mothers),

which resembled the same items offered as alternatives to restricted foods in

relation to restrictive feeding behaviours of avoiding access (see Section 4.4.1.1). A

few mothers encouraged dairy, meat or cereal products, where their child was

reluctant to consume these items. Mothers who did not specifically encourage fruit

and vegetables generally said their child already ate these to a satisfactory level.

Encouragement to eat was commonly influenced by mother’s motivation to

achieve a “balance” between consumption of “healthy” foods and “unhealthy” foods

restricted “in moderation”. Children were often encouraged to eat a certain amount

of “healthy” foods before accessing foods that were restricted “in moderation” or

they were encouraged to eat “healthy” foods to compensate for prior consumption of

foods restricted “in moderation” (see Section 4.4.1.2). Another common practice was

children’s access to dessert at mealtimes being dependent on them eating a

particular food or a certain amount of a meal, a practice that might also be regarded

as food reward (see Section 4.6.2).

Mothers also reported encouraging “healthy” foods to their child by:

modelling the consumption of these foods at meal times; talking about the food’s

nutritional value; making foods look attractive or fun; involving their child in the

selection or preparation; and placing healthy foods in a visible location e.g. fruit

bowl. Some of these practices resembled mothers’ restrictive feeding behaviours of

offering alternative “healthy” foods, associated with avoiding access to restricted

foods (see Section 4.4.1.1). More covert practices involved hiding disliked “healthy”

foods within other foods their children liked or adding a sauce to a meal.

Chapter 4: Qualitative Findings 135

In addition, there appeared to be two distinct motivations driving mothers to

encourage or pressure their child to eat. While some mothers were only concerned

about their child eating sufficient “healthy” foods, others also aimed to achieve

“variety” in their child’s diet, which sometimes included less healthy foods. Mothers

aiming to just achieve a “healthy” diet tended to encourage their child to eat

“healthy” foods within the range of foods their child liked and sometimes their child’s

preferences for the way it was prepared (see Addendum 4.1, Box 32 for additional

quotes). Mothers who also wanted to achieve “variety” more commonly reported

practices of encouraging their child to try a certain amount of a food they were not

keen to eat, commonly different types of vegetables (see Addendum 4.1, Box 33 for

additional quotes).

4.6.2 Instrumental Feeding 4.6.2.1 The dilemma of food rewards

When mothers were asked whether they gave food as a reward, the most

common response was to say “no” initially but then proceed to provide examples of

giving foods or drinks restricted “in moderation” in association with encouragement to

eat “healthy” foods or for good behaviour. The giving of food as a reward was clearly

regarded as undesirable by most mothers “...I actually don't really like thinking about

them as rewards...” (Veronika, 8:2,4) (see Addendum 4.1, Box 34 for further quotes).

Some mothers elaborated that they felt “guilty” or “disappointed” with themselves for

using food as a reward but also highlighted how enticing this practice was because it

seemed to work.

I definitely cringe at myself, but I do it... I feel of two minds about it. I feel guilty that I

do it because it’s probably not the best thing to be using as a reward. But it’s so

damn effective. (Tara, 8:4-6).

...as far as rewards go, I mean I don’t tend to do it a lot... But we’re probably all

guilty of going to the shops, and saying “Well if you behave yourself I’ll get you a

treat at the end of it” (Jasmyn, 8:4)

A number of mothers had mentioned “treats” repeatedly during the

interview but stated that they either did not or were less likely to give food as a

reward. “...I try not to always obviously give food rewards because I think that’s once

again a bad habit. So yeah but we do, special treats.” (Victoria, 3:14). This finding

136 Chapter 4: Qualitative Findings

prompted further enquiry into mother’s beliefs about the difference between giving

food as a reward or as a “treat”. Most mothers believed that a food reward had to be

earned by the child doing something good, whereas a “treat” was unconditional.

Tara elaborated that “...a reward is probably always a treat in a sense. But a treat is

not necessarily a reward, because... they’ll have treats that have no direct link to

behaviour...” (Tara, 8:12-14). However, a few mothers suggested that there was no

difference, “I think a treat means... something special so they view it as a reward

you know... I don’t think there’s a difference.” (Melanie, 8:22) (see Addendum 4.1,

Box 35 for additional quotes).

Foods and drinks mothers reported giving as a reward were commonly the

same high sugar items mothers reported restricting “in moderation” and giving as

“treats” e.g. chocolates, lollies, biscuits, juices. The exception was ice cream and

sweetened yoghurt, which were repeatedly mentioned as restricted dessert items

given as rewards or “treats” but rarely mentioned in response to the initial interview

question about restricted foods and drinks (see Section 4.2.1). In addition, school

tuckshop meals were used as a reward by some mothers and did not necessarily

include foods mothers said they restricted, although the foods described commonly

resembled fast foods, such as hamburgers or chicken nuggets. However, some

mothers indicated that the school tuckshop reward was also about the social context

of joining in with peers rather than just the foods involved.

4.6.2.2 Food reward practices

Three groups of instrumental feeding practices associated with restrictive

feeding were reported by mothers: restricted foods as a reward for eating healthy

foods, restricted foods as a reward for good behaviour and withholding restricted

foods in response to bad behaviour. As mentioned in Section 4.6.1, a number of

mothers made reference to children’s access to “dessert” or “treats” being dependent

on them eating what they deemed to be a sufficient amount of a “healthy” meal.

While this practice may be regarded as a food reward for eating “healthy” foods,

most mothers reported that they did not regard this practice as giving a food reward

but rather that if their child could not eat their dinner they were too full for dessert

and they often related this to achieving a “balanced” diet. However, mothers’

descriptions commonly resembled conditional access to dessert or a “treat” after

dinner, which aligns with the concept of food given as a reward. “I don't think the kids

look at it as a reward. I think they just look at it as l’m not going to have dessert

Chapter 4: Qualitative Findings 137

unless I eat my dinner.” (Veronika, 8:2) (see Addendum 4.1, Box 36 for additional

quotes). This suggests that some mothers desire to achieve consumption of a

certain amount of “healthy” foods or “variety” may be contributing not only to

pressure to eat healthy foods but also to presentation of restricted foods as rewards.

Karren described the sequence of events that led her to decide to use a restricted

food as a reward to encourage (pressure to eat) her child to eat “healthy” meals.

I never used to believe in desserts until I realised it kind of eased the battle of

getting veggies in... it kind of helps her to complete her meal... it’s not always easy

to feed children you know, broccoli, and brussel sprouts... As long as there’s a little

bit of ice cream at the end of the day, she doesn’t care... So dinnertime became

more pleasant again because it started becoming a battle and I didn’t want it to be

an issue anymore (Karren, 2:14,18 & 4:10).

Some mothers justified that dessert was not a reward because they did not

overtly say to their child beforehand that dessert was dependent on them eating

dinner. “I’m trying very hard not to say ‘You have to finish your plate full of food

before you get some ice cream’” (Pip, 8:2). However, Tara recognised that even

though she did not vocalise this connection, her children were aware of this pattern

of events, “I try not to say, you know, ‘You can have berries if you finish your meal’

...but they know that is the case, you know...” (Tara, 6:9). (see Addendum 4.1, Box

37 for additional quotes). Thus, some mothers appeared to regard the giving of a

“treat” or food reward in retrospect, as acceptable and preferable to promising one in

advance for eating healthy foods. Mothers also cited examples of either promising or giving food rewards in

retrospect for good behaviour or achievements. Promising restricted foods as a

reward for good behaviour seemed to be more acceptable to mothers than promising

restricted foods as a reward for eating “healthy” foods. However, some highlighted

that they promised rewards or “treats” to enable them to “get things done” or to keep

their child “quiet” and sometimes expressed “guilt” associated with this practice,

“…But it’s so easy to do sometimes. ‘I just want to get something done’. So you

know I think I am a little bit guilty of that sometimes.” (Jasmyn, 8:6). Some mothers

appeared to deal with their dilemma of giving a food reward by requiring a build-up of

good behaviour over a number of days or exceptional behaviour to achieve a reward

so that they were infrequent (see Addendum 4.1, Box 38 for additional quotes).

Others specifically emphasised that they were more likely to use non-food rewards

138 Chapter 4: Qualitative Findings

for completing a meal or good behaviour, regarding this practice as better than giving

a food as a reward.

Mothers also commonly withheld food rewards when their child behaved

badly or did not achieve the behaviour associated with a promised reward (see

Addendum 4.1, Box 39 for additional quotes). But some also expressed concern

about going back on a promise of a reward and said they would only reverse the

promise if their child’s behaviour was unusually bad.

…if I’ve already kind of promised it I like to stick to that, otherwise they’re not going

to trust me the next time... but if... Ben’s gone and whacked Casey or vice versa...

then I just say “Right, you’re not getting this Casey” (Penny, 8:6)

...I try to help her to show some good behaviour so I can still give her that reward if

you know what I mean. Because I’d feel a bit mean not giving her things that I’ve

promised. (Mhari, 8:8)

4.7 THEME 6: THE INFLUENCE OF MOTHERS’ OWN PREFERENCES

A novel, uncanvassed and common feature of conversations was the

relationship between mothers’ own preferences and sometimes fathers’ preferences

for the foods they restricted their child from consuming “in moderation”, as well as

the connotations about these restricted foods they conveyed to their child. Mothers

used a range of favourable words and phrases when referring to foods and drinks

they restricted “in moderation”, as shown in Figure 4.1 (see Addendum 4.1, Box 40

for additional quotes).

yummy ♦ absolute treat ♦ big treat day ♦ amazing foods

something special ♦ special treat

fabulous drink ♦ lucky devils ♦ the good sweet stuff

big payoff when camping ♦ they’re great

something I knew they would love ♦ taste good ♦ taste nice

nice family time ♦ so exciting ♦ joyful experience

Figure 4.1. Words used by mothers to describe foods and drinks they restrict “in moderation”

Chapter 4: Qualitative Findings 139

Mothers also commonly referred to their own desires for or the need to

restrain themselves in relation to these foods and drinks, with some suggesting that

their restrictive feeding practices were as much for them as for their child. “...then of

course the problem is that you try not to think about those jelly beans calling out my

name from the cupboard.” (Pip, 3:20) (see Addendum 4.1, Box 41 for additional

quotes).

Mothers’ own preferences seemed to influence their decision of whether to

totally restrict an item or restrict it “in moderation”. For example, Pip restricts her

child’s intake of high sugar foods “in moderation”, such as jelly beans, which she

clearly has a preference for herself (see quote above). In contrast, she reports

totally restricting some specific fast foods and states that she does not like this food

herself, “So, again that’s a health preference, but also a food preference. I don’t like

any of those, so we don’t tend to do that.” (Pip, 1:16). However, some food items

that mothers said they did not like were not deliberately restricted but just did not

feature in family life (i.e. inadvertently restricted) (see Section 4.4). When prompted,

mothers explained that neither parent was interested in consuming this item or they

disliked it and as a consequence it did not feature in their family life. “...if I don’t eat

it, I tend to not to do a lot of it... I don’t buy cakes and things like that because I’m

not eating them myself. So I don’t think about it. The ones I’m not so keen on are

definitely more out than at home.” (Lisa, 3:69-75,101). (see Addendum 4.1, Box 42

for additional quotes). This suggests that restricted foods consumed at home are

likely to be linked to parent preferences, with the exception of foods given as gifts

such as lollies (see Section 4.4.1.1).

Furthermore, while mothers advocated the need to avoid negatively

modelling the consumption of restricted foods to their children (see section 4.4.2.2),

Margot and Penny reflected that this was hard to achieve because of parents’ own

preferences for these foods.

...the hardest thing is modelling good behaviour for your children. So if, I guess, the

grown-ups didn’t have the need to eat chocolate, chips and junk food, then it would

never come up for the children.(Margot, C:2).

140 Chapter 4: Qualitative Findings

‘But I don’t think there’d be many parents out there that are that perfect with their

kids to say, “You will only have great food in the house” I don’t know, how. If they

could get away with that. Because of course... the parent would have to not have

any bad stuff as well... (Penny, 5:8)

Margot and Penny’s skepticism is demonstrated by mothers’ reports

presented in Section 4.4.2.2. Examples highlighted how some mothers attempt to

consume restricted foods and drinks they like out of their child’s sight, but were also

commonly “caught” and felt obliged to share them with their child. The behaviour of

sharing also suggests that mothers believe that their child has the same desire for

the foods and drinks they choose to restrict “in moderation” as themselves. As

mentioned in Section 4.3.1, mothers commonly explained that restricting these

foods “in moderation” meant that their child was not “missing out”, being “deprived”

or “starved” of these foods or drinks. Although these comments were related to a

desire for social inclusion to some extent, some were clearly also related to the

mother’s opinion of the desirability of these foods themselves. “I don’t want to deny

her the joy of, or the freedom of experiencing all these naughty foods all at once. It’s

part of being a kid, and all the memories you make from it.” (Karren, 3.44) (see

Addendum 4.1, Box 43 for additional quotes). Others also referred to their belief that

the pleasure of consuming these foods is an important component of enjoyment at

children’s parties. “...that’s what parties are for really isn’t it? To have a treat, so I let

him go for it.” (Tegan, 3:46).

However, mothers’ and fathers preferences were not always associated

with their restriction decisions and language. For example, while Heidi included a

juice popper in her child’s school lunch box and referred to it as, “…his big treat for

big school. That’s lucky” (Heidi, 1:14), she also said that neither parent particularly

liked juice or consumed it on a regular basis. However, she referred to soft drink as

a “fabulous drink” (Heidi, 4:2) but totally restricted her son from consuming it. It is

possible that the offering of the juice popper may have been a sweet drink substitute

for the soft drink she desired but believed was of less “nutritional value” and less

preferable for her son to consume. Lisa and Joanne also totally restricted their

children from consuming soft drinks but consumed it themselves (see Section

4.4.2.2). These findings suggest a complex “balance” of mothers’ desire for child

health, assessed “nutritional value” of a food or drink and mothers’ perceptions of

child happiness derived from consuming an item.

Chapter 4: Qualitative Findings 141

4.8 SUMMARY OF KEY THEMES EMERGING FROM THE FINDINGS The aim of this component of the study was to gain a greater understanding

of the dimensions of the restrictive feeding phenomenon by interviewing a sample of

mothers with first born children, aged 5 to 6 years old. The sequential mixed

methods approach meant that the themes arising in this component of the study

were established and reviewed with existing literature prior to the design and

selection of variables for the quantitative component of the study reported in

Chapter 5. While this involved analysis of these findings in the context of current

literature at this stage, only a summary of these findings are presented here with a

full discussion presented as part of the integrated qualitative and quantitative

discussion in Chapter 6, Section 6.2.

Theme 1: Foods and drinks restricted and level of restriction

Knowledge of the specific foods and drinks restricted by parents was

identified as a gap in the literature (see Chapter 2, Section 2.6.3). Findings

highlighted the common foods and drinks restricted by this sample of mothers.

Findings also indicated that foods and drinks were either totally restricted or

restricted “in moderation”, with individual mothers applying different levels of

restriction to different foods and drinks. All mothers restricted some foods or drinks

“in moderation” but only soft drinks and fast foods were totally restricted by some

mothers, within this sample of 5 to 6 year old children. A common pattern of

differential targeting of specific foods and drinks was also apparent amongst

mothers. Soft drinks, other sweet drinks and fast foods were reported to be most

highly restricted. Sweet biscuits, cakes and other sweet snacks were restricted to a

lesser extent. Mothers’ reports also suggested an association between child

familiarity with a restricted food and greater child interest in a food, which is

consistent with existing evidence suggesting that children’s repeated intake of a

food (low restriction) is associated with higher child liking for a food (see Chapter 2,

Section 2.6.3). However, evidence of these associations for foods and drinks likely

to be targeted for restriction is limited and these findings contrast with experimental

restriction studies, which claim that high restriction of a food (reduced access) is

associated with higher child preferences for that food (see Chapter 2, Section 2.3).

142 Chapter 4: Qualitative Findings

Theme 2: Mothers’ motivation for restricting foods and drinks

Consistent with existing literature (see Chapter 2, Section 2.6.2), restrictive

feeding was found to be motivated predominantly by a desire for child health, with

child weight only featuring as a secondary motivation for some. However, this study

extended existing knowledge by identifying that mothers’ motivation is more

complex than just a desire for child health. Mothers instead strive for “balance”

between competing desires for both a healthy and happy child. Motivation to either

totally restrict or restrict a food “in moderation” was related to mothers’ perceptions

of the relative “nutritional value” of different restricted foods and their perceptions of

child happiness derived from social inclusion or the pleasure of consuming the food.

Such motivations were also related to different desires for lifelong habits, either

learning to consume “in moderation” or developing a dislike for the restricted food.

While mothers reported an association between familiarity and child liking for a

restricted food in Theme 1, they also suggested that it is preferable to provide

restricted foods “in moderation” rather than totally restrict. The basis of this

contradictory belief was unclear from the qualitative data but may be related to

experiences following the introduction of and child development of liking for

restricted foods.

Theme 3: How mothers restrict foods and drinks: restrictive feeding practices

Individual mothers use a diverse range of restrictive feeding practices,

which encompasses both mothers’ restrictive feeding behaviours (actions) and their

associated communication. These are varied by different restricted foods and drinks,

different contexts and at different child ages, suggesting that this phenomenon is

likely to be inherently inconsistent. This factor combined with a common pattern of

differential targeting of foods and drinks amongst mothers indicated more variability

in an individual mother’s practices than between mothers.

Sub-theme 3a: Mothers’ restrictive feeding behaviours

While the specific restrictive feeding behaviours reported to be used by

mothers were consistent with the range of restrictive feeding practices reported in

the literature, this study identified that such behaviours can be grouped into three

different types: “rules”, flexible judgement and avoiding access. These are used by

mothers to operationalise two characteristically different overarching intentions, total

Chapter 4: Qualitative Findings 143

restriction and restriction “in moderation”. They are also flexibly applied to different

restricted foods and drinks by individual mothers. While mothers reported control

over their child’s home environment, they reported challenges in managing social

influences from children’s parties, grandparents and school food environments.

Firmness and consistency was advocated by mothers but the realities of everyday

life hindered their good intentions, resulting in feelings of “guilt” and inconsistent

application of intended practices. Consistent “rules” or “habits” were reported to

result in child behaviour associated with their learnt expectations but the qualitative

data did not present evidence of an association between different restrictive feeding

behaviours used by mothers and child preferences for restricted foods and drinks.

Sub-theme 3b: Mothers’ restrictive feeding communication

The findings of the present study suggest that mothers’ restrictive feeding

communication determines whether a restrictive feeding practice is applied overtly

or covertly, rather than the type of restrictive feeding behaviour. Individual mothers

apply both overt and covert restrictive feeding communication to different restricted

foods and drinks, in different contexts and at different times. A novel finding was that

mothers also conveyed variable positive, neutral or negative connotations about

restricted foods and drinks to their child via their overt communication. In particular,

the presentation of restricted foods as “treats” (positive connotations) was a novel,

uncanvassed and repetitive feature of conversations and appeared to be an integral

part of restriction “in moderation”. With regard to non-verbal communication, most

mothers attempted to avoid negatively modelling the consumption of restricted foods

and drinks but with variable success. In contrast, some mothers consumed

restricted foods or drinks in front of their child without letting their child consume

them but reported child responses resembling a lack of interest in that food or drink.

The present study’s findings of variable parent communication associated with

restrictive feeding combined with existing evidence that connotations of a food or

drink communicated to children can influence their perception of that food or drink

(see Chapter 6, Section 6.2.3.2), suggests that this component of restrictive feeding

could potentially influence child preferences for restricted foods and drinks.

Theme 4: Patterns of restrictive feeding over time

Existing literature examining patterns of restrictive feeding over time is

limited and inconclusive (see Chapter 2, Section 2.6.6). Mothers’ reports in the

144 Chapter 4: Qualitative Findings

present study suggested that restrictive feeding is most commonly reduced as

children age, with predominantly covert total restriction progressively changing to

overt restriction “in moderation”. However, a small number of mothers reported

subsequently increasing restrictive feeding behaviour in response to growing child

interest in a restricted food. Mothers reported that their children’s interest in a

restricted food or drink grew after they had been introduced to the item and a

number of uncanvassed reports of younger siblings suggested that children’s earlier

exposure to a restricted food was associated with greater child interest in that food.

These findings were consistent with existing evidence that children’s early exposure

to a food is associated with higher child liking of that food. However, existing

evidence of these associations for foods and drinks likely to be targeted for

restriction is limited and does not clarify whether early exposure influences child

preferences independently from later child intake of restricted foods or drinks (see

Chapter 2, Section 2.6.6).

Theme 5: Associations with other controlling feeding practices

While practices of pressure to eat and food rewards were unrelated to

totally restricting a food or drink, both were used in conjunction with the provision of

restricted foods and drinks “in moderation”. Restriction of foods “in moderation” was

commonly associated with mothers’ use of pressure to eat “healthy” foods to

achieve a “balance” between the consumption of “unhealthy” and “healthy” foods. In

addition, a common practice aimed at achieving consumption of a “healthy” meal

involved the giving of a restricted food as a reward. Exploration of the concept of

food rewards revealed that mothers commonly distinguished between the giving of

foods as a “treat” as opposed to a reward. Mothers’ reports of giving a restricted

food as a “treat” appeared to be an integral part of restriction “in moderation” (see

Theme 3b), whereas the giving of foods as a reward resembled a separate concept.

However, while mothers commonly claimed not to use food rewards, they gave

examples of practices resembling this concept associated with giving restricted

foods and drinks. As giving a food as a reward has been found to increase child

preferences for the reward food (see Chapter 1, Section 1.1), the giving of restricted

foods as a reward could coincidently increase child preferences for the restricted

food.

Chapter 4: Qualitative Findings 145

Theme 6: The influence of mothers’ own preferences

A novel, uncanvassed and repetitive feature of conversations was mothers’

expressions of their own preferences for the foods and drinks they restricted “in

moderation”. Their own preferences appeared to influence decisions of whether to

restrict an item totally or “in moderation”; the perceived contribution a restricted item

would make to their child’s happiness; and the connotations about the restricted

item they communicated to their child, including whether the item was regarded as a

“treat”. Such associations had not been reported in the existing literature examined.

4.8.1 Overall Summary

The themes presented here are discussed in more detail as part of the

integrated discussion with the findings of the quantitative component presented in

Chapter 6. Analysis of these emergent themes and existing knowledge (see Chapter

2, Section 2.6) informed decisions regarding the subsequent quantitative component

of the study reported in Chapter 5.

Figure 4.2 outlines an interim conceptual framework reflecting the findings

of the present study at this point. Findings suggest that mothers’ motivation for a

healthy and happy child, as well as their own preferences for specific restricted

foods and drinks, influence their restrictive feeding decisions in relation to different

foods and drinks (Themes 2 & 6). These dimensions influence a mother’s restrictive

feeding intentions to either totally restrict or restrict a food or drink “in moderation”.

This in turn may influence child age of introduction to a restricted food or drink

(Theme 4), the level of restriction applied (Themes 1) and mothers’ restrictive

feeding practices (Theme 3), the latter of which includes restrictive feeding

behaviours (Theme 3a) and associated communication (Theme 3b). It is these four

dimensions that may directly influence children’s restrictive feeding experiences with

different foods and drinks. Other controlling feeding practices commonly used by

mothers in conjunction with restrictive feeding, such as pressure to eat “healthy”

foods and the giving of restricted foods as a reward, are external to this

phenomenon but may influence children’s experiences in relation to restricted foods

and drinks (Theme 5).

146 Chapter 4: Qualitative Findings

Figure 4.2. Interim conceptual framework showing associations between

emergent themes of the restrictive feeding phenomenon.

Earlier Experiences (Theme 4)

Restrictive Feeding Intentions

For a restricted food or drink (Theme 1) • Total restriction • In moderation • Inadvertent

Motivation Healthy & Happy Child (Theme 2) Mothers’ own liking (Theme 6)

Level of Restriction (Theme 1)

Child Restrictive Feeding Experiences

Practice: Behaviours (Theme 3a)

Other controlling feeding practices (Theme 5)

Practice: Communication (Theme 3b)

Chapter 5: Quantitative Method & Findings 147

Chapter 5: Quantitative Method & Findings

5.1 INTRODUCTION

As mentioned in Chapter 3, Section 3.2.1, this quantitative component of

the study was informed by the findings of the preceding qualitative component. This

component of the study aimed to complement and extend the knowledge gained

from the qualitative component and existing knowledge in two ways. Firstly, to

expand the conceptual understanding of the restrictive feeding phenomenon and

secondly, to identify the dimensions of this phenomenon that might be important to

include in a measure of restrictive feeding. However, this was limited to the variables

available within the secondary data source (i.e. NOURISH database; Daniels et al.,

2009).

The sample for this component of the study included control participants in

the NOURISH trial (Daniels et al., 2009) who were still active at child aged 5 years

(n = 211). The characteristics of this sample are shown in Chapter 3, Section

3.2.2.2, Table 3.1.

Research questions

Within the scope of the secondary data and considering the findings of the

qualitative component of this study and existing literature, the following research

questions were posed.

2. What are the patterns of child intake frequencies of a selection of commonly

restricted foods and drinks at 5 years old and how do these patterns align

with children’s progressive introduction to and development of their liking for

these foods and drinks at ages 14 months, 2 years, 3.7 years and 5 years?

3. What are the unique associations between child intake frequency at 5 years,

child early exposure and mother’s own liking for a selection of commonly

restricted foods and drinks and child liking for the same items at 5 years old?

148 Chapter 5: Quantitative Method & Findings

These research questions were addressed separately in two parts. Part I

addressed research question 2 and involved examination of patterns of descriptive

data. Part II addressed research question 3 and involved analysis of cross-sectional

associations between selected variables by binary logistic regression. Methods and

findings are reported separately for these two parts in Sections 5.3 and 5.4

respectively, and summarised in Section 5.5. Discussion of the findings is integrated

with discussion of findings from the qualitative component of the study and

presented in Chapter 6, Section 6.2.

Part I: Patterns of descriptive data

The qualitative component of the study suggested that mothers restrict

foods and drinks to different levels and that a common pattern of differential

targeting of foods and drinks amongst mothers may exist (see Chapter 4, Section

4.8, Theme 1). Examination of quantitative descriptive data was intended to assist

with clarifying qualitative reports of variability in children’s access to restricted foods

and drinks and hence different levels of restriction applied to different restricted

foods and drinks.

This examination was extended to include child age of introduction and

child liking for restricted foods and drinks at four different child age points (14

months, 2 years, 3.7 years and 5 years). The purpose was to examine patterns of

descriptive data between children’s current intake of these food and drinks, their age

of introduction and their liking for the same food or drink over time. Analyses of

these patterns of descriptive data were intended to complement qualitative reports

of the nature of this phenomenon (see Chapter 4, Section 4.5), providing a

quantified picture of variations between items, as well as a perspective of change

over time as children age.

Part II: Associations with child liking for restricted foods and drinks

A number of dimensions of the restrictive feeding phenomenon were

highlighted by the qualitative component of this study (see Chapter 4) but only those

that directly influence the child outcomes of interest would need to be included in a

measure of restrictive feeding. With this in mind, this part of the study aimed to use

inferential statistical analysis to examine cross-sectional associations between key

dimensions of the phenomenon that might be directly associated with the child

Chapter 5: Quantitative Method & Findings 149

outcomes of interest, as indicated by findings of the qualitative component of this

study and existing literature.

Chapter 2, Section 2.5 proposed that children’s preference for, liking for or

wanting to consume restricted foods and drinks are the most appropriate outcome

measures to assess the effects of parent restrictive feeding on children’s future risks

of developing diet-related disease or obesity. Child liking was the only measure of

this type available within the secondary data source, so was selected as the

outcome measure. Selection of restricted foods and drinks included in the analyses

was based on mothers’ reports of items commonly targeted for restriction in the

qualitative study. In addition, qualitative data suggested that mothers provide

different levels of access to different restricted foods and drinks and descriptive data

examined in Part I of this component of the study was consistent with this pattern

(see Section 5.3.3). For this reason, analyses were performed on each selected

restricted food and drink item separately in Part II, rather than combining them into a

composite measure.

Qualitative data indicated that four key dimensions of the restrictive feeding

phenomenon might directly influence children’s restrictive feeding experiences and

hence children’s diet-related outcomes. These are: child intake (Theme 2), child

early exposure (Theme 4), and mothers’ restrictive feeding practices; both restrictive

feeding behaviours (Theme 3a) and restrictive feeding communication (Theme 3b)

(see Chapter 4, Section 4.8, Figure 4.2). Existing literature indicated that children’s

early exposure and/or repeated exposure to a food or drink may increase their

preferences or liking for that food or drink (see Chapter 2, Sections 2.6.6 & 2.6.3).

However, studies examining these associations for the types of foods and drinks

potentially targeted for restriction by parents are limited. As mentioned in Chapter 2,

these associations may be different for restricted foods and drinks, due to children’s

innate preferences for the types of foods and drinks potentially targeted for

restriction (see Chapter 2, Section 2.6.6). Further examination of these associations

for restricted foods and drinks could add knowledge to understanding the effects of

restrictive feeding on child liking for these foods and drinks and hence future diet-

related outcomes.

In addition, different parent restrictive feeding behaviours (e.g. rules,

flexible judgement, avoiding access) and differences in associated communication

(e.g. covert or overt and positive, neutral or negative connotations) revealed by the

150 Chapter 5: Quantitative Method & Findings

qualitative component of this study (see Chapter 2, Sections 4.4.1 & 4.4.2), could

potentially have differential effects on child liking for restricted foods and drinks.

While the qualitative component of the study and existing literature did not provide

evidence of differential effects of different parent restrictive feeding behaviours on

child food preferences (see Chapter 2, Section 2.6.4), existing literature does

suggest that parent communication can influence child perceptions of a food and

hence potentially influence child food preferences (see Chapter 6, Section 6.2.3.2).

However, no suitable measures are currently available to examine the effects of

different restrictive feeding practices (see Chapter 2, Sections 2.4.2, 2.6.4 & 2.6.5).

This meant that the potential contribution to child liking for restricted foods and

drinks associated with mothers’ restrictive feeding behaviours and restrictive feeding

communication could not be examined as part of this study.

However, mothers’ own liking for restricted foods and drinks was an

uncanvassed, repetitive theme emerging from the qualitative data. Qualitative data

also suggested that this dimension was associated with mothers’ decisions to

restrict a food or drink in moderation rather than totally restrict it and hence greater

child access to that food or drink. It also suggested an association with mothers’

overt communication with positive connotations about a restricted item (see Chapter

4, Section 4.7). The dimension of mothers own liking for restricted foods and drinks

was included as a predictor of child liking for restricted foods and drinks for two

reasons. Firstly, to assess whether this dimension is associated with child liking for

restricted foods and drinks beyond its association with child early exposure and child

intake. Secondly, if a unique association was found this would indicate that another

direct mediating variable associated with mothers’ liking, such as mothers’ restrictive

feeding communication, is uniquely associated with child liking for restricted foods

and drinks. However, further research would be required to establish which variable

or variables might mediate such an association. This would include consideration of

restrictive feeding behaviours and potential covariates such as food rewards (see

Chapter 4, Section 4.6.2) and/or a genetic component (see Chapter 2, Section

2.6.3).

Chapter 5: Quantitative Method & Findings 151

5.2 SELECTION OF VARIABLES FROM THE NOURISH DATABASE

The following four variables of interest were selected from the NOURISH

database (Daniels et al., 2009).

• Child intake frequency of selected restricted foods and drinks.

• Child age by when they had tried selected restricted foods and drinks.

• Child liking for selected restricted foods and drinks.

• Mothers’ own liking for selected restricted foods and drinks.

Data were available at child ages 14 months, 2 years, 3.7 years and 5

years for the child liking and child age by when tried variables. Data for child intake

frequency was only available at child aged 5 years and mothers’ own liking data was

collected when children were 2 years old. Child intake frequency was the only intake

measure available in the NOURISH database (Daniels et al., 2009) for the types of

foods and drinks being examined. The alternative option of intake amount was not

available in a useable form from this database. However, the measurement of child

intake frequency was consistent with the majority of other studies examining

associations between child food intake and preferences (see Chapter 2, Section

2.6.3).

As mentioned in Section 5.1, selection of restricted food and drink items

was based on common items reported to be restricted by mothers in the qualitative

component of this study (see Chapter 4, Section 4.2.1). In addition, consideration

was given to the food and drink items available, the grouping of items within the

NOURISH database (Daniels et al., 2009), and the ability to match items between

the variables of interest. Seven food and drink items were selected to represent

children’s intake frequency. These were matched with nine food and drink items

selected to represent child age by when tried, child liking and mothers’ own liking.

Two different scales were required to be used to measure child intake frequency of

foods and drinks. This was because the CDQ (Magarey et al., 2009) included in the

NOURISH survey to measure intake frequency did not include a measure that

separated soft drink from other sweet drinks. As soft drink was reported to be

restricted very differently to other sweet drinks by mothers and one of only two items

potentially representing total restriction (see Chapter 4, Section 4.2.1), a separate

measure was sought. Another measure within the NOURISH database that provided

152 Chapter 5: Quantitative Method & Findings

this separation, but only measured drinks, was selected. The following measures of

variables were selected from the NOURISH database.

Child intake frequency

• Five food items: sweet biscuits & cakes, lollies, ice cream, savoury biscuits

& chips [crisps], takeaway [e.g. McDonalds, KFC, Fish & Chips, Chicken

Shop] (Response scale: Intake frequency in past 7 days = 0, 1, 2, 3, 4, 5,

6+) (Source: CDQ, Magarey et al., 2009).

• Two drink items: fizzy/soft drink33, fruit drink (Response scale: Intake

frequency per week = Never, < 1, 1-3, 4-6, 6+) (Source: NOURISH survey,

Daniels et al., 2009).

Child age by when tried, child liking and mothers’ own liking

• Nine food and drink items: sweet biscuits, cakes, lollies, ice cream, savoury

biscuits, chips (crisps), fast foods [e.g. KFC, McDonalds], soft drink/fizzy

drink34 and fruit drink (Response scale: never tried, dislikes a lot, dislikes a

little, neither likes/dislikes, likes a little, likes a lot) (Source: Food/drink liking

scale, Wardle, Sanderson, et al., 2001).

5.3 PART I: PATTERNS OF DESCRIPTIVE DATA 5.3.1 Introduction

To address research question 2 (see Section 5.1), this part of the study

examined descriptive data patterns of child intake frequency at 5 years and

alignment with patterns of age by when children had tried and children’s liking for

the same food and drink items at ages 14 months, 2 years, 3.7 years and 5 years.

The longitudinal data were not sufficiently robust to meet assumptions required for

general estimation equations (GEE) due to insufficient cell counts for logistic

regression and inadequate sample sizes for analyses between food and drink items,

which were the associations of interest. This part of the analyses was therefore

33 Carbonated sweet drinks 34 Carbonated sweet drinks

Chapter 5: Quantitative Method & Findings 153

limited to patterns of descriptive data only. The measures and method of data

preparation are described in Section 5.3.2 and the findings presented in Section

5.3.3.

5.3.2 Measures and method of data preparation

Three variables of child intake frequency, child age by when tried, and child

high liking were examined in this part of the study in relation to the selected

restricted food and drink items described in Section 5.2. See Table 5.1 for a

summary of these variables and Appendix L, Table L.1 for further details.

Frequencies for each data variable were converted to valid percentages and

presented in display tables for visual examination of patterns of data. Valid

percentages represent the percentage of frequencies of completed responses for

the specific variable at the specific time point of collection. Actual percentages, data

frequencies and samples sizes by item are shown in Appendix M.

Table 5.1

Variables Included in Descriptive Analysis

Variable Measure (scale) Time points Source

Child intake frequency of restricted foods and drinks

Valid percentage of sample, weekly intake frequency (scale: 4 pts - <1/week, 1/week, 2/week, 3+/week)

Child aged 5 years

Foods scale: CDQ, Magarey et al., 2009 Drinks scale: Daniels et al., 2009

Child age by when tried restricted foods and drinks

Valid percentage of sample who had ‘tried’ the food/drink item (scale: 5pts - dislikes a lot to likes a lot), with never tried responses excluded.

4 time points: Child aged 14 months, 2 years, 3.7 years, 5 years.

Wardle, Sanderson, et al., 2001

Child high liking for restricted foods and drinks

Valid percentage of sample who had a high liking for food/drink item (scale: 1 pt - likes a lot), with the excluded group (non-high liking) being 5 pts (never tried to likes a little).

4 time points; Child aged 14 months, 2 years, 3.7 years, 5 years.

Wardle, Sanderson, et al., 2001

Original frequencies for soft drinks and fruit drink were collected as one category for 1-3 times/week. These data have been split evenly between 1, 2 and 3/week categories to provide consistency with data collected for food categories. The 3+/week category for soft drinks and fruit drink also included data for categories of 4-6 times/week and > 6 times/week. See Appendix M for data frequencies and percentages by original categories (Table M.1) and combined categories (Table M.2).

154 Chapter 5: Quantitative Method & Findings

5.3.3 Findings

5.3.3.1 Patterns of child intake frequency of restricted foods and drinks

Figure 5.1 shows patterns of child intake frequency for selected restricted

foods and drinks reported by mothers when children were 5 years old. This variable

indicates the current level of restriction of an item, with lower intake frequencies

indicating higher levels of restriction and higher intake frequencies indicating lower

levels of restriction. Actual percentages and frequencies of child intake are shown in

Appendix M, Table M.2. Findings show that children’s weekly intake frequency of

sweet drinks was much lower than for the selected sweet foods, with soft drink being

the least frequently consumed item and, therefore, the most highly restricted.

Takeaway foods were the least frequently consumed food item, with very few

children consuming these foods more than once a week (6%). Approximately half of

the sample reported their child consumed lollies, ice cream and chips/savoury

biscuits once a week or less but sweet biscuits/cakes were consumed most

frequently (least restricted), with almost half of the sample (48%) consuming these

items three or more times a week.

Figure 5.1. Child intake frequency of selected foods and drinks at 5 years

n = 191-194 (samples sizes varied between items).

Soft drinkFruit drink

TakeawayLollies

Ice creamChips/Savoury bisc

Sweet Bisc/Cake

010

20

30

40

50

60

70

80

90

100

< 1/week 1/week 2/week 3+/week

Val

id P

erce

ntag

e

Chapter 5: Quantitative Method & Findings 155

5.3.3.2 Patterns of children’s exposure to restricted foods and drinks over time

Figure 5.2 shows the percentage of children who had tried a selected

restricted food or drink reported by mothers when children were 14 months, 2 years,

3.7 years and 5 years old. Actual percentages and frequencies of children having

tried a food or drink are shown in Appendix M, Table M.3. Findings show

progressive exposure of children to restricted foods and drinks over time. Nearly all

children (96-100%) had tried sweet biscuits, cake, lollies, ice cream, savoury

biscuits and potato chips by 3.7 years old. The percentage of children having tried

soft drink, fruit drink and fast foods was lowest across all time points, with 26% of

children still not having tried soft drinks by 5 years old and 14% and 12% not having

tried fast foods and fruit drinks respectively. Sweet biscuits and cakes had most

frequently been introduced by the time children reached 14 months (71% and 66%

respectively) and more than 50% of children had tried ice cream and savoury

biscuits by this age. A lower proportion of children had tried lollies and potato chips

at 14 months, which markedly increased by the time children had reached 2 years

old and almost all had tried these items by the time children were 3.7 years old (96%

and 98% respectively).

156 Chapter 5: Quantitative Method & Findings

Figure 5.2. Percentage of child sample responses who had tried

selected foods and drinks by stated child age

n = 183-199 (samples sizes varied between items and data collection points).

5.3.3.3 Patterns of children’s liking for restricted foods and drinks over time

Figure 5.3 shows the percentage of children in the sample reported by

mothers to have a high liking (likes a lot) for the selected restricted foods and drinks

when children were 14 months, 2 years, 3.7 years and 5 years old. Actual

percentages and frequencies of child high liking for foods and drinks are shown in

Appendix M, Table M.4. Findings show a progressive increase in the percentage of

children with a high liking for restricted foods and drinks as they get older. The

proportion of children with high liking for soft drinks, fast foods and fruit drink were

the lowest across all time points, with approximately only half of the children in the

sample having developed a high liking for these food and drink items by 5 years old

(40%, 53% and 61% respectively). This finding aligned with later introduction and

lower intake frequency of these foods and drinks at 5 years. This was in contrast to

the other food items (sweet biscuits, cake, lollies, ice cream, savoury biscuits and

potato chips), where higher percentages of children had developed a high liking for

these items at younger ages and more than 80% of children had developed a high

liking for these foods by the time they reached 5 years old. However, while sweet

biscuits were the most highly liked item when children were 14 months old (51%),

ice cream became the most highly liked item by 3.7 years (91%). Also, lollies were

0 20 40 60 80 100

Potato chips

Savoury Bisc

Fast foods

Ice cream

Lollies

Cake

Sweet bisc

Fruit drink

Soft drink

Valid percentage of food or drink tried

Food

/drin

k ite

m

14 mths

2 years

3.7 years

5 years

Chapter 5: Quantitative Method & Findings 157

one of the least liked items when children were 14 months old (8%) but liking

increased sharply at 2 years (46%) and 3.7 years old (77%). Children’s high liking

for lollies then rose to similar percentages to child high liking for other food items,

where child high liking had been more apparent at 14 months old e.g. cake and

savoury biscuits. Potato chips showed a similar pattern to some degree, with a

sharp increase in high liking between 14 months and 2 years old. The higher liking

shown for these foods at 5 years old then aligned with the higher percentage of

children introduced to these foods and children’s intake frequency of these foods at

5 years old.

Figure 5.3. Percentage of child sample with high liking (likes a lot) for

selected restricted foods and drinks by stated child age

n = 183-199 (samples sizes varied between items and data collection points).

5.4 PART II: ASSOCIATIONS WITH CHILD LIKING FOR RESTRICTED

FOODS AND DRINKS

5.4.1 Introduction

As mentioned earlier, this part of the study involved examination of cross-

sectional associations between the selected variables from the NOURISH database

(Daniels et al., 2009) by binary logistic regression in response to research question

0 20 40 60 80 100

Potato chips

Savoury Bisc

Fast foods

Ice cream

Lollies

Cake

Sweet bisc

Fruit drink

Soft drink

Valid percentage of high liking (likes a lot) for food or drink

Food

/drin

k ite

m

14 mths

2 years

3.7 years

5 years

158 Chapter 5: Quantitative Method & Findings

3 (see Section 5.1). The purpose of the analyses was to identify which dimensions

of the restrictive feeding phenomenon might need to be included in a measure used

to assess the effects of restrictive feeding on child liking.

5.4.2 Method 5.4.2.1 Measures: predictor and outcome variables

Three predictor variables of child high intake frequency, child early

exposure and mothers’ own high liking were selected to examine associations with

child high liking. Variables for child high intake frequency, child early exposure (child

age when tried) and child high liking were the same as shown in Section 5.3.2,

Table 5.1. The variable of mothers’ own liking used the same scale and food and

drink items as for child liking (Wardle, Sanderson, et al., 2001), shown in Section

5.3.2, Table 5.1 and was reported by mothers when children were 2 years old.

Further details of these measures are shown in Appendix L, Table L.1.

Participant responses for each variable and food or drink item were

reduced to dichotomised groups as indicated in Table 5.2. This approach was

required to meet assumptions for statistical analysis because the child high liking

data was highly positively skewed and the child intake frequency data was highly

negatively skewed for the more highly restricted items. The variability in the

distribution of child intake frequency data in food and drink items required the

dichotomised splits to vary between food and drink items, as detailed in Table 5.2.

Likewise, child early exposure (child age when tried) data were dichotomised at the

child aged 2 year time point for the more highly restricted items of soft drink, fruit

drink, fast foods and lollies, whereas data was dichotomised at the child aged 14

month time point for all other food items that were introduced earlier (sweet biscuits,

cakes, lollies, ice cream, savoury biscuits, chips). See Appendix M for original data

distributions and Appendix N for details of dichotomised data. Table 5.2 summarises

predictor and outcome variables examined by regression for research question 3.

Dichotomised data groups were labelled ‘1’ and ‘2’, with ‘1’ being the reference

category.

Chapter 5: Quantitative Method & Findings 159

Table 5.2

Variables Included in Binary Logistic Regression Analysis

Variable type

Reference variable

Scale Time points

Sources

Predictor Child high intake frequency of restricted foods and drinks

Dichotomised scale varied by items. Soft drink and fruit drink

1= <1 to 6+/week 2= Never

Fast foods 1= 1+/week 2= <1/week

Sweet biscuits, cakes, lollies, ice cream, savoury biscuits, potato chips [crisps]

1= 2+/week 2= <2/week

Child 5 years

Drinks: Daniels et al., 2009 Foods: CDQ, Magarey et al., 2009

Predictor Child early exposure to (age by when tried) restricted foods and drinks

Dichotomised scale 1= Exposed (likes a lot to dislikes a lot, scale pt 1-5) 2= Not exposed (never tried, scale pt 6) 2 year time point: soft drink, fruit drink and fast foods 14 month time point: sweet biscuits, cakes, lollies, ice cream, savoury biscuits, chips

Child 14 months or 2 years

Wardle, Sanderson, et al., 2001

Predictor Mothers’ own high liking for restricted foods and drinks

Dichotomised scale 1= High liking (likes a lot, scale pt 1) 2= Non-high liking (likes a little to dislikes a lot, scale pt 2-5) Never tried (scale pt 6) coded as missing data.

Child 2 years (only time point collected)

Wardle, Sanderson, et al., 2001

Outcome Child high liking for restricted foods and drinks

Dichotomised scale 1= High liking (likes a lot, scale pt 1) 2= Non-high liking (likes a little to dislikes a lot, scale pt 2-5) Never tried (scale pt 6) coded as missing data.

Child 5 years

Wardle, Sanderson, et al., 2001

Note. 1= reference variable; 2=non-reference variable Child age selected was based on the distribution of data suitable for analysis. There was variation in the proportion of children being introduced to different foods and drinks at different ages.

The same food and drink items as described in Section 5.2 were applied for

these analyses. While the child intake frequency and child liking measures

contained similar foods and drinks, they were provided as fewer item groups in the

child intake frequency data (seven items) than for the child and mother liking and

child early exposure data (nine items). In order to match these for analysis, the

single intake frequency item group for sweet biscuits and cake was matched with

two separate child and mother liking/child early exposure item groups (sweet

biscuits and cake) and the single intake frequency item group of chips and savoury

biscuits was matched with two separate child and mother liking/child early exposure

item groups (chips and savoury biscuits) as shown in Table 5.3.

160 Chapter 5: Quantitative Method & Findings

Table 5.3

Matching of Restricted Food and Drink Items Between Variables

Seven items for child intake frequency variable

Nine items for tried and high liking variables ᵇ

Soft/fizzy drinks Soft/fizzy drinks Fruit drink Fruit drink Sweet biscuits & Cake Sweet biscuits

Cake Lollies Lollies Ice cream Ice cream Potato chips (crisps) & Savoury biscuits

Potato chips (crisps) Savoury biscuits

Fast foods Fast foods.

Foods: CDQ, Magarey et al., 2009; Drinks: Daniels et al., 2009. ᵇ Wardle, Sanderson, et al., 2001.

5.4.2.2 Measures: child and maternal characteristic covariates

There is a lack of theoretical basis for including maternal and child

characteristic variables as covariates in these analyses. The purpose of controlling

for a covariate is to eliminate potential confounding. For a variable to be a

confounder it must be predictive of the outcome variable independently from its

association with the predictor variable (Rothman, 1986). However, child and

maternal characteristics may be associated with particular parenting practices and

family dietary habits that affect the child outcome variable being examined, rather

than be independent confounders. For example, Howard et al.’s (2012) study found

characteristics of younger maternal age, higher maternal BMI, shorter duration of

breast feeding and heavier child birth weight to be positively associated with children

having tried a range of non-core foods by 2 years old. As evidence suggests that

child exposure to foods may be associated with child liking (see Chapter 2, Section

2.6.3 & 2.6.6), the addition of associated characteristics could potentially distort

findings rather than control for confounding. For this reason, characteristic

covariates were examined separately to assess whether they influenced the

direction or significance of predictions.

Table 5.4 shows the six maternal and child characteristics selected for

examination as covariates on the basis of their potential association with mothers’

use of restrictive feeding practices reported in the literature: child gender, child birth

weight z-score, maternal education, maternal age, maternal BMI and duration of

Chapter 5: Quantitative Method & Findings 161

breast feeding. Details of these variables and the rationale for inclusions are

outlined in Appendix O, Table O.1.

Table 5.4

Child and Maternal Characteristic Covariates Included in Binary Logistic Regression

Analysis

Reference variable Scale Time points

Child gender (male) Dictomised scale 1= male 2= female

First contact (child 4 months)

Child birthweight z-score (high)

Continuous scale – z-score Birth (hospital records)

Breast feeding duration (longer)

Continuous scale - weeks Child 2 years

Maternal education (University)

Dictomised scale 1= university educated - yes 2= university educated - no

First contact (child 4 months)

Maternal age (older) Continuous scale – years and months

Age at birth

Maternal BMI (high) Continuous scale – kg/m² First contact (child 4 months)

5.4.2.3 Analysis of data

Figure 5.4 outlines the analysis model. This model examined prediction of

child high liking by the three predictors of child high intake frequency, child early

exposure and mothers’ own high liking.

Child intake frequency Child early exposure Child high liking Mothers’ high liking

Figure 5.4. Prediction model for research question 3.

162 Chapter 5: Quantitative Method & Findings

Binary logistic regression was selected as the most appropriate method to

examine associations between the variables of interest. IBM SPSS version 22 was

used for these analyses. Data had been double entered, checked and cleaned by

NOURISH study staff prior to this analysis. This analysis was performed for each of

the nine selected food and drink items separately. Restricted food and drink items

were matched for analyses as described in Section 5.4.2.1, Table 5.3, resulting in nine sets of analyses. Missing data were not imputed but excluded from the analysis

for that specific food or drink item. In addition, participant responses of never tried in

the child liking scale (child aged 5 years) and mothers’ own high liking scale

(collected at child aged 2 years) were excluded from analysis because it could not

be determined whether a child or mother liked an item if they had never tried it.

Initially, crude (bivariate) binary logistic regressions were performed

between each of the predictor variables and the child liking variable for each of the

selected restricted food and drink matched items. Multivariable binary logistic

regressions were then performed including the three predictors and the six selected

child and maternal characteristic covariates (child gender, child birth weight z-score,

maternal education, maternal age, maternal BMI and duration of breast feeding),

with child high liking as the outcome variable. The three predictors were forced into

the model simultaneously and the six covariates were entered by the backward

selection method (likelihood ratio) for each of the nine matched food and drink

items. This provided models including just the three predictors together (prediction

models, see Figure 5.4) and a series of backward selection models including all

three predictors and variations involving the six maternal and child covariates

(adjusted models). Maternal and child covariates that did not contribute to or made a

minimal contribution to the prediction models were progressively removed by the

automatic backward selection program, which produced a series of adjusted

models. Very little change was indicated for the -2 log likelihood values between

initial adjusted models including all covariates and final adjusted models, where the

covariates that made a minimal contribution to the model had been removed. In all

cases, the final adjusted covariate model presented by the backward selection

method was selected and examined for effect size changes in comparison to the

model with just the three predictors (prediction model as shown in Figure 5.4).

Adjusted models including maternal and child characteristic covariates

were examined separately from the models including just the three predictors. As

said, this was because the characteristic covariates were theoretically likely to

Chapter 5: Quantitative Method & Findings 163

influence the predictors rather than independently confound the outcome variable.

They would also potentially distort effects shown by the predictors on child liking for

each food and drink item. This meant that comparison of effects between food and

drink items would be compromised by inclusion of different covariates potentially

showing different effects for different food and drink items.

Multivariable binary logistic regressions were also performed with the

removal of one predictor in turn for all combinations of two predictors for each of the

food and drink items. This analysis informed assessment for confounding between

the three predictors. Instances of confounding were reported with the findings in

Section 5.4.3.

5.4.3 Findings

5.4.3.1 Overview of findings

Table 5.5 displays a summary of binary logistic regression findings for

prediction of child high liking by three predictors of child high intake, child early

exposure and mothers’ own high liking. It displays odds ratios and significance of

findings from the prediction model shown in Section 5.4.2.3, Figure 5.4. Odds ratios

(OR) represent child high liking for each food and drink item as opposed to child

non-high liking for the same item. P-values of < 0.05 were considered statistically

significant and provided a guide to the reliability of reported odds ratios. Details of

both bivariate and the prediction model regressions are shown in Appendix P.

Overall findings for this model showed that mothers’ own high liking for a

restricted food or drink item predicted the highest odds of child liking for most of the

restricted food and drink items examined. Child high intake frequency predicted

higher odds of child high liking for the sweet foods and drinks examined but did not

predict higher odds of child high liking for the savoury foods examined. Child early

exposure did not predict higher odds of child high liking, with the exception of

savoury biscuits, although odds predicted were modest and not significant.

Confounding between predictors was determined by changes in significance or

effect sizes (B > 20% change). Where confounding was evident by this criterion,

effect changes were highlighted in the report of findings that follows. Data for the

item of ice cream was found to be unreliable due to very high levels of high child

liking in the sample (94% of data) and crosstabs showed some cells with very low

164 Chapter 5: Quantitative Method & Findings

frequencies (< 5). Findings for this item have, therefore, been excluded from this

part of the study.

The contribution to variance explained by the predictors was described

using the Nagelkerke’s pseudo-R² and has been reported in Table 5.5 as R².

Variance explained by the three predictors varied between items, with soft drinks

showing the most variance explained (Nagelkerke R² = 38.7) and lollies showing

minimal variance explained (Nagelkerke R² = 3.8) by these predictors for child high

liking. Lollies were also the only item that did not show a significant association with

any of the predictors. Potato chips (crisps) showed the lowest variance explained

(Nagelkerke R² = 5.3) by the three predictors of the savoury foods examined and

were the second lowest of all the items examined.

Inclusion of the maternal and child characteristic covariates in the

prediction models did not change the significance of key predictors or the order of

highest predicted odds. Furthermore, there were no systematic patterns of

association between any of the covariates and the outcome measure, child high

liking. See Appendix Q for adjusted odds with inclusion of covariates and Appendix

P for details of regression analysis, including raw bivariate analysis, multivariate

analysis (three predictors) and analysis adjusted for selected child and maternal

characteristic covariates.

Chapter 5: Quantitative Method & Findings 165

Table 5.5

Prediction of Child High Liking by Child High Intake Frequency, Mothers’ Own High Liking

and Child Early Exposure for Eight Selected Restricted Food and Drink Items at Child Aged

5 Years

Food or drink n

Child high intake frequency Mothers’ own high

liking Child early exposure R²

OR (95% CI) OR (95% CI) OR (95% CI) Sweet food & drink items Soft drink 127 11.06*** (4.38, 27.93) 1.80 (0.63, 5.12) 1.19ᵇ (0.47, 3.00) 38.7 Sweet bisc. 165 4.84** (1.80, 13.02) 2.15 (0.80, 5.83) 0.60 (0.19, 1.89) 13.4 Fruit drink 148 2.47* (1.09, 5.59) 4.72** (1.51, 14.80) 0.50ᵇ (0.23, 1.09) 14.5 Cake 165 1.75 (0.70, 4.37) 3.29** (1.36, 7.96) 1.15 (0.47, 2.81) 10.1 Lollies 171 1.57 (0.68, 3.61) 1.72 (0.67, 4.44) 1.29ᵇ (0.55, 3.02) 3.8 Savoury food items Fast food 148 1.18 (0.57, 2.40) 3.77** (1.57, 9.05) 1.21ᵇ (0.59, 2.47) 11.0 Savoury bisc. 166 0.94 (0.40, 2.21) 2.70* (1.10, 6.62) 1.69 (0.72, 3.96) 7.5 Potato chips 166 1.05 (0.48, 2.31) 2.51* (1.13, 5.61) 1.09 (0.46, 2.61) 5.3

Note. OR = odds ratio. CI = 95% confidence intervals of OR. R² = Nagelkerke. The prediction model includes three predictors together without maternal and child characteristic covariates (see Section 5.4.2.3, Figure 5.4) Child had been exposed to the item by 14 months. ᵇ Child had been exposed to the item by 2 years. * p < .05. ** p < .01. *** p < .001. 5.4.3.2 Child intake frequency

Table 5.5 shows that child high intake frequency predicted higher odds of

child high liking for the sweet foods and drinks examined but did not predict child

high liking for any of the savoury foods. Child high intake frequency for soft drink

predicted the highest odds for child high liking than any other item examined, with

child high intake frequency predicting 11.06 times greater odds of child high liking

than a lower child intake frequency of soft drink (95% CI: 4.38, 27.93, p = .001). In

addition, the total variance in child high liking for soft drinks explained by the three

predictors was much higher than for any other restricted item examined (Nagelkerke

R² = 38.7) and was almost totally explained by child high intake frequency in the

bivariate analysis (see Appendix P, Table P.1). Sweet biscuits were the only other

item where child high intake frequency was the highest predictor for child high liking

and the odds predicted were the second highest of all items examined (OR 4.84,

95% CI: 1.80, 13.02, p = .002). Child high intake frequency also predicted significant

odds of high child preference for fruit drink (OR 2.47, 95% CI: 1.09, 5.59, p = .030)

but this was secondary to prediction by mothers’ own high liking. While child high

intake frequency did not predict significant odds of child high liking for cake and

lollies, the predicted odds still indicated a positive trend for both items.

166 Chapter 5: Quantitative Method & Findings

5.4.3.3 Mothers’ own high liking

While child high intake frequency predicted the highest and second highest

significant odds of child high liking for soft drink and sweet biscuits, mothers’ high

liking most commonly predicted the highest odds of child high liking across the

range of restricted foods and drinks examined. Mothers’ high liking predicted the

highest and significant odds of child high liking for sweet items of fruit drink (OR

4.72, 95% CI: 1.51, 14.80, p = .008) and cake (OR 3.29, 95% CI: 1.36, 7.96, p =

.008). Significant odds were not predicted for the other three sweet items but

findings still showed a positive trend towards mothers’ high liking predicting child

high liking (soft drink, sweet biscuits and lollies). Bivariate odds predicted by

mothers’ high liking for soft drink were significant (OR 2.56, 95% CI: 1.06, 6.18, p =

.036) but confounded by the child high intake frequency predictor, reducing odds to

non-significance in the prediction model (OR 1.80, 95% CI: 0.63, 5.12, p = .269).

Mothers’ high liking predicted significant odds of high child liking for all the savoury

foods examined and was the only predictor to predict significant odds for any of the

savoury foods examined (fast foods, OR 3.77, 95% CI: 1.57, 9.05, p = .003; savoury

biscuits, OR 2.70, 95% CI: 1.10, 6.62, p = .030; chips, OR 2.51, 95% CI: 1.13, 5.61,

p = .024).

While mothers’ high liking predicted the highest odds of child high liking for

lollies, odds predicted were the lowest of all items examined and the only item

where the highest odds predicted were not significant (OR 1.72, 95% CI: 0.67, 4.44,

p = .259). As mentioned in Section 5.4.3.1, the total variance in child liking for lollies

explained by the three predictors together was also the lowest of all the restricted

items examined (Nagelkerke R² = 3.8).

5.4.3.4 Child early exposure

Table 5.5 shows that child early exposure predicted fairly low and non-

significant odds of child high liking for all the restricted food and drink items

examined. The highest odds of child high liking predicted by child early exposure

was for savoury biscuits, although this was still relatively modest and not significant

(OR 1.69, 95% CI: 0.72, 3.96, p = .228). Bivariate odds showed that child early

exposure only predicted significant odds of child high liking for soft drink (OR 3.23,

95% CI: 1.56, 6.68, p = .002), which was confounded by child high intake frequency

in the prediction model (OR 1.19, 95% CI: 0.47, 3.00, p = .713). With the exception

Chapter 5: Quantitative Method & Findings 167

of soft drink, the minimal associations between early exposure and child liking were

not explained by child high intake frequency and confounding analysis showed the

predictor of mothers’ own liking had minimal additional influence on these

associations (see Appendix R, Table R.1). An unusual finding was the negative

associations between child early exposure and child high liking for fruit drink and

sweet biscuits in both the bivariate and prediction models (see Appendix P, Tables

P.2 & P.3). These findings suggested that early exposure to these items reduces the

odds of child high liking at 5 years old, although these findings were not significant.

5.5 SUMMARY OF FINDINGS

Research question 2

What are the patterns of child intake frequencies of a selection of commonly

restricted foods and drinks at 5 years old and how do these patterns align with

children’s progressive introduction to and development of their liking for these foods

and drinks at ages 14 months, 2 years, 3.7 years and 5 years?

Examination of descriptive data showed variability in children’s intake

frequency of common restricted items identified in the qualitative component of this

study. Soft drinks, fruit drink and fast foods were restricted the most (low intake

frequency) and sweet biscuits and cake restricted the least (high intake frequency).

Patterns of children’s introduction to items showed a progressive increase in access

for all items as children became older. The pattern of progressive introduction

aligned with the variation in children’s intake frequency at child aged 5 years, with

sweet biscuits having been introduced earliest also showing the highest intake

frequency at 5 years. Soft drinks, fruit drink and fast foods were more likely to be

introduced at a later age and showed the lowest intake frequency at child aged 5

years. However, the pattern for lollies was notably different. While a relatively lower

percentage of children had been introduced to lollies at 14 months, introduction

accelerated when children reached 2 and 3.7 years old. A similar but not as

pronounced pattern was also observed for potato chips (crisps).

Variability in child high liking for the same restricted items showed a

corresponding progressive pattern of increasing high liking with increasing child age.

Soft drink, fruit drink and fast foods were the least liked items, which were also the

items introduced at older child ages and had the lowest child intake frequency at 5

168 Chapter 5: Quantitative Method & Findings

years. In contrast, sweet biscuits and other items that were introduced earlier were

more frequently consumed at child aged 5 years and showed higher levels of child

high liking across child ages. However, while lollies (and to some degree potato

chips) tended to be introduced later, their pattern of accelerated introduction around

2 to 3.7 years old aligned with similar levels of intake frequency and high liking by 5

years old, to other items that had been introduced earlier.

Research question 3

What are the unique associations between child intake frequency at 5 years, child

early exposure and mother’s own liking for a selection of commonly restricted foods

and drinks and child liking for the same items at 5 years old?

Examination of associations between selected variables by multivariable

binary logistic regression showed that mothers’ own high liking and child high intake

frequency each uniquely predicted higher odds of child high liking for the sweet

foods and drinks examined. However, only mothers’ own high liking predicted higher

odds of child high liking for the savoury foods examined. Child early exposure did

not predict significant odds of child high liking for any of the foods or drinks

examined.

Mothers’ own high liking most commonly predicted the highest odds of child

high liking across the range of restricted food and drink items examined but child

high intake frequency for soft drink and sweet biscuits predicted the highest odds for

child high liking of all the associations examined.

Overall, the variance in child high liking explained by the three predictors of

child early exposure, child intake frequency and mothers’ own high liking varied

between items. Soft drinks showed the most variance explained by the predictors,

whereas lollies showed minimal variance explained by them. This suggests that

predictors beyond those examined may influence child liking for the restricted foods

to differing extents, with child liking for lollies potentially influenced to the greatest

extent by variables not examined in this study.

The findings of this component of the study are discussed together with the

findings of the qualitative component of the study in Chapter 6, Section 6.2.

Chapter 6: Discussion & Conclusions 169

Chapter 6: Discussion & Conclusions

6.1 INTRODUCTION

This study argued that there is a lack of clear definition and

conceptualisation of how the restrictive feeding phenomenon is experienced by

mothers and their children. It proposed that this has hindered the development of

effective measures to assess how this phenomenon might contribute to children’s

risks of diet-related diseases and obesity. The aim of this study was twofold. Firstly,

to gain a more in-depth understanding of the restrictive feeding phenomenon and

develop an initial conceptual framework that identifies its key dimensions. Secondly,

to identify the key dimensions of this phenomenon that may influence child liking for

restricted foods and drinks. This was for the purpose of identifying the dimensions

that might be important to include in a measure aiming to assess the effects of

restrictive feeding on children’s future dietary health (see Chapter 2, Section 2.8).

The intention was that knowledge gained from this study would provide an initial

step towards future development of more construct valid measures of restrictive

feeding used to assess children’s diet-related outcomes (see Chapter 1, Section

1.2). As discussed in Chapter 3, a sequential mixed methods approach was

selected to fulfil the aim of this study. The initial qualitative component involved

interviewing a sample of mothers and their first born children, aged 5 to 6 years old

(n = 29). A set of sensitising concepts provided direction for this study based on

gaps in current literature (see Chapter 2, Section 2.6) and further uncanvassed

themes emerged in this exploratory component of the study (see Chapter 4). The

quantitative component of the study provided more objective analysis of a larger

sample of mother and child dyads (n = 211) but was limited by the variables

available within a secondary data source (NOURISH trial, Daniels et al., 2009). This

component complemented and extended findings emerging from the qualitative

component and existing knowledge. The qualitative and quantitative findings have

been reported in Chapters 4 and 5 respectively.

This chapter forms the final part of the sequential mixed methods approach,

presenting an integrated discussion of the qualitative and quantitative findings in the

context of existing research literature. It builds on the potential dimensions of the

restrictive feeding phenomenon presented in Chapter 2, Section 2.6 to propose an

170 Chapter 6: Discussion & Conclusions

initial conceptual framework incorporating the dimensions of restrictive feeding

identified by the present study (Sections 6.2 and 6.3). It also discusses the

implications for existing measures of restrictive feeding and how restrictive feeding

might be measured in the future (Sections 6.4 and 6.5). Section 6.6 makes

recommendations for further research to continue to build empirical evidence for an

evidence-based conceptual framework of the restrictive feeding phenomenon and

Section 6.7 proposes potential options for translating findings into practical

measures. Section 6.8 and 6.9 highlight the implications for practice and the

strengths and limitations of the study. Section 6.10 presents the final conclusion of

the study.

6.2 TOWARDS A CONCEPTUAL FRAMEWORK: REVISITED

Chapter 2, Section 2.6 outlined a preliminary set of dimensions of the

restrictive feeding phenomenon based on existing knowledge from both qualitative

and quantitative studies. Sections 6.2.1 to 6.2.7 revisit these dimensions,

elaborating with the new knowledge gained from the qualitative and quantitative

components of the present study. Section 6.3 outlines how these dimensions might

relate to each other and contribute to child liking for restricted foods and drinks.

These together, present an initial conceptual framework of the restrictive feeding

phenomenon to provide a basic framework for building an evidence-base. The

following six dimensions of the restrictive feeding phenomenon presented are based

on the six emergent themes from the qualitative component of the study, extended

with evidence from quantitative findings and existing studies.

1. Foods and drinks restricted and level of restriction.

2. Mothers’ motivation for restrictive feeding.

3. Restrictive feeding practices.

3a. Mothers’ restrictive feeding behaviours.

3b. Mothers’ restrictive feeding communication.

4. Patterns of the restrictive feeding phenomenon over time.

5. Associations between restrictive feeding and other controlling feeding

practices.

6. The influence of mothers’ own liking for restricted foods and drinks.

Chapter 6: Discussion & Conclusions 171

6.2.1 Dimension 1: Foods and drinks restricted and level of restriction

Restricting children’s intake of a targeted food or drink is what parents are

fundamentally aiming to achieve with their restrictive feeding practices. However,

the dimension of children’s access to restricted foods and drinks within the

restrictive feeding phenomenon has not been considered by measures of parent

restrictive feeding used in cohort studies to date (see Chapter 2, Sections 2.6.3).

The findings of the present study propose that there are potentially two components

to this dimension that need consideration. Firstly, identification of the specific foods

and drinks targeted for restriction by parents and secondly, how children’s intake

(level of restriction) of these foods and drinks might influence their preferences for

them (see Chapter 4, Section 4.2).

With regard to the first point, existing literature provides very little

information about which foods and drinks parents target for restriction (see Chapter

2, Section 2.6.3). The qualitative component of this study identified foods and drinks

reported to be restricted by mothers for their 5 to 6 year old first born children. It

found that all mothers restricted their children from consuming some foods and

drinks and mothers varied the level of restriction (restricted intake) they applied to

different foods and drinks (see Chapter 4, Section 4.2). Most foods and drinks were

reported to be restricted in moderation, with only soft drinks (carbonated sweet

drinks) and fast foods (e.g. McDonalds, KFC, Hungry Jacks) reported to be totally

restricted by some mothers in this sample. Quantitative descriptive data clarified a

similar pattern of variation of child intake frequency (i.e. level of restriction) for a

selection of commonly restricted foods and drinks reported in the qualitative

component of this study. This showed sweet drinks and fast foods/takeaway to be

most highly restricted (least frequently consumed by children) and cakes and sweet

biscuits to be least restricted (most frequently consumed by children) for this sample

of 5 to 6 year olds (see Chapter 5, Section 5.3.3.1). Interestingly, sweet drinks,

which were found to be most highly restricted, do not feature in current measures of

restrictive feeding (see Chapter 2, Section 2.4.2).

Another novel finding was that mothers reports of differential levels of

restriction applied to different foods and drinks suggested similar targeting of items

amongst mothers in this sample. Furthermore, reported levels of restriction

appeared to vary more by specific restricted foods and drinks than by overall levels

of restriction applied between individual mothers (See Chapter 4, Section 4.2.1).

172 Chapter 6: Discussion & Conclusions

These findings strongly suggest that measurement of child intake of specific

restricted foods and drinks is likely to be a more valid measure of level of restriction

than using composite scores of foods and drinks, which has been utilised in cohort

studies to date (see Chapter 2, Section 2.4.3.2). Furthermore, the qualitative and

quantitative findings of the present study show a similar order of differential targeting

of items to Gubbels et al.’s (2009) study. Gubbels et al. found a similarly high

proportion of 2 years olds were not allowed to consume soft drinks (42%) but the

proportion of children not allowed other restricted items was markedly lower (sweets

[lollies], 9.9%; crisps [potato chips], 5.9%; cake, 4.1%; cookies, 1.4%) (n = 2578).

Koh et al.’s (2010) findings also suggested similar differential targeting of the

introduction of items with only 32% of children having been introduced to cordial and

soft drinks in the first year of life, in contrast to 92% already introduced to biscuits

and cakes. Together, these findings suggest that there may be a common pattern of

differential targeting for restricted foods and drinks beyond the present sample. If

this is the case, a standard list of commonly restricted foods and drinks could

potentially be established to examine this phenomenon, although targeting could

vary between different cultures with different food traditions.

Qualitative data suggested higher child interest in a restricted food or drink

that is familiar to them and disinterest in unfamiliar restricted foods or drinks when

these were made available in social situations (see Chapter 4, Section 4.2.2). While

the limited existing evidence of these associations for foods and drinks potentially

targeted for restriction was consistent with these findings (Birch & Marlin, 1982;

Grimm et al., 2004; Hartvig et al., 2015; Liem & de Graaf, 2004; Sullivan & Birch,

1990) (see Chapter 2, Section 2.6.3), the present quantitative study showed

differences in findings between sweet and savoury items examined. Quantitative

findings were consistent with qualitative reports and existing evidence for the sweet

foods and drinks examined35, showing an association between higher child intake

(low restriction) of these items and high child liking. However, findings did not show

a comparable pattern of results for the savoury foods examined i.e. fast foods,

savoury biscuits and potato chips (see Chapter 5, Section 5.4.3.2). While further

investigation is required to establish whether these findings might be replicated in

other samples, Tindall, Smith, Peciña, Berridge, and Aldridge (2006) did find that

stimulation of “pleasure hotspots” in the brain (ventral pallidum) of rats showed

different responses for sweet and salty foods. They found that neurological liking 35 Soft drink, fruit drink, lollies, cakes, sweet biscuits and ice cream.

Chapter 6: Discussion & Conclusions 173

responses for salt taste only matched that of sucrose (sugar) when test animals

were salt depleted. This suggests that it is possible that associations between

children’s intake and liking for sweet and savoury foods may vary. However, neither

qualitative nor quantitative data in the present study provided evidence of an

association between higher restriction (low intake) and higher child preferences for a

restricted food or drink. Therefore, the findings of the present study do not support

the claims made by short-term restriction experiments, that restriction of a food

increases a child’s preference for it (Fisher & Birch, 1999a; Jansen et al., 2008;

Jansen et al., 2007; Ogden et al., 2013; Rollins et al., 2014a) (see Chapter 2,

Section 2.3). Overall, the findings for this dimension of the restrictive feeding

phenomenon suggest that children’s level of restriction of a food or drink is an

important dimension of restrictive feeding to measure, due to the potential

associations between children’s intake and liking for restricted foods and drinks.

Furthermore, these findings suggest that such measurement needs to be specific to

the restricted food or drink rather than assessing the effects of this phenomenon

using a composite measure of restricted foods and drinks.

Dimension summary

A set of foods and drinks reported to be commonly restricted by mothers

was identified by the present study. Mothers apply different levels of restriction to

different foods and drinks and a common pattern of differential targeting of foods

and drinks was apparent amongst mothers. Consistency with existing studies of

child access to different foods and drinks, suggests a possible common pattern of

differential restriction of foods and drinks beyond this study. While qualitative

findings suggest that children’s familiarity with restricted foods and drinks are

positively associated with higher child interest in that food or drink, quantitative

findings only confirmed an association between higher child intake frequency and

high child liking for the sweet foods and drinks examined. No association was found

for the savoury foods examined. The findings of the present study do not support the

findings of existing experimental restriction studies, which suggest that higher

restriction of a food is associated with greater child preferences for a food (see

Chapter 2, Section 2.3). Findings were instead consistent with existing evidence of

an association between repeated intake of sweet foods and drinks and child liking

for that food or drink (see Chapter 2, Section 2.6.3), although such an association

was not found for savoury foods. The findings of the present study suggest that

children’s level of intake of restricted foods and drinks is an important dimension to

174 Chapter 6: Discussion & Conclusions

include in measurement of the restrictive feeding phenomenon. In addition,

restricted foods and drinks need to be examined separately because different levels

of restriction tend to be applied to different foods and drinks by individual mothers.

6.2.2 Dimension 2: Mothers’ motivation for restrictive feeding

Mothers’ motivation for restrictive feeding was predominantly for their

child’s health, with motivation to prevent child weight gain only mentioned as a

secondary consideration by some. The predominant motivation for child health was

consistent with other qualitative studies, which included participants from a range of

socio-economic groups and ethnic origins (Alderson & Ogden, 1999; Carnell et al.,

2011; Herman et al., 2012; Moore et al., 2007; Sherry et al., 2004; Ventura et al.,

2010) (see Chapter 2, Section 2.6.2). These findings do not suggest a dichotomy of

parent motivations to restrict for either health or weight reasons, as proposed by

Musher-Eizenman and Holub’s (2007) scale. However, it is recognised that further

research with different samples, including greater numbers of heavier children or

older children, may elicit parent motivation for restrictive feeding specifically related

to child weight (see Chapter 2, Section 2.6.2).

Qualitative reports also revealed that mothers perceived relative “nutritional

value” of a specific restricted food or drink commonly contributed to restriction

decisions. This novel finding suggested that items perceived as offering the lowest

“nutritional value” by a mother were restricted to the greatest extent and visa versa.

However, inconsistencies in mothers applying their own criteria suggested that

mothers’ motivation was more complex than a simple desire for their child to have a

“healthy” diet. For example, while mothers commonly stated that they totally

restricted soft drink because it is “just sugar” and offers “no nutritional value”, no

mothers totally restricted lollies, which they also suggested had “no nutritional

value”. Another novel finding was that mothers appeared to “balance” their

perception of “nutritional value” with the perceived enjoyment their child would

derive from consuming the restricted food or drink. Their desire for children to “join

in” socially provided some explanation but mothers also reported presenting these

items as “treats” within family controlled environments (see Chapter 4, Section

4.4.1.1). This suggested that a factor beyond social inclusion may also be

influencing mothers’ decisions to provide children with restricted foods. Pescud and

Pettigrew’s (2014a) and Roberts and Pettigrew’s (2013) qualitative studies

concluded that mothers’ motivation to give such foods as treats may be related to

Chapter 6: Discussion & Conclusions 175

their perceived need to secure their children’s affections. However, the present

study’s findings were more suggestive of mothers being motivated by a desire for

child happiness related to the pleasure of consuming of these foods. Mothers

commonly expressed the belief that their child would be “deprived” or “missing out” if

they did not have access to these desirable “unhealthy” foods and some even

suggested a belief that their child would obtain enjoyment from “overindulging” in the

consumption of restricted foods (see Chapter 4, Section 4.3.1). Therefore, mothers’

motivation for “balance” in the present study appeared to be related to two

competing motivations for a healthy but happy child, with a happy child being based

on mothers’ perceptions of child happiness derived from consuming these foods and

drinks, as well as social inclusion.

Chapter 2, Section 2.2 highlighted that current literature has not presented

a clear definition or concept of restrictive feeding. A novel finding in the present

study was that mothers reported two distinct restrictive feeding intentions, total

restriction and restriction in moderation. There were items that they intended to

totally restrict, with the desire for child health being paramount and a perception that

there was “no need” for their child to consume these items. On the other hand, there

were items that, “it’s okay to have a treat occasionally” (Carolyn, 2:2), which were

allowed or given in moderation to “balance” mothers’ motivations for both a healthy

but happy child. Mothers appeared to want to believe that a “little” amount of these

foods and drinks would contribute to their child’s happiness through social inclusion

and the personal pleasure derived from eating these foods, but be insufficiently

harmful to their child’s health to outweigh the pleasure experienced. Some mothers

even expressed the belief that providing restricted foods in moderation, is preferable

to being highly restrictive, suggesting that high restriction leads to a child wanting

the food more (See Chapter 4, Section 4.3.1). While this appeared to be a

contradiction to mothers’ reports of an association between child familiarity and

preferences for restricted foods (see Chapter 4, Section 4.2.2), some mothers’

referred to this association applying when children became older. This could mean

that this belief relates to later experiences following child familiarity with a restricted

food (see Chapter 4, Section 4.5.1). However, mothers’ own reports of children’s

responses to restricted foods in social situations did not support an association

between higher child restriction (low intake) and high preference responses (see

Chapter 4, Section 4.5.2). An alternative explanation to these reports may be that

176 Chapter 6: Discussion & Conclusions

mothers’ are rationalising36 to reassure themselves that their own decision to allow

their child to consume restricted items in moderation is preferable.

As said, two different restrictive feeding intentions, total restriction and

restriction in moderation, were identified. In addition, a third but rarer category was

highlighted by the present study and labelled as inadvertent restriction. This arose

where mothers stated an intention to restrict a food but took no deliberate action

because the food was rarely accessible to the child in their natural lives. Not only

were these different restrictive feeding intentions found to involve different levels of

restriction for different foods and drinks (see Section 6.2.1), but they were also

associated with different clusters of restrictive feeding characteristics across the

range of dimensions identified as constituting the restrictive feeding phenomenon.

Qualitative findings also suggested that these differences are likely to lead to

different child feeding experiences, which potentially have differing effects on

children’s diet-related outcomes. Clusters of characteristics associated with these

different restrictive feeding intentions are discussed further in relation to other

dimensions of the restrictive feeding phenomenon in Sections 6.2.3 to 6.2.6 and are

summarised in Section 6.2.7, Table 6.2.

Dimension summary

Mothers’ motivation for restrictive feeding appeared to be influenced by

competing desires for both a healthy and happy child, with perceptions of child

happiness derived from certain foods and drinks being associated with mothers’

decision to restrict a food or drink in moderation rather than totally restrict it. In

relation to this, three characteristically different restrictive feeding intentions were

apparent, total restriction and restriction in moderation, as well as inadvertent

restriction, which involved an intention to restrict but without any deliberate action

taken. These different intentions were found to be associated with different clusters

of characteristics across a range of dimensions constituting the restrictive feeding

phenomenon and were applied variably by individual mothers to different foods and

drinks.

36 ‘Rationalisation’ was first highlighted in psychoanalysis by Ernest Jones in 1908 (Jones, 1908). He defined it as ‘the inventing of a reason for an attitude or action the motive of which is not recognised’ and ‘...justified by...providing a false explanation that has a plausible ring of rationality'. It is a defence mechanism used to justify or avoid true explanations to controversial behaviour or feelings, making these consciously tolerable by plausible means of reasoning.

Chapter 6: Discussion & Conclusions 177

6.2.3 Dimension 3: Restrictive feeding practices

What constitutes restrictive feeding practices has not been clearly defined

by existing studies (see Chapter 2, Sections 2.4.2) and measures of restrictive

feeding have only included limited reference to some parent restrictive feeding

behaviours (actions) (see Chapter 2, Sections 2.6.4). Qualitative findings of the

present study suggest that the concept of restrictive feeding practices should be

expanded to include parent’s associated communication (see Chapter 4, Sections

4.4.1 and 4.4.2). In this context, Section 6.2.3.1 discusses the sub-theme of

mothers’ restrictive feeding behaviours (Theme 3a) and Section 6.2.3.2 discusses

the sub-theme of mothers’ restrictive feeding communication (Theme 3b).

6.2.3.1 Dimension 3a: Mothers’ restrictive feeding behaviours

Qualitative findings in the present study suggested that mothers use three

main types of restrictive feeding behaviours: rules, flexible judgement and avoiding

access. Such differentiation in types of restrictive feeding behaviours has not been

reported in existing qualitative studies (see Chapter 2, Section 2.6.4). However,

specific feeding behaviours reported in the present study were consistent with

existing studies, although the present study reported a number of additional

behaviours mothers use outside the home and within social contexts (see Chapter

4, Section 4.4.1.4). Table 6.1 below shows mothers’ restrictive feeding behaviours

reported in the present study for family-controlled environments, grouped by the

identified three types of restrictive feeding behaviours (first column). The second

column shows how parent restrictive feeding behaviours reported in other qualitative

studies and those included in measurement scales align with the three types of

restrictive feeding behaviours proposed by the present study. Practices included in

measurement scales used in quantitative cohort studies are highlighted in bold type

(second column).

178 Chapter 6: Discussion & Conclusions

Table 6.1

Comparison of Restrictive Feeding Behaviours Reported in the Present Study with Those

Reported in Existing Qualitative Studies or Included in Measurement Scales in Quantitative

Studies

The present qualitative study Other qualitative studies and measurement scales (Lead author, date)

Avoiding access • Avoid access at home: don’t buy often, buy

limited amount, don’t buy at all. • Keep restricted items out of sight e.g. lolly

bags. • Throw some gifted lollies away. • Offer healthy options instead of restricted

items e.g. fruit • Offer homemade healthy versions of

restricted foods e.g. pizza, cake. • Mother avoid negative modelling by

consuming restricted food out of child’s sight.

• Avoid (or limit) visits to fast food outlets. • Diluting juice or soft drink.

• Not buy /keep restricted foods in the home (Ogden, 2006; Jansen, 2014 [covert scale]; Ventura, 2010; Moore, 2007; Sherry, 2004; Martinez, 2014)

• Not allow child to consume restricted food at home (Ventura, 2010).

• Keep foods out of child’s reach/sight at home (Birch, 2001 [CFQ]; Jansen, 2014 [overt scale]; Carnell, 2011)

• Hide restricted foods from child (Sherry, 2004) • Negotiate or offer alternative healthy or healthier

food (Moore, 2007; Carnell, 2011; Sherry, 2004) • Try not to eat unhealthy foods when child

around (Ogden, 2006 [Covert scale]) • Avoid going to cafes or restaurants that sell

unhealthy foods (Ogden, 2006; Jansen, 2014 [Covert scale]; Moore, 2007)

• Give small helpings at meals to control weight (Musher-Eizenman, 2007)

Rules • Limit when offered by rules or routine e.g.

time of day, day of week, after meal, special occasions.

• Must eat dinner before dessert. • Child not allowed to have restricted food

eaten by parents, ”mummy’s and daddy’s food” e.g. chips.

• Limit number, portion or packet size of restricted item.

• Food rules (when, where, how much) (Martinez, 2014; Herman, 2012)

• Limit restricted food to certain times or special occasions (Moore, 2007; Carnell, 2011; Martinez, 2014)

• Limit quantity or portion of a restricted food child allowed (Ventura, 2010; Carnell, 2011; Sherry, 2004; Martinez, 2014)

• Don’t allow to eat between meals, so won’t get fat (Musher-Eizenman, 2007)

Flexible judgement • Flexibly judge the amount of restricted

food consumed over the day or week to achieve a “balance”

• Give “healthy” foods prior to accessing “unhealthy” foods

• Limit when offered by “surprises” • Compensate with “healthy” foods at home

for ‘unhealthy’ foods at parties and social events.

• Amount gauged by mother by saying: “no” or “that’s enough” after a certain amount consumed.

• Situational flexibility to limit restricted food intake over period of time e.g. consider previous days intake (Carnell, 2011)

• Limit when perceive eating too much (Ventura, 2010)

• Restricted food only made available with parent permission (Carnell, 2011)

• Verbal discouragement e.g. tell stop eating, say “no” to requests (Carnell, 2011; Herman, 2012)

• If eats more at one meal, restrict eating at next meal (Musher-Eizenman, 2007)

Items included in measurement scales in bold type.

Qualitative findings also suggest that individual mothers tend to use a

range of restrictive feeding behaviour types (i.e. rules, flexible judgement, avoiding

access), with the same mother applying different behaviours to different foods and

drinks, in different contexts and at different times. Total restriction of a food or drink

mostly involved behaviour related to avoiding access, with some mothers applying

overt rules. However, restriction in moderation of a food or drink often involved all

Chapter 6: Discussion & Conclusions 179

three types of behaviour within different contexts and over the course of the day or

week, (see Chapter 4, Section 4.4.1). Therefore, types of restrictive feeding

behaviours may not be distinct to groups of mothers but rather flexibly used by

individual mothers, as well as flexibility used in relation to a specific food or drink.

This finding was consistent with reports of mothers using a wide range of behaviours

in other qualitative studies (Moore et al., 2007; Ventura et al., 2010) and reference

to mothers’ striving for balance, rather than abiding by rigid patterns of practices

(Carnell et al., 2011; Moore et al., 2010).

The implications of these findings are firstly that the complex array of

restrictive feeding behaviours an individual mother might use is likely to be difficult to

measure and it is unclear whether a valuable distinction between individual mothers’

range of behaviours would be possible. Secondly, no evidence that different

restrictive feeding behaviours have different effects on children’s preferences for

restricted foods and drink was found in existing literature (see Chapter 2, Section

2.6.4) or presented by the qualitative data in the present study. Qualitative data only

suggested that rules might elicit what some mothers’ regard as more desirable child

behaviour responses than children’s responses to some forms of flexible judgement

or mothers’ inconsistent behaviour (see Chapter 4, Section 4.4.1.3). Such behaviour

responses are consistent with existing knowledge of child behaviour conditioning

(Domjan, 2015) but this evidence does not extend to differences in child food

preferences associated with different parent restrictive feeding behaviours.

As mentioned in Section 6.2.1, measurement scales to date do not

measure children’s level of restriction. Instead, they focus on levels of parent activity

(see Chapter 2, Section 2.4.2). The qualitative data provided a number of examples

where mothers’ reported restrictive feeding behaviours did not necessarily reflect

children’s level of access to restricted foods and drinks (see Chapter 4, Section

4.4.1.1). In addition, Holland et al.’s (2014) study suggested that higher scores on

the CFQ restriction scale (Birch et al., 2001) may even reflect greater child access to

restricted foods (see Chapter 2, Section 2.4.4). Measurement of child intake directly

is preferable for determining the level of restriction. What is important to determine

for restrictive feeding behaviours is whether different behaviours independently

influence child diet-related outcomes. However, existing measures do not

differentiate a range of alternative types of restrictive feeding behaviours, such as

rules, flexible judgement and avoiding access, in order to assess whether different

behaviours result in different diet-related outcomes for children.

180 Chapter 6: Discussion & Conclusions

The CFQ restriction scale (Birch et al., 2001) only includes one restrictive

feeding practice related to avoiding access. Although Ogden et al. (2006) and

Jansen et al. (2014) provide a covert scale with a set of avoiding access behaviours,

the overt scales do not provide a complementary set of practices to assess variation

in behaviours. Likewise, Musher-Eizenman and Holub’s (2007) scale does not

provide complementary sets of types of practices (see Chapter 2, Section 2.4.2).

Further research is required to establish whether different restrictive feeding

behaviours independently influence child preferences (or liking or wanting) for

restricted foods and drinks before a decision regarding the inclusion or exclusion of

this dimension within measurement of restrictive feeding can be considered. If

restrictive feeding behaviours do not independently influence child preferences (or

liking or wanting) for restricted foods and drinks then this dimension may not need to

be included in a measure aiming to assess the effects of restrictive feeding on

children’s risk of developing diet-related diseases or obesity.

Another factor to consider is that the influence of home and social

environments on children’s liking for restricted foods and drinks may vary between

specific restricted items. Quantitative findings indicated that different dimensions of

the restrictive feeding phenomenon may have varying effects on child liking for

different foods and drinks. The lowest total variance explained by the three

predictors examined in the quantitative component of this study (mothers’ liking,

child intake, child early exposure) was for lollies (see Chapter 5, Section 5.4.3.1).

This finding corresponded with mothers’ qualitative reports suggesting that of all the

restricted items examined, children’s access to lollies was most influenced by

variables outside the home, such as parties and gifts from relatives (see Chapter 4,

Section 4.4.1.1). This suggests that different dimensions of parental restrictive

feeding within family and social environments, as well as potential associated

covariates (e.g. food rewards, see Section 6.2.5), may exert variable effects on child

liking for different restricted foods and drinks. Such variability between items has not

been considered by studies to date but appears to be an important aspect of this

phenomenon to consider in future studies.

Dimension summary

The present study identified three main types of restrictive feeding

behaviours: rules, flexible judgement and avoiding access. Individual mothers

applied these behaviours flexibly, with variation relating more to different restricted

Chapter 6: Discussion & Conclusions 181

foods and drinks and contexts than to different groups of mothers. It is likely that

individual mothers’ use of multiple restrictive feeding behaviours may prevent

meaningful distinction between mothers. Furthermore, this study found no evidence

of an association between restrictive feeding behaviours and child preferences (or

liking or wanting) for restricted foods and drinks, although further research is

required to clarify these associations. If a unique association between restrictive

feeding and child preferences (or liking or wanting) for restricted foods and drinks is

not subsequently found, this complex dimension may not need to be included in a

measure of restrictive feeding aiming to assess effects on children’s risk of diet-

related diseases or obesity.

6.2.3.2 Dimension 3b: Mothers’ restrictive feeding communication

Qualitative data suggests that the concept of restrictive feeding practices

should be expanded to include parent communication (see Chapter 4, Section

4.4.2). Current measures of restrictive feeding do not include reference to parent

communication associated with restrictive feeding practices (see Chapter 2, Section

2.4.2) and only one study examining restrictive feeding communication was

identified. This study examined mothers’ affective tone of restrictive feeding

communication associated with mother and child characteristics but did not extend

to assessing specific effects on child outcomes (Pesch et al., 2016). While Ogden et

al. (2006) contributed an important conceptual distinction between overt and covert

feeding practices (see Chapter 2, Section 2.2 and 2.6.5) these concepts were

presented in terms of parent feeding behaviours. Ogden et al.’s covert scale was

presented with items resembling a set of parent restrictive feeding behaviours of

avoiding access (see Chapter 2, Section 2.4.2) but the qualitative component of this

study found that these behaviours could be delivered either covertly or overtly,

depending on the associated communication. For example, while some mothers

avoided fast food outlets completely, not all mothers did this covertly, with some

overtly discussing the reasons for avoidance with their child. In addition, other

mothers reported avoiding fast food outlets but attended them on a limited basis,

often with the child being aware of an overt rule about access. Likewise, mothers’

reports of avoiding buying restricted food and drink items at the supermarket usually

involved buying the items less often or in limited amounts rather than not at all. Even

the covert practice of not taking a child to the supermarket did not preclude the

restricted items being bought and overtly given to the child on a limited basis at

home (see Chapter 4, Section 4.4). The present study, therefore, proposes that

182 Chapter 6: Discussion & Conclusions

mothers’ communication associated with a restrictive feeding behaviour needs to be

measured in order to determine whether a restrictive feeding practice is delivered

overtly or covertly.

Another novel finding was that qualitative data provided examples of

mothers’ overt communication, with distinct variations in positive, neutral and

negative connotations about different restricted foods and drinks. This is a

dimension of restrictive feeding practices that has not been considered by previous

research or reflected in measurement scales (see Chapter 2, Section 2.4.2). All

mothers said they spoke overtly to their child about foods and drinks they restrict in

moderation and they commonly reported using language with positive connotations

about the restricted item or reference to the item tasting good. Furthermore, the

uncanvassed and novel finding that mothers’ frequently refer to foods restricted in

moderation as “treats” suggests that this is an integral part of restriction in

moderation (see Chapter 4, Section 4.4.2.1). This raises the question of whether

children’s responses and outcomes related to restriction in moderation could be

associated with the presentation of the restricted food as a “treat”, rather than

because the food is restricted. Furthermore, the concept of giving a restricted food

as a “treat” may have similarities with the giving of foods as rewards, which is

generally defined by the research community as a separate controlling feeding

practice (Wardle et al., 2002) (see Section 6.2.5).

In contrast, qualitative data suggested that mothers tend to use more

factual language when talking to their child about unrestricted foods, saying that

these foods are “healthy” and good for your body (see Chapter 4, Section 4.4.2.1).

This variation in language when referring to restricted and unrestricted foods was

remarkably similar to Worsley, Baghurst, Worsley, Coonan, and Peters (1984)

finding that children’s concepts of foods reflected polarising oppositions, where

vegetables were commonly regarded as good for you but chocolate was regarded

as tasting good. While no studies examining the effect of parent verbal

communication on children’s liking for restricted foods and drinks were identified,

Pliner and Loewen (1997) reported that verbal communication suggesting that a

food tastes good reduced children’s neophobia towards a food but communication

that it’s good for you had no effect on neophobia. Some mothers highlighted that

calling a “healthy” food a “treat” could positively influence their child’s perception of

that food but there were very few examples of this application given (see Chapter 4,

Section 4.4.2.1). Therefore, while mothers in the present study may be teaching

Chapter 6: Discussion & Conclusions 183

their children about which foods are good for them, their common reference to

restricted foods as “treats” and tasting good may be encouraging their children to

like the foods they restrict in moderation more than the “healthy” foods they want

them to eat.

Verbal communication could also be accompanied by non-verbal

communication with positive connotations in the form of facial expressions or

modeling consumption of restricted foods or drinks. Such non-verbal communication

could influence child preferences for a restricted food during periods of access

associated with in moderation restriction. Evidence quite clearly suggests that

modeling consumption of a food positively influences children’s liking, selection and

intake of foods (Addessi et al., 2005; Bevelander, Anschutz, & Engels, 2012; Birch,

Zimmerman & Hind, 1980; Brown & Ogden, 2004; Duncker, 1938; Harper &

Sanders, 1975; Hobden & Pliner, 1995; Romero, Epstein, & Salvy, 2009; Salvy,

Vartanian, Coelho, Jarrin, & Pliner, 2008). Studies also suggest that mothers are the

most influential models for young children (5 to 7 years) (Harper & Sanders, 1975;

Salvy, Elmo, Nitecki, Kluczynski, & Roemmich, 2011) and that a food perceived as

valued by a respected other, such as a parent, teacher or peer, may influence a

child’s perception of that food and hence their liking for and wanting to consume that

food (Birch et al., 1980; Birch, 1986; Epstein, Leddy, Temple, & Faith, 2007). In

addition, repeated pairing of a restricted food or drink with pleasurable events such

as special family outings, parties or other social events, which in moderation

restriction tends to involve (see Chapter 4, Section 4.4.1), has been found to

enhance a child’s preference for a food (De Castro, 1994; Epstein et al., 2007;

Johnson, Bellows, Beckstrom, & Anderson, 2007; Ventura & Worobey, 2013).

Interestingly, Dickens and Ogden (2014) found that parents’ use of controlling

feeding practices (measured by Ogden et al.’s (2006) overt and covert controlling

feeding scale) had no effect on children’s consumption of unhealthy snacks a year

after they had left home but negative parent modelling of unhealthy snacks

continued to influence children’s consumption of unhealthy snacks. This evidence

suggests that verbal and non-verbal communication conveying positive connotations

about restricted foods or drinks associated with overt in moderation restriction, could

increase children’s preferences for these items and hence impact on children’s diet-

related outcomes.

In contrast, mothers commonly referred to foods and drinks they totally

restricted (soft drinks and fast foods) with negative connotations. They recalled

184 Chapter 6: Discussion & Conclusions

conversations with their children referring to fast food outlets as “disgusting” and a

“fat shop”, and to soft drinks as being “not good for you”, “full of sugar” or “rots your

teeth” (see Chapter 4, Section 4.4.2.1). Greenhalgh et al., (2009) found that

modelling dislike towards a food influenced young children’s dislike for a food and

was not reversed by subsequent positive modelling for the same food (n = 35, age 5

to 7 years; n = 44, age 3 to 4 years). Likewise, Stark, Collins, Osnes, & Stokes

(1986) found that negative verbal feedback about “unhealthy” foods increased

children’s intake of alternative “healthy” foods. Therefore, while communication with

positive connotations about restricted foods may increase a child’s preferences for a

restricted food, negative overt messages could be a powerful deterrent to the

development of child preferences. This suggests that while Ogden et al. (2006)

proposed that covert control may be preferable to overt control, further consideration

needs to be given to whether overt communication with negative connotations is

more or less effective at reducing child preferences for a restricted food than no

communication (covert). This is another component of this dimension that has not

been considered by restrictive feeding studies to date. Overall, restrictive feeding

communication is an integral part of the restrictive feeding phenomenon and the

present study proposes that the concept of restrictive feeding practices be

broadened to include this aspect. While further evidence is required, the

combination of the present study’s findings and existing evidence suggest that

communication associated with restrictive feeding practices is potentially an

important dimension to include in a measure of restrictive feeding.

Dimension summary

The present study expands Ogden et al.’s (2006) concepts of overt and

covert feeding practices, suggesting that parents’ communication associated with

restrictive feeding practices more readily differentiates overt and covert restrictive

feeding than parents’ restrictive feeding behaviours. A novel finding was that

mothers’ overt communication associated with restrictive feeding practices may

convey positive, neutral or negative connotations about restricted foods and drinks,

which existing evidence suggests may have differing effects on child preferences for

foods and drinks. In particular, mothers’ common reference to foods restricted in

moderation as “treats” appears to be an integral component of the restrictive feeding

phenomenon. Both verbal and non-verbal communication with positive connotations

about a restricted item could potentially enhance a child’s liking for a restricted food.

It is proposed that the concept of restrictive feeding practices be broadened to

Chapter 6: Discussion & Conclusions 185

include restrictive feeding communication and that further consideration is given to

the potential importance of including this dimension in a measure of restrictive

feeding.

6.2.4 Dimension 4: Patterns of restrictive feeding over time

Qualitative findings suggested that restrictive feeding is most commonly

reduced as children age, with mothers progressively changing their approach from

predominantly total restriction applied covertly to overt restriction in moderation.

Most items were restricted in moderation by the time children were 5 years old, with

only soft drinks and fast foods reported to be still totally restricted by some mothers.

This direction of change was consistent with Nielsen et al.’s (2013) qualitative study,

finding that children had predominantly been introduced to restricted high-sugar

foods and rules by 13 months old (see Chapter 2, Section 2.6.6). Qualitative findings

were also consistent with quantitative descriptive data patterns, which showed

progressive introduction to the selected restricted foods and drinks. Most children

had been introduced to most of the restricted items examined by 3.7 years old. This

was with the exception of soft drinks, fruit drinks and fast foods, which were the

same items reported to be most highly restricted in the qualitative component of the

study (see Chapter 5, Section 5.3.3.2).

However, this predominant pattern of reducing restriction as children aged

was inconsistent with existing quantitative studies. Farrow and Blissett (2012) found

that parents’ restrictive feeding was consistent between child ages 2 to 5 years. On

the other hand, Daniels et al. (2015) reported a trend of increasing parent restrictive

feeding between 2 to 3.7 years followed by consistency between 3.7 to 5 years, for

the same NOURISH sample used in the present study. However, inconsistencies

between these findings and qualitative reports in the present study may be due to

the CFQ restriction scale (Birch et al., 2001) being used as the measure of parent

restriction in Daniels et al.’s and Farrow and Blissett’s studies. This scale may reflect

greater parent restricting behaviour associated with greater child access to restricted

foods and drinks, rather than higher restriction (see Chapter 2, Section 2.6.6). If this

is the case, Daniels et al.’s findings align with the pattern reported in the present

qualitative study, indicating increasing parenting restrictive feeding behaviours

associated with increasing child exposure and access to restricted foods. While this

does not explain Farrow and Blissett’s findings of consistency, the higher

commencing CFQ restriction scale scores in Farrow and Blissett’s study could

186 Chapter 6: Discussion & Conclusions

reflect earlier child introduction to restricted foods than for the NOURISH sample

and hence parent restrictive feeding behaviours being consistent from an earlier

age. Farrow and Blissett’s findings showed a commencing mean score of 3.27

(0.67) for the CFQ restriction scale (Birch et al., 2001) at child aged 2 years as

opposed to 3.00 (0.05) for control participants in Daniel et al.’s study. Mean scores

at child aged 5 years were then similar for both studies, 3.25 (0.68) and 3.22 (0.06)

respectively.

As discussed in Section 6.2.1, qualitative data suggested that children

develop a higher liking for restricted foods once they had been introduced to them

and they had become familiar. In addition, mothers’ uncanvassed comparisons

between their 5 year old study child and younger siblings suggested that children

exposed to restricted items at younger ages displayed higher preference behaviours

towards these items. Such an association has been indicated by previous studies in

relation to healthy foods (Anez et al., 2013; Beauchamp & Mennella, 1998;

Cashden, 1994; Cooke et al., 2004; Liem & de Graaf, 2004; Schwartz et al., 2011;

Skinner et al., 2002) but there is limited evidence of this association for the innately

liked foods likely to be targeted for restriction, as well as whether such an

association might be independent of current intake (see Chapter 2, Section 2.6.6).

Quantitative descriptive data patterns of child introduction to and high liking for

restricted foods and drinks aligned with qualitative data findings, although these

patterns also aligned with higher child intake frequencies at 5 years (see Chapter 5,

Section 5.5). However, binary logistic regression analysis subsequently found

minimal to no association between child early exposure and child high liking for the

restricted items examined at 5 years, after adjusting for current child intake

frequency. Even before adjusting for child intake frequency, soft drink was the only

item to show significant bivariate odds (OR 3.23, 95% CI: 1.56, 6.68, p = .002).

These findings appeared to contradict qualitative reports in the present study and

Mallan et al.’s (2016) significant findings for a bivariate association between child

early exposure and child high liking for a set of non-core foods37, using the same

NOURISH sample (See Chapter 2, Section 2.6.6). One explanation for this

discrepancy could be that Mallan et al.’s (2016) sample was younger than the

present study i.e. 3.7 years. Soft drink, which showed a bivariate association in the

present study, was also found to be the item most likely to be introduced at a later 37 Ice cream, chips/corn chips, fast foods, sweet biscuits, savoury biscuits, lollies, cake (doughnuts, buns, pastries), muesli bars, chocolate, fruit sticks/straps, hot chips, chocolate spreads, honey/jam, vegemite, cheese spread/dip, peanut butter, fruit gel/jelly.

Chapter 6: Discussion & Conclusions 187

child age (see Chapter 5, Section 5.3.3.2). Therefore, it may be that as children

become older and have more frequent access to readily liked restricted foods,

earlier exposure becomes less significant for child liking. This may also explain why,

despite the relatively later introduction of lollies and potato chips shown in the

descriptive data patterns of the present study, children’s high liking for these items

at 5 years old aligned with the later accelerated introduction and relative intake

frequency by 5 years old (see Chapter 5, Section 5.5). Another potential reason for

differences in findings between the present study and Mallan et al.’s study was the

different foods and drinks examined. Mallan et al. used a composite measure of a

broad range of non-core foods and not all of these were identified as restricted foods

in the present study. However, Mallan et al.’s larger sample size (n = 340) may have

provided greater potential to detect significant differences. Further research is

required but these initial findings suggest that child early exposure may not be an

important dimension of the restrictive feeding phenomenon, being superseded by

current intake as children become older.

Furthermore, while the present study’s findings suggest a common

direction of progressive reduction in children’s restriction of foods and drinks up until

5 years old, a small number of mothers recounted experiences of their child’s

progressive exposure to restricted foods followed by later restriction. This finding

suggested that two alternative paths may be followed, with the first being a linear

increase in access to restricted foods as children age and the second being a

pattern of increasing access, with subsequent reversion to greater limitations. This

second path might be more common as children age or in samples of children with

different characteristics e.g. heavier weight.

As mentioned in Section 6.2.2, some mothers expressed a belief that in

moderation restriction is preferable to total restriction otherwise children would

desire restricted foods more, which contradicted other evidence presented.

However, the evidence presented for this association was not in relation to mothers’

own experiences but rather observation of other mothers and children (see Chapter

4, Section 4.5.2). This belief may be explained by mothers rationalising their

decision to restrict foods and drinks in moderation (see Section 6.2.2). However, it is

also possible that reported observations reflect a pattern of responsive child

behaviour subsequent to children becoming familiar with restricted foods, as

suggested by evidence presented in Chapter 4, Section 4.5.2. Temple (2014) also

suggests that neuro-adaptive changes may result from repeated exposure to sweet

188 Chapter 6: Discussion & Conclusions

foods, which may enhance an individual’s desire (wanting) to consume the food

(See Chapter 2, Section 2.6.3). However, such a response would not determine a

difference in child preferences (or liking or wanting) for a restricted food between

restricted and unrestricted children. It would be a behavioural response to conditions

of access to a liked food and liking may have developed due to frequent exposure in

a scenario of low restriction.

Dimension summary

Restrictive feeding is most commonly reduced as children age, with

predominantly covert total restriction progressively changing to overt restriction in

moderation, although the child age at which these changes occur varies between

restricted foods and drinks. However, a less common alternative pattern, where

mothers allowed lower levels of restriction when children were younger followed by

higher levels of restriction when older, needs further consideration. Such a pattern

may result in different child responses to restrictive feeding than for children

experiencing linear reducing levels of restriction. Child early exposure to restricted

foods and drinks may influence early child food preferences but this association may

be superseded by children’s current intake as they age. This suggests that early

exposure may not be an important dimension of the restrictive feeding phenomenon.

6.2.5 Dimension 5: Associations with other controlling feeding practices

Chapter 2, Section 2.2 highlighted that there is no universally agreed

delineation between different controlling feeding practices and there is a lack of

evidence to clarify whether proposed concepts and delineations might reflect how

these activities present in everyday lives. A novel, uncanvassed component of

restrictive feeding communication emerging from the qualitative data was mothers’

repeated reference to giving the foods they restrict in moderation as “treats” (see

Section 6.2.3.2). As mentioned in Section 6.2.3.2, the giving of restricted foods as

“treats” appears similar to the concept of giving foods as a reward. While Birch et

al.’s (2001) inclusion of two food reward items in the CFQ restriction scale

suggested a relationship between giving food as a reward and restrictive feeding,

Wardle et al. (2002) defined food rewards as a separate controlling feeding practice

(see Chapter 2, Section 2.4.2.1). A number of authors have also questioned the

inclusion of food reward items in the CFQ restriction scale and found that these

items did not relate, statistically, to the other items in the scale (Cardel et al., 2012;

Chapter 6: Discussion & Conclusions 189

Corsini et al., 2008; Jansen et al., 2014; Musher-Eizenmann & Holub, 2007; Gregory

et al., 2010a, 2010b; Sud et al., 2010). The findings of the qualitative component of

this study suggested that mothers tend to make conceptual distinctions between

“treats” and food rewards. While the concept of “treats” is integral with restriction in

moderation (see Section 6.2.3.2) the concept of food rewards, contingent on child

behaviour, does not directly relate to activities of restrictive feeding. However, while

“treats” and rewards may have different conceptual associations with the restrictive

feeding phenomenon, they both involve the presentation of restricted foods with

positive connotations, which may increase children’s preferences for restricted foods

(Pliner & Loewen, 1997). Therefore, the giving of a restricted food as a reward

should be included as a covariate when examining the effects of restrictive feeding

on child preferences for restricted foods and drinks because foods given as rewards

are also the restricted foods being examined and may confound the effects

observed.

Qualitative findings also suggested that pressure to eat “healthy” foods was

often used in conjunction with in moderation restriction to compensate for

“unhealthy” restricted foods consumed (see Chapter 4, Section 4.6.1) and this was

consistent with Carnell et al.’s (2011) qualitative study findings. Mothers’ reports

also suggested a predominant concern for sufficient child intake of “healthy” foods,

regardless of the calories that may have been consumed from “unhealthy” foods.

These reports appear to be consistent with Brown and Ogden’s (2004) quantitative

study, which found that children of parents who reported greater firmness in

controlling their child’s intake ate more of both healthy and unhealthy foods (n =

112, aged 9 to 13 years). Ogden et al. (2006) and Spruijt-Metz et al. (2002) also

found that the same parent often scored highly on both restriction and pressure to

eat scales of the CFQ (Birch et al., 2001). However, if the CFQ restriction scale

reflects greater parent activity associated with greater child access to restricted

foods (see Chapter 2, Section 2.4.4), the association between these scales would

be consistent with the qualitative findings in the present study. In addition, qualitative

data suggested that the most common use of food rewards was associated with

encouraging consumption of a “healthy” meal, which was also consistent with the

findings of other qualitative studies (Moore et al., 2007; Petrunoff, Wilkenfeld, King,

& Flood, 2012; Ventura et al., 2010). While pressure to eat “healthy” foods is not

conceptually part of restrictive feeding and would not directly influence child

preferences for restricted foods and drinks, it may be coincidently associated with

child outcome measures related to child weight or eating behaviours (e.g. EAH)

190 Chapter 6: Discussion & Conclusions

(Birch, Birch, et al., 1982). Therefore, the practice of pressure to eat “healthy” foods

should be included as a covariate when examining the effects of restrictive feeding

on child outcome measures related to child weight or eating behaviours (e.g. EAH)

but not for measures of child preference (or liking or wanting) for restricted foods

and drinks. Where this practice is included as a covariate, it may also be important

to distinguish between motivation to use pressure to eat to achieve a balance

between “healthy” and “unhealthy” foods as opposed to motivation to increase

overall energy intake due to concerns that a child is not consuming enough calories.

In contrast to the associations found for in moderation restriction, qualitative

findings suggest that mothers’ intentions to totally restrict or inadvertently restrict

foods and drinks did not include the practice of presenting the restricted food to a

child on a limited basis and hence the potential of it becoming a “treat” or food

reward. Nor were these intentions associated with pressure to eat “healthy” foods to

compensate for restricted foods consumed because these foods were not being

consumed by children. However, associations between in moderation restriction,

pressure to eat and “treats” revealed by this study may explain how the

phenomenon of restrictive feeding might be apparently related to the development of

EAH and hence the risk of developing obesity. As noted in Chapter 1, Section 1.1,

both food rewards (Birch, Birch, et al., 1982; Mikula, 1989; Newman & Taylor, 1992)

and pressure to eat (Birch, Birch, et al., 1982; Birch et al., 1984; Newman & Taylor,

1992) are associated with encouraging children to over-consume, resulting in eating

in the absence of hunger and hence increasing their risk of developing obesity

(Schachter, 1968).

Dimension summary

While food rewards are not an integral part of restriction in moderation,

foods given as rewards are always restricted foods and may coincidently increase

children’s preferences (or liking or wanting) for restricted foods. Therefore, use of

restricted foods as rewards is an important covariate to include in analysis

examining the effects of restrictive feeding. Mothers’ desire for a healthy but happy

child associated with restriction in moderation was also found to be commonly

associated with pressure to eat “healthy” foods. While this feeding practice would

not directly influence children’s preferences (or liking or wanting) for restricted foods

and drinks, it may coincidentally be associated with children’s weight and eating

behaviours, such as eating in the absence of hunger. Therefore, mothers’ use of

Chapter 6: Discussion & Conclusions 191

pressure to eat is an important covariate to include in analysis examining the effects

of restrictive feeding on child weight or eating behaviours.

6.2.6 Dimension 6: Mothers’ own liking for restricted foods and drinks

A novel, uncanvassed and repetitive feature of conversations emerging

from the qualitative data was mothers’ own preference for the items they restrict in

moderation. This was evident from the favourable language mothers commonly

used to describe the foods they restrict in moderation; their behaviour of consuming

these items out of their child’s sight (avoiding negative modelling); and mothers’

reference to their own desires or need to restrain themselves from consuming these

items (see Chapter 4, Sections 4.7 & 4.4.2.2). Mothers’ expressed own preference

for a restricted food or drink also appeared to be associated with their perception of

child happiness derived from consuming a restricted food or drink; greater child

access to the restricted food or drink; and mothers’ overt communication with

positive connotations about the restricted item, including whether the item was

regarded as a “treat” (see Chapter 4, Section 4.8, Theme 6). In contrast, mothers

mostly expressed a lack of interest in or dislike for the items they decided to

continue to totally restrict when children were 5 to 6 years old (e.g. soft drinks, fast

foods) or those that were inadvertently restricted (e.g. chips, cake). In addition,

these forms of restriction tended to be associated with either no maternal

communication (covert) with children about the restricted item or overt

communication with negative connotations (see Chapter 4, Section 4.7). These

findings were consistent with Howard et al.’s (2012) finding that mothers were

significantly less likely to offer a food they did not like to their child (n = 245, 2 years)

but the present study elaborated that communication was also likely to be different

for foods mothers liked or disliked.

Quantitative findings also showed that mothers’ own high liking for

restricted foods and drinks predicted higher odds of child high liking for the same

restricted item at child aged 5 years (see Chapter 5, Section 5.4.3.3), which was

consistent with other studies (Addessi et al., 2005; Breen et al., 2006; Cooke et al.,

2006; Howard et al., 2012; Laskarzewski et al., 1980; Lee et al., 2001; Oliveria et al.,

1992; Pérusse et al., 1988; Vauthier, Lluch, Lecomte, Artur, & Herberth, 1996). In

addition, these associations were found to exist independently from children’s level

of restriction (intake frequency) or early exposure to the restricted foods and drinks

examined. Mothers’ liking was also the only one of these predictors to show an

192 Chapter 6: Discussion & Conclusions

association with child liking for the savoury foods examined (fast foods, chips

[crisps], savoury biscuits) (see Chapter 5, Section 5.4.3.3). While heritability may be

considered as a factor contributing to associations between mother and child liking,

environmental effects are likely to be the major contributor to child liking for the

types of foods potentially targeted for restriction (Breen et al., 2006; Fildes et al.,

2014).

However, mothers’ own preferences would not directly exert an

environmental effect on their child’s food preferences. Such an association would be

mediated through a more direct variable such as: level of intake, early exposure,

restrictive feeding behaviour or restrictive feeding communication (see Chapter 4,

Section 4.8). As mentioned in Chapter 5, Section 5.1, this study was unable to

quantitatively examine the direct effects of mothers’ restrictive feeding behaviours or

associated communication on child liking for restricted foods and drinks but it did

determine that child liking for restricted foods and drinks was associated with a

factor beyond child level of intake or age of exposure. As said previously, existing

evidence suggests that communication with positive connotations about a food may

influence a child’s liking for a food and qualitative findings showed distinct variations

in mothers’ communication associated with their own liking for restricted foods and

drinks (see Chapter 4, Section 4.7). This suggests that mothers’ restrictive feeding

communication is a strong candidate as a potential mediating variable between

mother and child liking for restricted foods and drinks within the restrictive feeding

phenomenon. However, further research is required to clearly identify the

responsible mediating variable or variables within the restrictive feeding

phenomenon that might influence child preferences beyond child intake.

Dimension summary

Mothers’ expressed own preferences for the foods and drinks they

restricted in moderation was a novel, uncanvassed and repetitive feature of

conversations. Qualitative findings suggested that mothers’ own preferences for

restricted foods and drinks influenced their decisions of whether to restrict an item

totally or in moderation; the perceived contribution a restricted item would make to

their child’s happiness; and communication with positive connotations about the

restricted item. Quantitative results showed that mothers’ liking for restricted foods

and drinks influenced child liking for restricted foods and drinks independently from

child intake and early exposure and was the only one of these predictors to show an

Chapter 6: Discussion & Conclusions 193

association with child liking for the savoury foods examined. The combination of

qualitative findings and existing evidence indicated that mothers’ restrictive feeding

communication is a strong candidate as the potential mediating variable explaining

this association within the restrictive feeding phenomenon.

6.2.7 Summary of characteristics of restrictive feeding across dimensions

Table 6.2 summarises the characteristics of the restrictive feeding

phenomenon associated with different restrictive feeding intentions across the

identified dimensions of the phenomenon. This indicates different clusters of

characteristics associated with different restrictive feeding intentions, which may be

applied variably by individual mothers to different foods and drinks.

Table 6.2

Characteristics Associated with Mothers’ Restrictive Feeding Intentions Across Dimensions

Dimensions In moderation (most restricted items)

Total restriction (soft drink & fast food)

Inadvertent restriction (rarely, chips & cake)

1. Level of intake foods & drink

• give on a limited basis

• not allowed at all • not at home/rarely accessed

2. Motivation • “balance” healthy and happy child

• child health paramount

• desire to restrict

3a. Practices: behaviours

• avoiding access • rules • flexible judgement

• avoiding access • rules (sometimes)

• no deliberate practices

3b. Practices: communication

• covert (no communication)

• overt with positive connotations (mostly)

• commonly presented as “treats”

• covert (no communication)

• overt with neutral or negative connotations

• never presented as “treats”

• covert (no communication)

• overt with neutral connotations

• never presented as “treats”

4. Patterns over time

• Introduced earlier • More common as

child ages

• Progressively switch to in moderation

• Less common with age

• No change by mother • May access outside

family environment

5. Other controlling practices

• pressure to eat “healthy” foods to achieve “balance”

• give as food rewards

• unrelated: pressure to eat “healthy” foods

• unrelated: food rewards

• unrelated: pressure to eat “healthy” foods

• unrelated: food rewards

6. Mothers’ own Liking

• items commonly liked by mothers

• items commonly not liked by mothers

• mothers not interested in consuming

194 Chapter 6: Discussion & Conclusions

6.3 PROGRESS TOWARDS A CONCEPTUAL FRAMEWORK

Figure 6.1 outlines an initial conceptual framework reflecting all the findings

of the present study and review of literature. To reiterate, the qualitative component

of this study suggested that mothers’ own food preferences (Section 6.2.6) and their

desire for a healthy and happy child (Section 6.2.1) influence their restrictive feeding

intentions, which may vary by different restricted foods and drinks. These

dimensions influence how restrictive feeding is operationalised in terms of the level

of restriction applied by mothers and the restrictive feeding practices used. Level of

restriction encompasses two dimensions, when a child was introduced to a

restricted food or drink (early exposure) (Section 6.2.4) and current child intake of

the restricted item (level of restriction) (Section 6.2.1). Restrictive feeding practices

also include two dimensions, parent restrictive feeding behaviours (Section 6.2.3.1)

and the associated communication (Section 6.2.3.2). It is proposed that these four

key dimensions may directly influence child preferences (or liking or wanting) for

restricted foods and drinks. Therefore, these are the dimensions that need to be

considered for inclusion in a measure aiming to assess the effects of restrictive

feeding on children’s risks of developing diet-related diseases or obesity (see

Chapter 2, Section 2.5). Furthermore, the use of other controlling feeding practices

of pressure to eat and giving foods as rewards might confound associations

observed and should be considered as covariates when examining these

relationships.

Figure 6.1. Initial conceptual framework for associations between key dimensions of the

restrictive feeding phenomenon and child liking for a restricted food or drink.

Early Exposure

Motivation Healthy vs Happy Child Mothers’ own liking & perceptions.

Restrictive Feeding Intentions

Vary by restricted food or drink • Total restriction • In moderation • Inadvertent

Level of Restriction

Child Liking

Restrictive Feeding Practice Behaviours

Restrictive Feeding Practice Communication

Covariates eg. Other controlling practices

Chapter 6: Discussion & Conclusions 195

However, this is an under researched phenomenon and the evidence of

effects provided by the proposed four key dimensions in the initial conceptual

framework is not complete. Table 6.3 summarises the current state of evidence of

associations between these dimensions and child preferences (or liking or wanting)

for restricted foods and drinks concluded from the present study.

Table 6.3

Summary of Associations Between Restrictive Feeding Dimensions and Child

Preferences/Liking for a Restricted Food or Drink, Indicated by Existing Literature

and Findings of the Present Study

Restrictive Feeding Dimension

Evidence for associations with child preferences/liking

Existing Literature

Qualitative Study

Quantitative Study

Early Exposure healthy foods

restricted foods/drinks

Level Restriction healthy foods

limited evidence for restricted foods/drinks

Sweet foods/drinks

Savoury foods

Practice: Behaviours Mothers’ own liking Practice:

Communication limited evidence

= Evidence indicating an association between the dimension and child preferences/liking for restricted items = No evidence for a direct association between the dimension and child preferences/liking for restricted items

The next section considers the implications of these findings for existing

measures of restrictive feeding (Section 6.4) and Section 6.5 proposes how the key

dimensions of restrictive feeding identified by this study might be measured. Section

6.6 outlines further research required to clarify the role of these dimensions in

relation to the development of child preferences (or liking or wanting) for a restricted

food or drink.

196 Chapter 6: Discussion & Conclusions

6.4 IMPLICATIONS OF FINDINGS FOR EXISTING MEASURES OF PARENT RESTRICTIVE FEEDING

The findings of the present study highlighted a number of limitations to

existing measures of parent restrictive feeding. Firstly, a fundamental dimension of

the restrictive feeding phenomenon is the child’s level of restriction (restricted

intake) applied by parents to restricted foods and drinks (see Chapter 2, Section

2.6.3). The quantitative component of the present study confirmed a positive

association between frequency of intake and higher child liking for restricted sweet

foods and drinks, although an association was not evident for the savoury foods

examined (see Chapter 5, Section 5.4.3.2). None of the current measures of parent

restrictive feeding used in cohort studies to date have recognised this dimension of

restrictive feeding (see Chapter 2, Section 2.4.2).

Secondly, current measures used in cohort studies attempt to differentiate

a parent’s overall approach to restrictive feeding used for all restricted foods and

drinks e.g. high and low restricting parents (Birch et al., 2001) or overt and covert

restricting parents (Ogden et al., 2006; Jansen et al., 2014) (see Chapter 2, Section

2.4.2). However, the present study suggests that mothers tend to apply different

levels of restriction and may apply different restrictive feeding behaviours to different

restricted foods and drinks, as well as vary these by different contexts and at

different times (see Section 6.2.1 and 6.2.3.1). Such flexibility in the application of

restrictive feeding behaviours was consistent with other qualitative studies (Carnell

et al., 2011; Moore et al., 2010), indicating that parents’ restrictive feeding

behaviours are likely to be inconsistent by nature, involving a range of parent

behaviours rather than a single consistent response (see Section 6.4). This

suggests that current measures are unlikely to reflect the nature of this

phenomenon.

In particular, the findings of the present study suggested that the effects of

parent restrictive feeding on child diet-related outcomes needs to be examined by

specific types of restricted foods and drinks. None of the current measures of parent

restrictive feeding recognise this dimension of the phenomenon (see Chapter 2,

Section 2.4.2). Most items in existing scales use general terms for restricted foods,

such as “high-fat foods”, “junk foods”, “favourite foods” or “unhealthy foods” (Birch et

al., 2001; Ogden et al., 2006; Jansen et al., 2014; Musher-Eizenmann & Holub,

2007). Where specific foods are included they are not grouped to provide

Chapter 6: Discussion & Conclusions 197

differentiation between types of restricted foods. For example, the CFQ restriction

scale (Birch et al., 2001) refers to “sweet foods (lollies, ice-cream, cake or pastries)”

together in an item. Ogden et al.’s (2006) covert control scale includes one item

referring to “sweets [lollies] and crisps [potato chips]” and another item referring to

“biscuits and cakes” (see Chapter 2, Section 2.4.2, Table 2.4). Furthermore, none of

these scales mention soft drinks, which the present and other studies (Gubbels et

al., 2009; Koh et al., 2010) suggest may be most highly restricted and the only item

likely to represent total restriction by the time children reach 5 years old (see Section

6.2.1).

The third major dimension of parent restrictive feeding that could potentially

influence a child’s diet-related outcomes is restrictive feeding practices used by

parents to operationalise their restrictive feeding intentions. The present study

suggests that restrictive feeding practices consist of two dimensions; parent

behaviours used to restrict foods and communication associated with parent

behaviours (i.e. covert or overt communication and connotations conveyed about a

restricted food or drink). While this field of research has tended to refer to measuring

restrictive feeding practices, instruments developed have only at most provided

limited representation of parent restrictive feeding behaviours, with the dimension of

associated parent communication not being recognised at all by measures to date

(see Chapter 2, Section 2.4.2). Existing measures have predominantly attempted to

assess the frequency of parent behaviours as representing the extent of a child’s

restrictive feeding experience. As the qualitative findings highlighted, such

measurement is unlikely to be clearly reflective of the level of restriction experienced

by a child (see Section 6.2.3.1). In fact, Holland et al.’s (2014) study indicated that

greater use of parent restrictive feeding behaviours, indicated by higher scores on

the CFQ restriction scale (Birch et al., 2001), may be associated with greater child

access to restricted foods (see Chapter 2, Section 2.4.4). Furthermore, while the

literature and study findings suggest that children’s level of intake of restricted foods

and drinks and connotations of parent communication may influence child

preferences for restricted foods and drinks (see Sections 6.2.1 and 6.2.3.2), no

evidence that mothers’ restrictive feeding behaviours independently influence child

preferences (or liking or wanting) for restricted foods and drinks was found within

existing literature or within the present study. These findings suggest that existing

measures are unlikely to include the key dimensions of the restrictive feeding

phenomenon that might contribute to children’s preferences (or liking or wanting) for

restricted foods and drinks and hence children’s future diet-related outcomes.

198 Chapter 6: Discussion & Conclusions

Overall, the findings of the present study suggest that current measures of

parent restrictive feeding are measuring undefined aspects of this phenomenon. The

CFQ restriction scale (Birch et al., 2001) claims to differentiate high and low

restriction but Holland et al.’s (2014) study suggests that high scores on this scale

may be more closely aligned with lower restriction. Ogden et al.’s (2006) and Jansen

et al.’s (2014) covert scales may be reflecting higher parent restricting activities

more generally (see Chapter 2, Section 2.4.2), resulting in reduced intake of

“unhealthy” or energy dense foods (Ogden et al., 2006; Brown et al., 2008; Boots et

al., 2015; Durão et al., 2015). Furthermore, the complementary scales are not

mutually exclusive and are presented without evidence that they differentiate

between overt and covert practices (see Chapter 2, Section 2.4.2). Qualitative

findings suggest that while Ogden et al.’s and Jansen et al.’s covert scales may

resemble parent behaviour of avoiding access to restricted foods, these behaviours

can be accompanied by covert or overt communication (see Chapter 6, Section

6.2.3.2). Therefore, measures currently available are not likely to fully resemble or

differentiate the key dimensions of the restrictive feeding phenomenon as proposed

by the present study. Further consideration needs to be given to how a more

construct valid measure of parent restrictive feeding may be developed.

6.5 HOW RESTRICTIVE FEEDING MIGHT BE MEASURED

As mentioned in Section 6.3, only dimensions likely to influence the

proposed child outcome of interest would potentially need to be included in a

measure of restrictive feeding. Further research is required to clarify the key

dimensions of restrictive feeding that might directly influence child preferences (or

liking or wanting) for a restricted food or drink. At this stage, existing literature and

the findings of the present study suggest that the following four key dimensions

need to be considered: early exposure; level of restriction; parent restrictive feeding

behaviours; and restrictive feeding communication. In addition, these dimensions

may vary by specific restricted foods and drinks, which also need to be

accommodated in a measure of this phenomenon. How these dimensions might be

measured is proposed in Sections 6.5.1 to 6.5.5. In addition, potential covariates

relevant to include when examining this phenomenon are discussed in Section

6.5.6.

Chapter 6: Discussion & Conclusions 199

6.5.1 Restricted foods and drinks.

An appropriate measure needs to enable examination of restrictive feeding

by specific groups of food and drinks that reflect differentiation in parent targeting of

items. The aim would be to understand the effects of a specific parenting approach

to restrictive feeding on child preferences (or liking or wanting) for a specific

restricted item, rather than attempting to ascertain the effects of an overall parenting

approach, as current measures attempt to do. Consistency between findings of the

present study and existing studies suggests a potential common pattern of parent

targeting for different foods and drinks (see Section 6.2.1). If further research

confirms a common pattern of targeting, a common set of food and drink groups

could potentially be developed for measurement, although would need to be

adapted for different cultures.

The following preliminary list of restricted food and drink groups is based on

the items reported to be commonly targeted for restriction by mothers in the

qualitative component of this study and further examination of quantitative data

within the NOURISH database (Daniels et al., 2009). The groups of foods and drinks

included in Wardle, Sanderson, et al.’s (2001) liking scale (included in the NOURISH

database) corresponded fairly well with differentiation of items found by the

qualitative component of this study. The only changes suggested would be the

separation of chocolates and lollies and separation of cola soft drink from other soft

drinks because mothers commonly reported restricting these items differently. The

list below is intended as a starting point for further evaluation. Groups of foods and

drinks could potentially be amalgamated further if items are subsequently found to

be restricted by parents in a similar way.

Potential groups of restricted foods and drinks

• All soft drinks

• Cola soft drinks only

• Sweetened fruit juices (eg. poppers, juice box)

• Fast foods (eg. McDonalds, KFC, Hungry Jacks)

• Lollies (sweets)

• Chocolates

• Cake, slices, doughnuts etc.

200 Chapter 6: Discussion & Conclusions

• Sweet biscuits

• Sweet snack bars, muesli bars

• Ice cream, ice blocks

• Chips [Crisps] (e.g. potato chips, Twisties, corn chips, Burger rings)

• Flavoured savoury biscuits (e.g. Shapes, Jatz)

Additional items that might also be considered for inclusion are: flavoured

milk, 100% fruit juices, cordial, fruit roll ups.

6.5.2 Early exposure

The present study suggested that children’s earlier exposure to restricted

foods and drinks does not influence child liking for these items independently from

current intake by the time children are 5 years old. However, the scale used to

assess child liking in this study may have provided limited sensitivity. This scale was

developed to distinguish between likes and dislikes rather than levels of liking, which

would be more relevant for restricted foods and drinks (see Section 6.9.3).

Furthermore, the measure of age of introduction used in the present study does not

indicate the level of restriction experienced by the child at an early age, which may

also influence child preferences (or liking or wanting) for a restricted food or drink.

Further research is required to clarify associations between age of introduction,

earlier levels of restriction and current levels of restriction with child preferences (or

liking or wanting) for a restricted food or drink. If dimensions of age of introduction

and/or earlier levels of restriction are subsequently found to independently influence

later child preferences (or liking or wanting) for restricted foods and drinks, this

dimension could be included in longitudinal studies or added as a covariate for

cross-sectional analysis.

6.5.3 Level of restriction

The level of restriction experienced by a child should be included in a

measure of restrictive feeding. A direct measure of child intake of each restricted

food and drink group would be preferable to using subjective response scales, such

as those included in Ogden et al.’s (2006) overt/covert controlling feeding scale

(never, rarely, sometimes, often, always). Level of restriction could be measured by

either the child’s intake frequency or a quantified amount over a period of time for

each food or drink group. The present study measured child intake frequency of

Chapter 6: Discussion & Conclusions 201

foods using the data available from the NOURISH database (Daniels et al., 2009).

The scales specifically utilised within this survey instrument were the CDQ (Magarey

et al., 2009) for food groups and a scale measuring drink intake frequency

developed by the NOURISH investigators. These scales were not developed for the

purpose of the present study and provided highly negatively skewed distributions of

data for the more highly restricted items (see Section 6.9.3).

While further review is required to ascertain a preferred method of

measurement of child intake of restricted items, a scale with response categories

that provide a statistically normal distribution of data is desired to provide a more

sensitive measure of level of restriction. This study was required to dichotomise

skewed data to meet statistical assumptions. A set of potentially more suitable

response categories is proposed as a starting point for further evaluation. This has

been based on qualitative findings and review of the distribution of data provided by

the secondary source.

Frequency of restricted food or drink intake

• Never tried

• < 4 X year

• > 4 X year to < 1 X month

• > 1 X month to < 1 X week

• 1 X week

• 2 to 3 X week

• 4 to 5 X week

• 6 X week or >

6.5.4 Restrictive feeding practices: parent behaviours

While evidence that different restrictive feeding behaviours influence

children’s preferences for a restricted food or drink differently did not emerged from

the qualitative data (see Section 6.2.3.1) or existing literature (see Chapter 2,

Section 2.6.3), further research is required to clarify the potential influence from this

dimension. Notably, existing measures do not provide differentiation of parent

restrictive feeding behaviours (e.g. rules, flexible judgement, avoiding access).

Therefore, a new instrument or method of measurement needs to be developed to

202 Chapter 6: Discussion & Conclusions

assess whether different types of parent restrictive feeding behaviours exert

different influences on child food preferences (or liking or wanting) for a restricted

food or drink. If these do provide differential influence on child preferences (or liking

or wanting) for restricted foods or drinks, additional research would be required to

assess whether such influence is independent from restrictive feeding

communication and the level of restriction applied. The qualitative component of this

study and previous qualitative studies have indicated that parents’ application of

multiple restrictive feeding behaviours creates a complexity that is likely to be

difficult to measure and difficult to differentiate between parents (see Section

6.2.3.1). Therefore, if this complex dimension does not provide independent

influence on child preferences for restricted foods and drinks, it can be excluded

from a measure aiming to assess the effects of restrictive feeding on child

preferences (or liking or wanting) for restricted foods and drinks.

6.5.5 Restrictive feeding practices: parent communication

Quantitative findings suggested a unique association between mother and

child liking for a restricted food or drink beyond mere exposure (see Chapter 5,

Section 5.4.3.3). This indicated that a variable related to mothers’ restrictive feeding

practices may influence child liking for a restricted food or drink, although an

element of heritability also needs to be considered. The combination of qualitative

findings and existing evidence suggests that communication associated with

restrictive feeding practices would be a strong candidate as the more direct variable

mediating this association (see Section 6.2.3 and 6.2.6).

Covert approaches would always convey neutral connotations about a

restricted item because there would be no communication involved but overt

communication could involve positive, neutral or negative connotations about the

restricted item. The common practice of presenting sweet restricted foods to

children as “treats” may be captured by measuring positive connotations associated

with communication about the restricted item, although further research is required

to confirm this assumption. Four preliminary communication categories based on the

findings of the qualitative component of this study are outlined below. However,

further research is required to assess whether categories could be amalgamated.

For example, neutral connotations conveyed overtly may have a similar or different

effect to covert non-communication. Likewise, overt communication with negative

Chapter 6: Discussion & Conclusions 203

connotations about a restricted item may have a similar different effect to covert

non-communication.

Preliminary Communication Categories

• Positive connotations (overt)

• Neutral connotations (overt)

• Neutral connotations (covert - no communication)

• Negative connotations (overt)

6.5.6 Potential confounding variables Other controlling feeding practices

The qualitative component of this study suggested that restriction in

moderation may commonly co-exist with practices of pressure to eat “healthy” foods

(see Chapter 4, Section 4.6.1). However, there is no evidence that pressure to eat

“healthy” foods would directly influence children’s preferences (or liking or wanting)

for restricted foods and drinks, so it would not need to be included as a covariate

when assessing child preferences (or liking or wanting) for a restricted food or drink.

If child outcome measures related to eating behaviours or weight are being

examined, the practice of pressure to eat should be included as a covariate because

it has been found to be associated with greater consumption of foods and drinks in

the absence of hunger and hence increased risk of obesity (Schachter, 1968).

In moderation restrictive feeding was also found to commonly co-exist with

the giving of restricted foods as rewards, in conjunction with pressure to eat

“healthy” foods and for good behaviour (see Chapter 4, Section 4.6.2). As the giving

of a food as a reward may increase a child’s preference for the reward food (Birch,

Birch, et al., 1982; Mikula, 1989; Newman & Taylor, 1992), measuring the use of a

restricted item as a food reward is likely to be an important covariate. However,

further research is required to assess whether the giving of a restricted food as a

reward has an additional effect on child preferences (or liking or wanting) beyond

communication about a restricted food or drink with positive connotations.

204 Chapter 6: Discussion & Conclusions

Other variables of influence beyond the family-controlled environment.

It is recognised that children’s intake and preference for restricted items

may also be influenced by other carers and social settings, and quantitative findings

suggested that the extent of influence may vary between restricted items (see

Chapter 5, Section 5.5). Variables such as regular care by grandparents, attendance

at child care, school healthy eating policies and frequency of attendance at social

functions could be considered as covariates, although the unique contribution from

these external variables is likely to be difficult to measure.

6.6 FURTHER RESEARCH TO PROGRESS TOWARDS AN EVIDENCE-

BASED CONCEPTUAL FRAMEWORK. 6.6.1 Further research for the concept and measurement of restrictive

feeding.

The present study was intended to provide preliminary work towards a

conceptual framework of the restrictive feeding phenomenon to inform the

development of measures of this phenomenon. The study was predominantly

qualitative with some quantitative assessment using a secondary source of data that

was not collected for the purpose of this study. Recognising that this is preliminary

work, this study highlights areas for further research to build on these preliminary

findings. Table 6.4 proposes further research required to gain a greater

understanding of this phenomenon and progress towards an evidence-based

conceptual framework to underpin more appropriate measurement of this

phenomenon.

Chapter 6: Discussion & Conclusions 205

Table 6.4

Further Research Required to Progress Towards an Evidence-Based Conceptual

Framework of the Restrictive Feeding Phenomenon

Dimension Further research required Types of foods and drinks restricted

Restricted foods and drinks

• Clarify the food and drink groups targeted for restriction by parents within a range of different samples (e.g. ethnicity, socio-economic) to inform common groupings that reflect parents’ differentiation between items.

• Aim to minimise the number of groups of foods and drinks included in a measure but retain sensitivity to variation in parent restrictive feeding for different foods and drinks.

Level of restriction

Early exposure • Establish whether early exposure influences child preferences for restricted foods and drinks independently from current level of restriction (child intake) and whether effects are dependent on child age or a time period after introduction.

• If this dimension potentially influences child preferences for the study population being examined, it should be included as a covariate when assessing the effects of restrictive feeding.

Level of restriction

• Develop an effective measure of child intake (frequency or amount) of specific groups of restricted foods and drinks that provide sensitivity to the potential variability in levels of restriction commonly applied to different foods and drinks by parents.

• To assist with simplifying a measure, determine whether level of restriction influences child preferences in a linear way or whether there are critical levels of restriction having significantly different effects on levels of child preferences for restricted foods and drinks. Aim to identify 2 or 3 levels of restriction that could be applied to a simplified measure.

Parent restrictive feeding practices

Parent behaviours

• Develop an effective measure to differentiate parents’ use of different restrictive feeding behaviours (e.g. rules, flexible judgement, avoiding access).

• Assess whether this dimension influences child preferences for restricted foods and drinks independently from early exposure, level of restriction and parent communication associated with restrictive feeding practices.

• If this variable does not independently influence child preferences, it can be excluded from a measure aiming to assess the effects of restrictive feeding on child preferences.

Parent communication

• Develop an effective measure of parent communication associated with restrictive feeding practices to distinguish overt and covert communications, as well as positive, neutral and negative connotations conveyed about a restricted item.

• Establish whether child preference for items referred to as “treats” is captured by measurement of overt communication with positive connotations. If not, develop an additional measure to capture this aspect of communication.

• Establish whether the dimension of communication influences children’s preferences for restricted foods and drinks independently from early exposure, level of restriction and parents’ restrictive feeding behaviours.

In addition, further qualitative exploration of this phenomenon, as well as

with different samples, is likely to contribute further to knowledge of this

phenomenon. A better understanding of mothers’ and fathers’ beliefs about the

relative “nutritional value” and child pleasure derived from consuming a restricted

food or drink may assist with developing professional support strategies that

effectively address barriers to change (See Chapter 4, Section 4.3.2). A better

206 Chapter 6: Discussion & Conclusions

understanding of factors that contribute to parent restrictive feeding decisions (e.g.

mothers’ own food preferences, children’s social events) may also inform

development of effective health promotion strategies targeting both family-controlled

and children’s external eating environments.

6.6.2 An appropriate child outcome measure for assessing the effects of restrictive feeding.

Child preference (or liking or wanting) for a restricted item was selected as

the preferred child outcome measure because it potentially provides an indication of

what a child would choose to consume, carrying with it future risks of diet-related

chronic disease and possibly obesity (See Chapter 1, Section 1.1). As explained in

the literature review, child preferences for restricted foods and drinks are related to

two neurological circuits, child liking and wanting (See Chapter 2, Section 2.3.2).

Wanting is the motivational component of the urge to eat a food and is therefore a

stronger determinant of food intake than liking and it is the enhancement of this

aspect of the system that has been associated with disordered eating beyond satiety

and hence risk of obesity (Epstein et al., 2011; Epstein & Leddy, 2006; Epstein et

al., 2015; Rollins et al., 2014b; Temple et al., 2008). As mentioned in Chapter 2,

Section 2.6.3, Hartvig et al.’s (2015) study indicated that once liking was established

no further changes to liking may occur but the desire to consume an item (wanting)

may continue to increase with repeated exposure. This suggests that measurement

of child wanting to consume a food, which may have stronger associations with the

risk of obesity than liking (see Chapter 2, Section 2.3.2) is likely to be the preferable

outcome measure for studies of restrictive feeding. However, wanting tends to be

less stable than liking, altering in response to satiety states and food variety (Epstein

et al., 2011; Epstein et al., 2003; Raynor & Epstein, 2003; Temple, 2014; Vervoot et

al., 2016) and the sensitivity of wanting to these states may influence subject

responses observed in studies e.g. experimental restriction studies (See Chapter 2,

Section 2.3.2).

More recently, methods of measuring the relative reinforcing value (RRV) of

foods to individuals have been developed. That is how hard an individual is willing to

work to gain access to a particular food compared with an alternative reward, which

can be an alternative food or activity (Epstein et al., 2007). Finlayson et al. (2008)

have developed a computer based procedure, which measures child responses to

pictures of food items directly and claims to assess both children’s liking and

Chapter 6: Discussion & Conclusions 207

wanting for foods. This method would enable examination of children’s liking and

wanting for restricted foods and drinks under the same access conditions in order to

assess associations with a measure of children’s restriction experiences within their

natural environment. Such an approach may overcome potential sensory specific

satiety responses associated with previous experimental study designs (See

Chapter 2, Section 2.3).

Parent reporting or child reporting scales may offer a more economical and

practical method of assessing child food preferences (or liking or wanting) for larger

cohort studies. However, as previously mentioned, scales such as Wardle,

Sanderson, et al.’s (2001) food liking scale used in the present study, have

predominantly been developed to distinguish food likes and dislikes. The present

study demonstrated that such a scale is likely to produce highly skewed data due to

the tendency for most children to like restricted foods and drinks (see Chapter 5,

Section 5.4.2.1). A response scale that provides better differentiation between levels

of liking and/or wanting for restricted foods and drinks, in line with existing

knowledge of these neurological circuits, is required. As a starting point for further

research, the following potential categories reflect the variation in mothers’

descriptions of child responses to different restricted foods and drinks from the

qualitative data, although further refinement to align descriptions and categories with

knowledge of liking and wanting is required.

Potential categories of child responses to restricted foods and drinks

• Never tried this food/drink.

• Dislikes this food/drink.

• Not interested in this food/drink.

• Enjoys this food/drink when available but does not ask for it.

• Asks for this food/drink but readily accepts ‘no’.

• “Craves”, “nags” or “argues” for this food/drink.

208 Chapter 6: Discussion & Conclusions

6.7 DEVELOPING A PRACTICAL MEASURE OF RESTRICTIVE FEEDING

This section considers how the key dimensions of restrictive feeding might

be developed into a practical measure. If further research confirms that the two

dimensions of level of restriction (child intake) and restrictive feeding communication

fully capture the effects of restrictive feeding on child preferences (or liking or

wanting) for restricted foods and drinks (see Section 6.5), only these two dimensions

of the restrictive feeding phenomenon would need to be included in a measure.

While multivariate analysis could be performed with level of restriction being a

continuous variable and communication being a categorical variable (with potentially

four categories), the need to also examine these associations by categories of

different restricted foods and drinks adds a complexity to this measurement (see

Section 6.5.1). With further research, there may be scope to combine these

dimensions into a simplified measure of typologies of restrictive feeding to assess

the effects of restrictive feeding across categories of foods and drinks. Typologies

may also simplify interpretation for mothers in terms of level of restriction or context

of access. They can also be used to explore associations between typologies and

other variables related to parent feeding such as, general parenting style or mother

and child characteristics. Potential typologies are discussed in Section 6.7.1 and

other factors relevant to measuring the restrictive feeding phenomenon arising from

the present study are outlined in Section 6.7.2.

6.7.1 Potential restrictive feeding typologies

Measurement by typologies would require dimensions of level of restriction

and restrictive feeding communication to be classified into fewer categories. Such

classification might simply be low, medium and high for levels of restriction and

positive, neutral and negative connotations for communication (see Figure 6.2).

However, further research would be required to determine the most meaningful

delineation that reflects differences in effect on child preferences (or liking or

wanting). It might be that typologies could be reduced further if fewer categories

were sufficient to distinguish differing effects on children’s food preferences (or liking

or wanting) e.g. high and low levels of restriction and positive and negative/neutral

connotations of communication.

Chapter 6: Discussion & Conclusions 209

Figure 6.2. Potential restrictive feeding typologies: levels of restriction and communication.

An alternative delineation might be by locations of access, rather than

levels of restriction. For example, the present study found that some mothers

restricting in moderation only let their child access certain foods at social events and

totally restricted access to them at home (see Chapter 4, Section 4.4). Child

preferences (or liking or wanting) may vary by whether a child just has access to

restricted foods and drinks at social events versus those also accessing these items

in family controlled environments, which the present study suggested may also be

associated with mothers’ own preferences. Such delineation might involve the

following three classifications of location of access: none, at social events only or

within family-controlled environments and social events (see Figure 6.3). Again, the

number of typologies may be reduced for older children, where numbers having ‘no

access’ are likely to be very low for most restricted foods and drinks.

LEVEL OF RESTRICTION

High Low

High Medium Low

MO

THE

RS

’ CO

MM

UN

ICA

TIO

N

Pos

itive

N

eutra

l

Neg

ativ

e High

Overt negative restriction

Medium

Overt negative restriction

Low

Overt negative restriction

High

Covert or overt neutral

restriction

Medium

Covert or overt neutral

restriction

Low

Covert or overt neutral

restriction

High Overt positive

restriction

Medium Overt positive

restriction

Low

Overt positive restriction

210 Chapter 6: Discussion & Conclusions

Figure 6.3. Potential restrictive feeding typologies: context and communication.

There may be advantages and disadvantages of these alternative

typologies. While the taxonomy of low, medium and high is likely to be a more

accurate measure of actual food and drink intake, this measurement may be

influenced by social desirability bias (Van de Mortel, 2008). The alternative

taxonomy of locations of access would not provide an accurate measure of intake

but may be a better reflection of context, as well as potential associations with

parents’ own preferences. Further research is required to reveal the relevance of

different delineations and consider the practical guidance for parents that could

result from further research using such typologies. For example, a health promotion

strategy informing parents to refrain from supplying restricted foods and drinks at

home may be easier to promote than communication of specific levels of restriction,

which may also be harder for parents to manage effectively.

6.7.2 Other factors relevant to developing a measure of restrictive feeding

In the qualitative component of the study, mothers expressed “guilt” or

“disappointment” with themselves for not achieving the dietary standards they had

LEVEL OF ACCESS Low High No access Social only Social & Family

MO

THE

RS

’ CO

MM

UN

ICA

TIO

N

Pos

itive

N

eutra

l

Neg

ativ

e

Overt negative

Total restriction

Overt negative In moderation

total home restriction

Overt negative In moderation

restriction

Covert or overt

neutral Total or

Inadvertent restriction

Covert or overt

neutral In moderation or Inadvertent

total home restriction

Covert or overt

neutral In moderation

restriction

Overt positive Total

restriction

Overt positive In moderation

total home restriction

Overt positive In moderation

restriction

Chapter 6: Discussion & Conclusions 211

intended for their child (see Chapter 4, Section 4.4.1.3), which was similar to

findings by Pescud and Pettigrew (2014a). Feelings of “guilt” were also suggested

by mothers’ emphasis on giving “minimal” amounts and using words that implied a

lower frequency of child access to restricted foods than the actual levels reported.

Some also reassured themselves that the amount of “unhealthy” foods they give is

so small and so infrequent that it would not harm their children (see Chapter 4,

Section 4.4.1.3). Petrunoff et al. (2012, 3 to 5 years) and Pescud and Pettigrew

(2014b, 5 to 9 years) also reported similar findings of emphasis on “little” amounts

and exaggerated infrequencies amongst low income Australian families.

Furthermore, a number of mothers presented what they regarded as good

restriction practices early on in the conversation but later discussion about their

experiences revealed less positive practices, citing challenges they had faced in

achieving their ideal goals (see Chapter 4, Section 4.4.1.3). Herman et al. (2012)

also reported that mothers believed they should set limits on sweets and snacks but

experienced this as a major challenge and reported feelings of “guilt” because they

did not achieve their intended limits. This is an important consideration for

measurement of self-reported practices because these factors and mothers’ feelings

of “guilt” about providing “unhealthy” foods to their child are likely to result in social

desirability bias (Van de Mortel, 2008). A study by Sacco, Bentley, Carby-Shiels,

Borja, and Goldman (2007) found a lack of correspondence between mothers’ self-

reports during interview and observed feeding styles in two thirds of their sample.

This highlights a potentially significant contribution of bias reporting of good

intentions and selected positive experiences in preference to negative experiences,

as well as under reporting of children’s intake of restricted foods.

Mothers also demonstrated sensitivity to language and terminology used. A

prominent example was where mothers rejected the idea that they gave their child

food rewards, despite providing practical examples of giving foods as rewards (see

Chapter 4, Section 4.6.2.1). This example suggests that reference to food rewards

in the CFQ restriction scale (Birch et al., 2001) is unlikely to elicit mothers’ behaviour

in relation to giving restricted foods as rewards or the presentation of restricted

foods as “treats”. This may explain why Sud et al. (2010) found a significant

association between higher scores on the CFQ restriction scale (Birch et al., 2001)

and child BMIz when they excluded the two food reward items (6-items) but found

no association when they included the two food reward items (8-items) (see Chapter

2, Section 2.4.3.1, Table 2.5). Negative responses to these two items may have

212 Chapter 6: Discussion & Conclusions

reduced overall scores sufficiently to change the result to non-significance. Likewise,

this factor may have contributed to other authors finding a lack of alignment between

the two food reward items and other items in the CFQ restriction scale (Cardel et al.,

2012; Corsini et al., 2008; Jansen et al., 2014; Musher-Eizenmann & Holub, 2007;

Gregory et al., 2010a, 2010b; Sud et al., 2010). It is, therefore, important to consider

that terminology and language used could markedly influence results. The validity of

questions posed in self-reporting questionnaires or interviews may be improved by

giving careful consideration to the meanings mothers assign to language and

professional terminology, as well as using the language mothers use themselves.

The language used by mothers in the present study could provide a starting point for

phrasing of respondent questions.

Overall, further consideration needs to be given to how measurement

instruments might overcome these potential biases and be cognisant of mothers’

flexible use of restrictive feeding behaviours as a natural characteristic of this social

phenomenon. While self-reporting questionnaires may be relatively cheap and easy

to administer, they are not economical if they produce significantly biased results or

are not a representative measure of this social phenomenon. At worst, they may

cause harm by providing misconstrued information resulting in mothers changing to

more harmful practices e.g. reducing levels of restriction. It is therefore important to

consider the potential benefits and biases of different methods of measurement e.g.

observation, questionnaires, interview, experiments.

6.8 IMPLICATIONS FOR PRACTICE

Further research to inform development of more construct valid measures

of restrictive feeding was discussed in Section 6.6. This section expands on these

proposals with suggested implications for parenting practice (Section 6.8.1) and

broader community based initiatives (Section 6.8.2).

6.8.1 Implications for parenting practice This study suggests the following implications for parenting practice.

• There is currently no clear evidence that higher restriction (less frequent

child intake) of a food or drink is associated with higher child liking for that

food or drink. It is likely that lower restriction (more frequent child intake)

Chapter 6: Discussion & Conclusions 213

and familiarity of restricted sweet foods and drinks is associated with higher

child liking for that item. Practical parenting advice should suggest that

avoiding access and lower levels of intake are preferable pending further

research.

• Inform parents of how their language and modelling consumption of

restricted foods and drinks may influence their child’s liking for these foods

and drinks.

• Increase parents’ awareness of the influence their own food preferences

may have on their restriction decisions and their communication with

positive connotations about restricted items conveyed to their child (e.g.

“treats”).

• Inform parents that their beliefs about the desirability for restricted foods

are predominantly learnt and that their language and modelling can instead

be used to positively reinforce healthy foods as “treats” for their children

rather than the foods they want to restrict.

Such messages could be conveyed by health professionals that have

regular contact with parents of young children (e.g. general practitioners, child

health nurses, child carers, teachers and dieticians). General practitioners in

particular have high contact and credibility with the general public (Australian

Medical Association, 2010) and preventive health care messages delivered by them

are potentially very cost-effective (Segal et al., 2005; Royal Australian College of

General Practitioners, 2006; Wutzke, Conigrave, Saunders, & Hall, 2002). In

addition, this information could be conveyed by parenting websites and magazines

to ensure that messages are consistent and provide maximum reach.

6.8.2 Implications for broader community based initiatives

Individual mothers’ efforts to reduce children’s access to restricted foods

and drinks could be supported by the following broader community based initiatives

with cross-sector government support.

• Expand school food policies and target children’s social events, to

positively reinforce healthy foods and drinks as desirable “treats” and

214 Chapter 6: Discussion & Conclusions

encourage a further reduction in children’s access to targeted restricted

foods and drinks at organised social venues and schools.

• Work with food retailers to promote the purchase of healthy foods for

children and deliver key messages, such as healthy foods can be “treats”

e.g. free fruit for kids initiative in Australian supermarkets.

• Work with parenting media (websites, magazines and TV programmes) to

promote prominence in the key messages outlined in Section 6.8.1.

• Support government policy that promotes incentives for food retailers to

promote healthy foods as desirable (e.g. subsidies for healthy food, taxing

unhealthy foods) and continue to support incentives to remove attractive

packaging associated with unhealthy foods from highly visible areas of

shops or be associated with attractive free gifts.

6.9 STRENGTHS AND LIMITATIONS OF THE STUDY

6.9.1 Strengths of the study

A key strength of the present study was the mixed methods design. This

provided new knowledge of the dimensions of the restrictive feeding phenomenon,

as well as highlighting the potential key dimensions that might underpin future

development of a new measure of restrictive feeding. The qualitative component of

the study provided in-depth exploration and analysis of the restrictive feeding

phenomenon. This enabled the potential dimensions of this phenomenon to emerge

directly from participants’ reported real world experiences. While the sample size

was intentionally small in order to focus on gaining in-depth knowledge, some

diversity of participant characteristics was achieved, which contributed to the

potential range of experiences captured by the study. The sample had equal

representation from child genders and university/non-university educated mothers,

as well as 38% of participants having not been born in Australia.

The quantitative component of this study extended analysis of potential key

dimensions identified by the qualitative component. The NOURISH database

(Daniels et al., 2009), used as the secondary source for this study, contained a

range of variables collected at four child age points. This enabled more objective

Chapter 6: Discussion & Conclusions 215

assessment of reported patterns of restrictive feeding over time, as well as statistical

confirmation of potential cross-sectional associations suggested by the qualitative

component of the study. In addition, the findings of the qualitative component

contributed to appropriate selection of measures for the quantitative component.

This component of the study provided complementary information about the

dimensions of the restrictive feeding phenomenon and extended knowledge of how

some key dimensions might influence child liking for restricted foods and drinks.

Both components of the study were also derived from the same sample, which

supported comparative analysis of qualitative and quantitative findings.

6.9.2 Limitations of the qualitative component

While some diversity was provided in the sample, characteristics of

mothers and children included in the qualitative component of the study varied from

the sample invited for interview, with lower representation of low income families

and overweight/obese participants (see Chapter 3, Section 3.2.2.2, Table 3.2).

Other studies including participants from low socio-economic groups reported similar

parent motivations for restrictive feeding to the present study (Baughcum et al.,

1998; Sherry et al., 2004; Ventura et al., 2010) but Campbell et al.’s (2002) study

suggested that children within low socio-economic families are associated with

higher overconsumption of extra foods than those in higher socio-economic families.

While sample characteristics may influence findings, this study aimed to report on

the range of participant experiences and the sample did include some low income

families, as well as overweight and obese mothers and children. The present study

sample included ten mothers and four children who were overweight and four

mothers and one child who were obese, as defined by the WHO (see Chapter 3,

Section 3.2.2.2, Table 3.2). Weight management might be a more prominent

motivator of restrictive feeding in samples with different weight profiles, ethnic

origins or socio-economic status, although other studies with mixed ethnic and

socio-economic samples reported findings consistent with the present study

(Herman et al., 2012; Sherry et al., 2004; Ventura et al., 2010) (see Section 6.2.3.1).

However, there may have been further differences, beyond measurable

characteristics, between mothers who volunteered for the qualitative study and

those who did not volunteer. While the invitation letter encouraged mothers who

believe they do not restrict foods and drinks to volunteer as well, those volunteering

were probably more likely to be aware of their food restricting practices and

216 Chapter 6: Discussion & Conclusions

interested in this aspect of parenting than those who did not volunteer. In addition, it

is possible that mothers who did not feel positive about their approach to restrictive

feeding may not have volunteered. It is, therefore, likely that the sample of mothers

interviewed presented a bias towards mothers who are aware that they are applying

restrictive feeding practices, as well as those that believe they are applying good

practices.

Social desirability bias is common in studies containing socially sensitive

items (Van de Mortel, 2008) and the findings of the qualitative component of the

study suggested a strong possibility of bias. Qualitative reports suggested that

selected realities presented were more likely to represent good intentions or events

on a good day rather than reflect the range of experiences (See Chapter 4, Section

4.4.1.3). This finding challenges the reliability of mothers’ reports, in relation to

children’s access to restricted foods and drinks, as well as mothers’ reported

practices.

Information on the specific foods and drinks restricted by mothers may

have been more effectively collected via a survey due to the deductive nature of this

information. However, limited time and resources meant that identification of types

of restricted foods and drinks was ascertained during the interviews, complemented

by descriptive data of target foods and drinks presented in the quantitative

component of this study.

6.9.3 Limitations of the quantitative component

Mothers participating in this study were self-selected and the sample only

included those still active in the control group of the NOURISH trial (Daniels et al.,

2009) when children were 5 years old. This sample included higher proportions of

older, married and university educated mothers within higher income families and

lower representation from overweight mothers than participants declining to

participate in the NOURISH trial or lost to follow up (see Chapter 3, Section 3.2.2.2,

Table 3.1). Such retention bias should be considered when extrapolating these

findings beyond this sample. Further research is required to ascertain whether the

findings of this study are more widely applicable to other populations.

Chapter 6: Discussion & Conclusions 217

A major limitation to this component of the study was that the data were not

collected for the purpose of this study, which resulted in a number of limitations that

are outlined below.

Grouping of restricted foods and drinks and measurement of level of restriction (child intake)

The groupings of foods and drinks in Wardle, Sanderson, et al.’s (2001)

food liking scale (included in the NOURISH survey, Daniels et al., 2009)

corresponded fairly well with differentiation between levels of restriction of items

reported in the qualitative component of the study. The only changes suggested in

future research would be the separation of chocolates and lollies and separation of

cola soft drink from other soft drinks because some mothers restricted these items

differently.

The CDQ (Magarey et al., 2009) and the intake frequency of drinks scale

developed by the NOURISH investigators were selected as the most suitable scales

available from the secondary source (Daniels et al., 2009). Unfortunately, drink

items of cordial and soft drink had been combined in the CDQ. As soft drink was

likely to be one of only a few items representing mothers’ intention to totally restrict

an item, separation of this item from other drinks restricted in moderation was

desirable. However, this meant that two separate scales that asked slightly different

questions were used (see Appendix L, Table L.1).

The groupings of foods in the CDQ (Magarey et al., 2009) intake scale

provided less differentiation of items than the food liking scale (Wardle, Sanderson,

et al., 2001) and did not reflect the variability of restriction of items reported in the

qualitative study. Cakes and sweet biscuits were combined, chips and savoury

biscuits were combined and lollies were included with muesli and fruit bars in this

scale. This limited differential analysis of child intake and preferences. Furthermore,

child intake data were collected as mothers’ retrospective reports via survey, which

relied on mother’s ability to recall their child’s intake over the past seven days or

assess their usual intake. In addition, potential social desirability bias suggested by

the qualitative study, may have contributed to under-reporting of children’s

frequency of intake of restricted items (see Section 6.7.2).

218 Chapter 6: Discussion & Conclusions

Neither the CDQ (Magarey et al., 2009) or the NOURISH drinks scale

(Daniels et al., 2009) provided sufficient frequency of intake categories appropriate

for differentiating levels of intake for the most highly restricted items. This resulted in

highly skewed data for these items and data for child intake frequency of sweet

drinks should be considered with caution. The dichotomous split of never and any of

the child intake variable for the two drink items (soft drink and fruit drink) was

deemed necessary but potentially over simplified variation in frequency of intake

between participants. In addition, a significant proportion of mothers who indicated

that their child never had soft drink or fruit drink in the intake scale also indicated

that their child had tried these items in the child liking scale (discrepancies of 34%

for soft drink and 19% for fruit drink). This suggested that a proportion of responses

of never, may have represented low but not nil intake.

Measurement of child and mother liking for restricted foods and drinks

Data for child food and drink liking were collected via mothers’ reports on

Wardle, Sanderson, et al.’s (2001) food and drink liking scale. While this measure is

not a direct measure of child liking, Skinner et al. (1998) found that mothers’ reports

correlated highly with child self-reports of food preferences.

However, the child food and drink liking scale did not provide sufficient

alternative options to differentiate between levels of liking relevant to restricted foods

and drinks. The only like categories were likes a little and likes a lot. As the

restricted foods and drinks examined were highly liked by most children in the

sample, this resulted in highly skewed data in the likes a lot category for most items.

This skewed data resulted in the need to dichotomise data and apply binary logistic

regression in order to meet statistical assumptions, which reduced the potential

sensitivity of the analysis. Furthermore, responses of never tried were excluded from

the regression analysis because participants liking for the item could not be

assessed if they had not tried it. However, this resulted in reduced sample sizes for

the more highly restricted items (soft drink, fruit drink, fast foods).

The same liking scale (Wardle Sanderson, et al., 2001) was applied to

assess mothers’ own liking in the NOURISH survey (Daniels et al., 2009) and this

was used as the measure of mothers’ own liking for restricted foods and drinks in

the present study. This measure did not pose the same difficulties as the child liking

Chapter 6: Discussion & Conclusions 219

data because the data was not so highly skewed and there were low frequencies in

the never tried category.

Measurement of child early exposure to restricted foods and drinks

The age by when children had been introduced to an item was used as the

measure of early exposure but varied considerably by item. To enable suitable

distributions of data for statistical analysis, the child early exposure variable was

dichotomised at the child aged 2 year time point for the more highly restricted items

and at the child aged 14 month time point for less restricted items.

While exclusion of participant responses of never tried from the binary

logistic regression analysis made sense for the child and mothers’ own liking

variables, this reduction in the model samples distorted the child early exposure

variable for soft drink, fast foods and fruit drink. This is because a number of child

participants who had still never tried these items at 5 years old were excluded from

the sample. However, the alternative of including the never tried response would

have meant that participants whose liking for the item could not be assessed would

have been included as non-high liking.

Violations of assumptions for statistical analyses

Sample sizes were generally quite small (127 to 171) for the binary logistic

regression analyses. This combined with skewed data for child liking and child

intake variables may have impacted the robustness of the analyses. The small

samples and skewed data increased the possibility of type 2 errors due to

insufficient power, which may produce false negative findings. Inclusion of

participants from the intervention arm of NOURISH would have doubled the sample

sizes and potentially reduced the risk of this error. However, the intervention

participants may have been influenced by the child feeding intervention being tested

by the NOURISH study (Daniels et al., 2009).

Small sample sizes and skewed data for child liking and child intake

variables also meant that data did not meet the assumptions required for preferred

analysis methods using either structural equation modelling or ordinal regression

(Tabachnick & Fidell, 2007). These factors also meant that statistical examination of

patterns of longitudinal data over time by general estimations equations (GEE)

220 Chapter 6: Discussion & Conclusions

between different child ages and restricted items was not possible. Child liking data

for ice cream was so highly skewed that it did not meet assumptions for binary

logistic regression and was, therefore, excluded from statistical analysis.

6.10 CONCLUSION

In conclusion, exploration of the restrictive feeding phenomenon in the

present study suggested a need to reconceptualise restrictive feeding, with a

redirection of the current narrow focus on measuring parent restrictive feeding

behaviours towards identifying the key dimensions of the broader phenomenon

potentially influencing child preferences (or liking or wanting) for restricted foods and

drinks.

Qualitative findings indicated that restrictive feeding includes both level of

restriction and restrictive feeding practices, which appeared to vary more by different

restricted foods and drinks than between mothers in the present study. This

suggests that examination of the effects of restrictive feeding should be undertaken

in relation to specific groups of restricted foods and drinks rather than attempting to

make general comparisons between mothers. Two predominant restrictive feeding

intentions were evident, total restriction and in moderation restriction, which had

distinctly different characteristics across a range of dimensions constituting the

restrictive feeding phenomenon. Patterns of restrictive feeding over time suggested

progressive change in prominence from total to in moderation restriction, varying by

child age and by specific restricted foods and drinks.

The present study suggested that the level of restriction of a food or drink is

a fundamental dimension of the restrictive feeding phenomenon, which has been

largely ignored by cohort studies to date. Quantitative findings complemented

qualitative findings, showing that a lower level of restriction (higher child intake

frequency) of a sweet food or drink was cross-sectionally associated with child high

liking for the same restricted food or drink at child aged 5 years. However, an

association was not confirmed for the restricted savoury foods examined. With

regard to child early exposure, qualitative reports suggested an association with

child liking for restricted foods and drinks but quantitative analysis found that child

early exposure did not influence child liking for restricted foods and drinks

independently from children’s current intake frequency at 5 years old. This study

concludes that children’s intake of restricted foods and drinks is likely to be an

Chapter 6: Discussion & Conclusions 221

important dimension to include in a measure aiming to assess the effects of

restrictive feeding on children’s diet-related outcomes but children’s early exposure

may not be an important dimension.

With regard to parent restrictive feeding practices, this study proposes that

the concept be expanded to include associated parent communication, as well as

their restrictive feeding behaviours. The present study found that communication

determines whether a restrictive feeding practice is covert or overt. In addition,

distinct variation in mothers’ overt communication regarding the connotations of

restricted foods and drinks was also evident. This finding combined with existing

evidence of the effects of connotations conveyed in communication on child

preferences for foods, suggested that this dimension may be important to include in

a measure of restrictive feeding. In contrast, qualitative data and existing literature

did not provide any evidence that different restrictive feeding behaviours (e.g. rules,

flexible judgement, avoiding access) have differing effects on child preferences (or

liking or wanting) for restricted foods and drinks. However, further research is

required to clarify these associations and whether this dimension would be important

to include in a measure.

A dominant uncanvassed theme emerging from the qualitative component

of this study was the association between mothers’ own preferences for a restricted

item with decisions to restrict an item in moderation and mothers’ language

portraying positive connotations about the restricted item to their child. The

presentation of a restricted item as a “treat” during periods of access was integral to

restriction in moderation. This raises the question of whether it is this aspect of in

moderation restriction that may influence a child’s preference for a restricted food or

drink rather than because the food or drink is restricted. Quantitative analysis also

highlighted significant associations between mothers’ and children’s liking for

restricted foods and drinks independently of the level of restriction (child intake)

mothers applied. While the mediating variable or variables that explain the

association between mother and child liking for restricted foods and drinks could not

be identified in the present study, qualitative data and existing evidence combined

suggest that mothers’ overt communication conveying positive connotations about

restricted items could potentially be a key mediator.

Findings suggested that existing measures used in cohort studies present a

number of limitations, including: a lack of differentiation between different restricted

222 Chapter 6: Discussion & Conclusions

foods and drinks; absence of measurement of the level of restriction applied by

parents (child intake); lack of differentiation between restrictive feeding behaviours

potentially used by parents; and no consideration given to parent communication

associated with restrictive feeding practices. In addition, this study revealed a high

risk of social desirability bias, potentially resulting in underreporting of children’s

access to these foods and drinks. This suggests that careful attention needs to be

given to the phrasing of questions in self-reporting questionnaires, as well as

consideration of alternative methods to provide more valid measurement of this

phenomenon.

A key strength of this study was the mixed methods design, with knowledge

arising from the qualitative component and literature review being extended by

examination of quantitative data. However, there were a number of limitations.

Firstly, the samples included higher proportions of older mothers, higher income

families and lower representation of overweight and obese mothers and children

than those initially recruited to participate in the NOURISH trial (Daniels et al.,

2009); the population from which the samples in this study were selected. Secondly,

social desirability bias was a strong possibility for data collected for both the

qualitative and quantitative components of the study. Thirdly, the use of secondary

data for quantitative analysis presented limitations with regard to the variables

available for analysis and the highly skewed data, which limited the sensitivity of this

analysis.

The implications of the present study are firstly that there is currently no

clear evidence that higher restriction of a food (low child intake) is associated with

higher child liking for that food and hence associated future risks of diet-related

disease or obesity. The present study has presented evidence to the contrary.

Secondly, current measures of parent restrictive feeding used by cohort studies do

not reflect the key dimensions of the restrictive feeding phenomenon identified by

this study. While further research is required, the present study proposes that the

two key dimensions of level of restriction (child intake) and the connotations of

restricted foods or drinks communicated by parents could potentially capture the

effects of restrictive feeding on children’s diet-related outcomes. However, this study

also proposes a number of directions for further research before an evidence-based

conceptual framework is fully developed to support construct valid measurement of

this phenomenon.

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Appendices 247

Appendices

Appendix A

Literature review search strategies

A.1 Search strategy for quantitative studies of restrictive feeding Criteria for inclusion Intervention

Parent restrictive feeding used to limit the consumption of foods eaten by their

children.

Study Participants

All participants referred to as children, infants or toddlers, adolescents or teenagers

up to18 years, and parents of these children.

Outcomes

At least one outcome measure e.g. child weight or body mass index, child food

intake, child eating behaviour, child food preference (liking or wanting).

Time Period

Studies published in 1980 or later.

Study Design

All types of study design.

Language

Only papers available in English.

Peer reviewed

Only peer reviewed papers

Exclusion Criteria

• Studies that do not include assessment of the effect of parent restrictive feeding

in relation to at least one quantified child outcome measure.

• Studies published in journals that are not peer-reviewed.

248 Appendices

• General discussion papers, which don’t present data on effects.

• Studies not available in English or published before 1980.

• Studies conducted in developing countries.

• Studies of adults (over 18 years).

Search Strategy

The search included:

• searching published academic research via search words;

• hand searching relevant references included in extracted papers;

• hand searching new papers listed in alerts.

The following databases were used for the search

• Google Scholar

• PsycEXTRA

• Scopus/Science Direct

• PubMed

Search Terms a) Restrictive feeding studies

Search Words

Intervention (OR)

(title & keywords searched)

• Parent* parenting or parental or maternal or mothers or authori*

• Control or restrict* or feed* or eat*

• Overt and covert control (restrict*)

AND

Outcome (OR)

(title & keywords searched)

• Child* or paediatric

• *weight or weight*

• obesity or adiposity

• BMI or Body Mass Index

• intake or preference or liking

Appendices 249

• Palatable or non-core or discretionary foods

• Snack* (snacking) behavio#r

• Diet quality

• ‘Eating in the absence of hunger’

• Food responsiveness

• Eating behavio#r

AND

Types of participants (OR)

(title & keywords searched)

• Child*

• Infant*

• Toddler*

• Pre-school children

• School Children

• Primary School Children

• Adolescents

• Teenagers

b) Measures of restrictive feeding

Intervention (as above) (AND)

• Questionnaire

• Child feeding questionnaire (CFQ)

• Confirmatory factor analysis

• Parental control index

• Child eating behaviour questionnaire (CEBQ)

• Survey

• Observation

250 Appendices

A.2 Search strategy for qualitative studies of parent restrictive feeding

Criteria for inclusion Intervention

Qualitative assessment of at least one aspect of parent feeding related to restricting

foods or drinks.

Study Participants

All participants referred to as children, infants or toddlers, adolescents, teenagers

and parents of these children.

Outcomes

Qualitative theme related to at least one aspect of parent feeding related to

restricting foods or drinks.

Time Period

Studies published in 1980 or later.

Study Design

All types of qualitative study design.

Language

Only papers available in English.

Peer reviewed

Only peer reviewed papers

Exclusion Criteria

• Studies that do not include qualitative assessment of at least one aspect of

parent feeding related to restricting foods or drinks.

• Studies published in journals that are not peer-reviewed.

• General discussion papers, which don’t present assessment of qualitative data.

• Studies not available in English or published before 1980.

• Studies conducted in developing countries.

• Studies of adults (over 18 years).

Appendices 251

Search Strategy

Study type & Intervention (OR)

(Title & keywords searched)

• Qualitative OR interview* OR focus group* OR observation

AND

• Parent* parenting OR parental OR maternal OR mothers

AND

• Control* OR restrict* OR feed* OR eat* OR food*

AND

Types of participants (OR)

(Title & keywords searched)

• Child*

• Infant*

• Toddler*

• Pre-school children

• School Children

• Primary School Children

• Adolescents

• Teenagers

252 Appendices

Appendix B

Cohort studies examining restrictive feeding Table B.1 Cross-Sectional Studies Examining Associations Between Restrictive Feeding and Child Diet-Related Outcomes Author/Year Sample/Age Restriction

measure Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other association with restrictive feeding

Birch (USA) 2003

N=140 girls (mean 5.4yrs)

CFQ Change EAH protocol (Fisher & Birch, 1999b)

• Family Income • Maternal

Education • Maternal BMI Dichotomised: child

BMIz < & > 75th percentile

(None) Restriction & EAH adjusted

• ‘Perception child’s weight’ sig. associated weight status*** and restriction*.

• ‘Concern child overweight’ sig associated weight status*** and restriction* (modified by sig interaction**).

• Post hoc: girls > 75th % BMIz and mothers high restriction sig associated with mothers ‘concern child overweight’*

Blissett (UK) 2013

N = 171 (2-12 years) (UK & Germany)

CFPQ Restriction for weight scale

Child BMIz (Measured)

• Child age • Child BMI SDS • Parent age • Parent BMI • Parent Education • Parent eat dinner

with child • Parent emotional

eating

CFPQ Restriction for weight control & Child BMIz (+ve) r = 0.52* (Black Afro-Caribbean) (None) White British, White German

• Parent scores for restriction for weight control (CFPQ) significantly higher for Black Afro-Caribbean than White German* or White British***

Boots (Australia) 2015

N= 611 (2-7 years)

CFQ and Covert Control

FFQ: 2 groups - healthy & unhealthy snack foods . Frequency of snacks consumed per day

• Maternal educ • Maternal age • Child age • Socioeconomic

area

CFQ Restriction & Snack food frequency (Unhealthy & Healthy) (+ve) Unhealthy β= 0.29, p= .001 (-ve) Healthy β= -0.30, p= .001 Covert control & Snack food frequency (Unhealthy & Healthy) (-ve) Unhealthy β= -0.34*** (+ve) Healthy β= 0.28***

Parenting styles • CFQ: (+ve) parent demandingness (β= 0.13, p=

.002). (-ve) responsiveness (β= -0.31, p= .000) • Covert: (+ve) parent demandingness (β= 0.34,

p= .000). (None) responsiveness.

Brown (UK) 2008

N=518 (4-7yrs)

Covert Control

Child BMIz (Measured) Reported Intake 2 groups: 12 unhealthy snack foods & fruit and vegetables

• Parent age • Parent gender • Ethnicity • Marital status • Mat BMI • Mat Educ • Time work/home • Child age • gender

(None) Restriction & BMIz Covert restriction & child BMIz (-ve) Restriction & Intake unhealthy snacks (adjusted) Covert restriction (snacks) reduced unhealthy snacks, b = -.27** (+ve) Restriction & Intake Fruit & Veg (adjusted) Covert restriction (meals) increased fruit & veg intake, b = .16*

• Overt control had no sig effect on child BMIz

*p < .05. **p < .01. ***p < .001.

Appendices 253

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other association with restrictive feeding

Campbell (Australia) 2006

N=560 (5-6 yrs)

CFQ FFQ (kj/day) 5 groups: • daily energy

intake • high-energy

drinks • sweet snacks • savoury snacks • vegetables

• Mat Educ • Pressure to eat

(CFQ) • Monitoring eating

(CFQ)

(None) Restriction & FFQ • daily energy intake • high-energy (non-dairy) drinks • sweet snacks • savoury snacks • vegetables

NB: controlled for pressure to eat (CFQ scale)

• (+ve) Pressure to eat & FFQ 4 groups):daily energy intake**, high-energy (non-dairy) drinks*, sweet snacks*, savoury snacks*

• (None) Pressure to eat & FFQ vegetables.

Cardel (USA) 2012

N = 267 (7-12 years)

CFQ (3)

Child Adiposity Combined: Child BMIz (Measured), DEXA & TAAT

• Pubertal status • Child gender • Ethnicity

McSNP Genetic admixture (Cardel, 2011)

• Socio-economic status 4-factor Index (Hollingshead, 1975)

(+ve) CFQ Restriction & Child Adiposity (BMIz, DXA, TAAT) β= 0.26***

• (+ve) Restriction & pressure to eat (modified, CFQ scale, Birch, 2001) (r= - 0.46, p < 0.0001)

• (-ve) CFQ Restriction & higher socio-economic status (r = - 0.40, p < 0.0001)

• CFQ Restriction significantly higher for Hispanic and African American than European American (p< 0.05).

Carnell (USA) 2014

N = 432 (3-6 years, mean 4.4 yrs)

CFQ Food responsiveness (CEBQ)

• Child BMIz Restriction & Food responsiveness (+ve) β= 0.25***

Costa (Brazil) 2011

N = 109 6-10 years, mean 8.2 yrs)

CFQ Child BMIz dichotomized Excess weight (BMI > 85th %tile), healthy weight categories (BMI <85th %tile) (Measured)

• Other CFQ scalesᵇ (Birch et al., 2001)

• Parent BMI • Economic class

CFQ Restriction & Child excess weight (BMI > 85th) (+ve) significantly higher restriction score for children with excess weight*** Multivariate OR = 1.36***

• CFQ Restriction scores significantly higher for parents with excess weight (BMI >85%) than those with a healthy weight (BMI < 85%).*

• CFQ Restriction score not related to economic class

Dev (USA) 2013

N = 329 (2-5 years)

Restriction for weight control scale (measure used not referenced)

Child BMIz dichotomized Overweight/obese (> 85th %tile), other weight categories (<85th %tile) (Measured)

22 child obesity risk factors (Child and parent characteristics and child diet/lifestyle activities, parent feeding practices)

Restriction for weight control & Child Overweight or obese (BMIz) OR 1.75, p = 0.029 (β = 0.56)

*p < .05. **p < .01. ***p < .001.

254 Appendices

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other association with restrictive feeding

Durao (Portugal) 2015

N = 4122 (4 years)

CFQ Covert Control

EDF FFQ (prev. 6 months). 35 food items ᶜ (9 point scale, < 1Xmonth to 4 or >/day)

• Maternal BMI • Maternal educ • Maternal age • Maternal FFQ

score. • Child age • Child gender • Child BMIz

(-ve) CFQ Restriction & Energy-dense, micronutrient poor foods and beverages (EDF) Lower odds 0.81 [0.72-0.93] (-ve) Covert control & Energy-dense, micronutrient poor foods and beverages (EDF) Lower odds 0.81 [0.72-0.93]

Fisher & Birch (USA) 1999b

N=42 (3-6 years, mean 5 yrs)

RAQ

EAH measured by: Child total calorie intake of 10 snack foods ᶜ kilojoules consumed during experiment.

• Parent BMI • Child weight &

height, skin fold percentile scores (measured)

(+ve) Restriction & EAH Girls only (r = 0.59***)

(None) Restriction & EAH adjusted

(+ve) Restriction X gender & EAH Interaction effect ( β = 25.6*, R² = 0.19, n=43)

(+ve) Restriction & Child weight-for-height Boys only (r = 0.56***)

• Children’s weight for height predicted maternal restriction (β = 0.03*, n=36)

• Interaction of parent’s dietary restraint (Three Factor Eating Questionnaire, Stunkard & Messick,1985) X female child gender predicted maternal restriction (β = 1.28**, n=36).

Gregory (Australia) 2010b

N=141 (2-4yrs)

CFQ (6) BMIz (Reported) CEBQ

• Mat BMI • Mat Educ

(None) Restriction & BMIz r = -.05 (p ns) (+ve) Restriction & Food Responsive r=.32**, β = .28***

• (+ve) Restriction & Food Fussiness r=.17*, β ns • (+ve) Restriction & concern about child weight

r=.24**, β = .18*

Gray (USA) 2010

N=191 (7-17yrs)

CFQ BMIz (measured)

• Income • Marital status • Parent Educ • Ethnicity • Child age • Gender

(+ve) Restriction & BMIz r = .31*** (unadjusted) ANCOVA : F (2,184) = 17.75***, η² = .16 Post Hoc: t = 4.69*** (controlled for child age. Only sig covariate from examination of inter-correlations)

• Restriction & concern about weight r = .56*** • ‘Concern’ sig. mediator ‘restriction & child BMI:

Sobel test t=6.02, p< .001 (β = .03, p = .74, indirect effect = - .52)

• Restriction & parent BMIz r =.26** • Parent BMIz & Child BMIz r =.38*** • Child age & restriction r = -.23**

Gubbels (Netherlands) 2009

N=2578 (2yrs)

Parent-report Question: foods/drink allowed (Yes/No)

Weekly Intake Frequency

• M&F BMI • M&F Educ • M&F employ • M&F COB • Mat age • Gender • BMI 1 & 2 yrs • Hrs child care • Child behave • Child eat style

(-ve) Restriction & intake of specific restricted foods* (adjusted) (-ve) Restriction & clusters of snack foods Cluster 1:Snacks, β = -.14* to -.23** Cluster 2:(reversed): Cookies & cakes, β = -.08** (+ve) Restriction & intake of fruit & veg * (adjusted)

2 separate restriction groups of foods • Cluster 1 restrict ‘snacks’(sweets, crisps, sugar,

drinks) • Cluster 2 lack of restriction for (cookies &

cakes). NB. This was reversed for analysis. Significant results were related to high restriction levels for both clusters.

*p < .05. **p < .01. ***p < .001.

Appendices 255

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other association with restrictive feeding

Gubbels (Netherlands) 2011

N=2026 (5yrs)

CFQ BMIz (measured) Child intake: Total daily, fibre and sugar

• M&F BMI • M&F Educ • M&F employ • M&F COB • Mat age • Gender • Birth wt • Hungry/Picky eat

(+ve) Restriction & BMIz β=0.10***

(None) Restriction & child intake No significant associations with total energy, fibre, sugar intake.

• Restriction associated with Hungry eating style β=0.14***

• Restriction associated with Picky eating style (CFQ, Birch et al., 2001), β=0.21***

• Higher maternal BMI associated with lower restriction, β=-0.10**

Harris (Australia) 2014

N = 180 (3.7 years)

CFQ EAH protocol (Fisher & Birch, 1999b)

• Maternal BMI • Maternal educ • Maternal age • Child age • Child gender • Intro. to solids • Breast feeding

duration • Child BMIz

(None) Restriction & EAH

Hennessy (USA) 2010

N = 99 (9 years)

CFQ Child BMIz (Measured)

• Parent BMI • Parent gender • Parent educ • Parent age • Marital status • Child age • Child gender • Race/ethnicity

CFQ Restriction & Child BMIz (None) β= - 0.14, p= 0.26

• Restriction (CFQ) negatively correlated with (parent style dimensions) responsiveness (r = -0.26, p = 0.01)

Jani (Australia) 2015

N =152 (1-5 years) Indian decent living in Australia

CFQ Food responsiveness (CEBQ) Diet quality: number of non-core (n=25) and core (n= 24) foods consumed in 24 hrs (Chan, Magarey & Daniels, 2011)

• Maternal BMI • Maternal educ • Maternal age • Religion • Child age • Child gender • Child WFAz • Birthplace • Number siblings

(+ve) Restriction & Food responsiveness β= 0.31, p= 0.001 (None) Restriction & diet quality Number of non-core and core foods consumed (24 hours) not sig. related to restriction.

• (+ve) Restriction & emotional eating β= 0.28***

*p < .05. **p < .01. ***p < .001.

256 Appendices

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other association with restrictive feeding

Jansen (Netherlands) 2012

N = 4987 (4 years)

CFQ Child BMIz (Measured)

• Child gender • National origin • Child birth weight • Child age • Maternal Educ • Family income • Smoking

pregnancy • Maternal BMI • Paternal BMI • Maternal

Psychopathology • Paternal

Psychopathology

CFQ Restriction & Child BMIz (+ve) β= 0.09***

Child BMIz & CEBQ (adjusted for CFQ score) (+ve) Food Responsiveness β= 0.17*** (covariates but unadjusted for CFQ β= 0.21***) (- ve) Satiety responsiveness β= -0.17*** (covariates but unadjusted for CFQ β= - 0.21***)

Jansen (Australia) 2014

N = 462 (2 years)

FPSQ Overt & Covert Restriction Scales

Weight for age z-score CEBQ

n/a FPSQ Restriction & Child weight (None) FPSQ Restriction & Eating behaviours (CEBQ) (+ve) Overt Restriction scale Satiety responsiveness (r =.173***) Food responsiveness (r =.258***) (None) Covert Restriction scale

Other eating behaviours (+ve) Overt Restriction scale Fussiness (r =.132**) emotional overeating (r =.180***) emotional under-eating (r =.167***) desire to drink (r=.119*)

Lee (USA) 2001

N=192 girls (5 years)

CFQ BMIz change (measured) High fat (>30%) diet

• High fat/low fat intake groups

(+ve) Restriction & BMIz Restriction sig correlated with BMIz, r = .20** (unadjusted) (+ve) Restriction & high fat diet Restriction sig. correlated with high fat diet (independently of BMI), r = .17** (unadjusted) but not sig. correlated with total energy intake.

• Longitudinal change BMIz from 5 to 7 years was sig greater for girls on a high fat diet, r =.14* (unadjusted)

• Mothers and daughters fat intake sig correlated, r = .31*** (unadjusted) and more highly correlated than energy intake, r = .15* (unadjusted).

Mais (Brazil) 2015

N = 659 (5-9 years)

CFPQ restriction scales

Food frequency questionnaire. 13 ultra processed foods items summed. 5 point frequency scale, last 7 days.

n/a CFPQ Restriction for health scale (+ve) high intake ultra processed foods p = 0.007 (discriminate analysis)

• Restriction for weight control scale significantly associated with parent concern child overweight (p < 0.001).

• Restriction for health scale significantly associated with parent concern child overweight (p < 0.001) and concern child underweight (p < 0.026).

Musher-Eizenman (USA & France) 2009

N = 219 (131 mothers, 88 fathers) (3.7-6.8 years, mean = 5 yrs)

CFPQ restriction scales

Child BMIz (Measured)

n/a CFPQ Restriction & Child BMIz Restriction for health (+ve) OR 1.7 [1.2,2.2], p < 0.01 Restriction for weight control (+ve) OR 2.0 [1.4,2.8], p < 0.01

*p < .05. **p < .01. ***p < .001.

Appendices 257

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restriction results (predictor & outcomes)

Other association with restriction

Ogden (UK) 2006

N=297 (4-7 & 4-11yrs)

Covert Control Snacking behaviour Reported Intake: 12 unhealthy snack foods

• Parent age • Parent gender • Ethnicity • SEG • Mat BMI • Child age • Gender • Perceived child

weight

(-ve) Restriction & Intake unhealthy snacks Covert restriction & ‘unhealthy’ snacking b = -0.36*** (adjusted), 11.9% variance

• Covert restriction didn’t sig predict ‘healthy’ snacking behaviour.

• Lower parent BMI associated covert control (b=-0.24***) and perceived heavier child (b=0.2**) accounting for 10.3% variance.

Powers (USA) 2006

N=296 (2-5yrs)

CFQ BMIz (measured)

• Mat age & educ • Mat Employ • Mat Income • Marital status • Child age • Gender

(None) Restriction & BMIz Not sig. association overall (adjusted & unadjusted covariates) (+ve) Obese mothers (>30kg/m²): r = .20* (unadjusted) (-ve) Non-obese mothers (<30kg/m²) r = -.16* (unadjusted)

• Interaction: maternal obesity X restriction significant** (controlled for maternal covariates)

Rollins (USA) 2014c

N = 180 girls (5yrs)

RAQ: 4 restricting parent Profiles

EAH protocol (Fisher, 1999b) change

n/a (+ve) Restriction & EAH d = 0.75* Comparison of means between lowest and highest of 4 parent restricting profile groups

Shohaimi (Malaysia) 2014

N = 397 (7-9 years)

CFPQ Restriction for health & weight control scales

Child BMIz (Measured)

n/a CFPQ Restriction & Child BMIz Restriction for weight control (+ve) r = 0.38, p < 0.01 Restriction for health (None)

Spruijt-Metz (USA) 2002

N=120 (7-14yrs)

CFQ Total Fat Mass (TFM) (measured)

• SEG • Ethnicity • Gender • Energy intake

fat/other

(+ve) Restriction & TFM r = .26*** (unadjusted) β = -0.03 (p= ns) However, energy intake from fat sources was included as a covariate, which would be independently related to the outcome measure, TFM

• Restriction & pressure r = .28*** • Restriction & concern about weight r= .60*** • Energy intake from non-fat sources predicted

5% variance TFM. • Energy intake from fat sources not sig. predictor

of TFM.

*p < .05. **p < .01. ***p < .001.

258 Appendices

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other association with restrictive feeding

Sud (USA) 2010

N=70 (4-6yrs)

CFQ (6) CFQ (2)

BMIz (Measured) Energy Intake Energy Density (Food + Drink)

• Mat BMI • Income • Child age • Gender • Ethnicity

(None) Restriction & BMIz Overall (CFQ8) (p=0.6 ns) (+ve) non-obese parents r = .6* (unadjusted) ᶠ (none) obese/overwt parents r = -.3, p=0.07 (ns) (unadjusted) ᶠ (+ve) CFQ 6 restricting access r = .3* (unadjusted) ᶠ (-ve) CFQ 2 reward r = -0.3* (unadjusted) ᶠ (None) Restriction & Total Energy Intake (-ve) Restriction & Energy Density food & Drink CFQ8 r = -.3** (unadjusted) β = -0.3** (adjusted) (None) Restriction & Energy Density food only (adjusted/unadjusted) (-ve) owt/obese children (CFQ8 only) r = -.54** (unadjusted) ᶠ

Characteristics • Parent BMIz & Child BMIz r=.3* • Restriction not associated parent BMI Energy Density food & Total Energy Intake & BMIz • Total Energy X ED f+d r=.6*** • Total Energy X ED fd, r=.4* • ED fd+dr & BMIz ns • ED fd & BMIz ns • Child > BMIz selected lower ED food Note: lower density foods incl cola & pudding.

Taylor (Australia) 2011

N = 175 (7-11 years, mean 9.2 yrs)

CFPQ Restriction for weight control scale

Child BMIz (Measured) CDQ (Magarey, 2009) ᶢ Child liking scale (non-core foods)

• Child age • Child BMI (child

diet only) • Child Gender • Parent BMI • Parent Education

CFPQ Restriction for weight control & Child BMIz (+ve) β = 0.29, p < 0.01 CFPQ Restriction for weight control & Child non-core food intake (None) β = 0.02 ns CFPQ Restriction for weight control & Child liking non-core food None) β = -0.07 ns

• Child BMIz not significantly associated with child intake or liking of non-core foods.

Vollmer (USA) 2017

N = 148 (3-7 years, mean 4.55 years)

CFPQ Restriction for health & weight control scales

Preschool Adapted Food Liking Survey (PALS) (Peracchio et al., 2012)

• Parent educ • Child age • Child gender • Race/ethnicity

CFPQ Restriction & Preferences Restriction for health (+ve) β= 0.20, p= 0.024 (preference: high-fat, high-sugar foods) Restriction for weight control (None)

Warkentin (Brazil) 2016

N = 402 (3-5 years, mean 3.1 yrs)

CFPQ Restriction for health & weight control scales

Food frequency questionnaire. 13 ultra processed foods items summed. 5 point frequency scale, last 7 days.

n/a CFPQ Restriction for health scale (+ve) high intake ultra processed foods p = 0.008 (discriminate analysis)

• Parent concern child overweight significantly associated with restriction for health scale (p < 0.001) and restriction for weight control scale (p < 0.001)

*p < .05. **p < .01. ***p < .001.

Appendices 259

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other association with restrictive feeding

Webber (UK) 2010a

N=244 (7-9yrs)

CFQ Food Responsiveness (CEBQ)

• Ethnicity • Mat educ • Child age • Gender • Child BMI

(+ve) Restriction & food responsiveness β= 0.23*** (adjusted)

Webber (UK) 2010c

N=213 (7-9 years)

CFQ Child BMIz (Measured)

• Maternal educ • Maternal ethnicity • Child age • Child Gender

CFQ Restriction & Child BMIz (+ve) β= 0.16, p= 0.02

• Association between restriction (CFQ) and child BMIz became non-significant when concern child overweight added to the model (β= 0.04, p= 0.44). Concern mediates relationship between restriction and child BMIz.

• (+ve) CFQ Restriction & CFQ concern child overweight, β= 0.31***.

Wehrly (USA) 2014

N = 243 (4-6 years)

CFQ Child BMI-for-age (Measured) Child % body fat

• Child gender • Child age • Ethnicity • Family income

CFQ Restriction & Child BMI-for-age (None) CFQ Restriction & Child % body fat (None)

• CFQ Restriction and parent perceived child weight (+ve) (r = 0.40**)

• CFQ Restriction and CFQ pressure to eat (+ve) (r = 0.18**)

• CFQ Restriction significantly varied between ethnic groups Fs (4,221) = 2.53*. Asian parents reported higher restriction than white parents (Hispanic & non-hispanic) and black parents but the difference between Asian and black parents was marginally significant.

Ystrom (Norway) 2012

N=14122 (3 years)

CFQ 37-item food frequency questionnaire (own). Non-dinners foods (never to 4 or > a day) Dinner foods (1Xmonth or < to 5+ X week) Two dietary patterns ‘unhealthy’ and ‘wholesome’ identified by EFA.

• Marital status • Maternal BMI • Maternal educ • Maternal age • Work/homemaker • Child age • Child gender

Structural Equation Modelling (SEM) (-ve) Restriction & unhealthy diet β= - 0.07, p< 0.01 (+ve) Restriction & wholesome diet β= 0.10, p< 0.01

• Higher restriction scores associated with higher education, homemaker and boy child gender.

• Lower restriction scores associated with older mothers, higher maternal BMI.

• Mothers level of external locus of control (extent mother believes can control child behaviour by parenting skills) strong predictor of high restriction score.

Note. Maternal/Paternal BMI covariates were reported values unless otherwise stated. CFQ = Child Feeding Questionnaire, 8-item restriction scale (Birch et al., 2001); CFQ (3) = Child Feeding Questionnaire, items 1-3 from restriction scale (Birch et al., 2001), (see Section 2.4.2, Table 2.3); CFQ (6) = Child Feeding Questionnaire, 6-items from restriction scale (Birch et al., 2001), excluding 2 items referring to food rewards (see Section 2.4.2, Table 2.3, items 5 & 6); CFQ (2) = Child Feeding Questionnaire, 2 items referring to food rewards (Birch et al., 2001), (see Section 2.4.2, Table 2.3, items 5 & 6); Covert Control = Covert Control Scale (Ogden et al., 2006); RAQ = Restricting Access Questionnaire (Fisher & Birch, 1999b); CFPQ = Comprehensive Feeding Practices Questionnaire. Two restriction scales: restriction for health and restriction for weight control (Musher-Eizenman & Holub, 2007); FPSQ = Feeding Practices and Structure Questionnaire: overt and covert restriction scales (Jansen et al., 2014); CEBQ = Child Eating Behavior Questionnaire (Wardle et al., 2001b); DXA = Dual-energy X-ray absorptiometry; TAAT = Total abdominal adipose tissue (measured by computed tomography

260 Appendices

scanning (CT); TFM = Total fat mass; EFA = Exploratory factor analysis; FFQ = Food Frequency Questionnaire; EDF = Energy-dense, micronutrient poor foods and beverages; EAH = Eating in the Absence of Hunger; RRV = Relative reinforcing value. aSeven unhealthy foods: potato chips or other crisps, salty flavoured crackers, sweet biscuits, cake and pastries, chocolate and lollies, sugar sweetened drinks, hot fried snacks; 4 Healthy foods: fruit, vegetables, yoghurt, cheese (composite score of daily frequencies) (Giles & Ireland, 1996). bPerceived responsibility, perceived parent weight, perceived child weight concern about child weight, pressure to eat, monitoring. cTen snack foods: popcorn, pretzels, chips, fruit-chew candies, chocolate bars, chocolate chip cookies, ice cream, nuts, fig bars, frozen yoghurt. dFast food, instant noodles, soft drink, artificial juice, chips, sugared snacks, breakfast cereal, chocolate milk, crackers/biscuits/cakes, ice cream/popsicles, dairy desserts, processed meats. eComparison of means between lowest (unlimited access to snacks) and two highest parent restricting profile groups of (sets limits & restricts all snacks) and (sets limits & restricts high fat/sugar snacks) 4 parent restricting profiles (unadjusted). Very small sample, n = 23/180 in highest parent restricting profile group. (Snack foods: popcorn, pretzels, chips, fruit-flavoured chewy candies, chocolate, chocolate chip cookies, ice cream.). ᶠ Reported unadjusted values but stated that significance remained for adjusted values for these analyses. ᶢ Measure adapted from this scale for frequency of consumption of 13 non-core food and drink items (e.g. soft drink, confectionery and processed meats) in the past 24 hours. Response scale 7-points (0,1, 2, 3, 4, 5,6+ times a week) Child liking scale (non-core foods). Scale developed for study: child-reported 6 items (e.g. ‘If I could. I would eat chips, lollies and chocolate all the time.’). Response scale 5-point Likert-scale – 1 (no, not at all) to 5 (yes, a lot); (Internal consistency α = .83). *p < .05. **p < .01. ***p < .001.

Appendices 261

Table B.2 Longitudinal Studies Examining Associations Between Restrictive Feeding Practices and Children’s Diet Related Outcomes and BMI Author/Year Sample/Age Restriction

measure Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other associations with restrictive feeding

Birch (USA) 2003

N=140 girls Base: 5yrs Period: 4yrs

CFQ Change EAH

• Family Income • Maternal

Education • Maternal BMIz Dichotomised: child BMIz < & > 75th percentile

(+ve) Restriction & EAH Change • Higher levels of restriction (girls) at 5

yrs sig predicted higher EAH at 7 yrs*** and 9 yrs**.

Association > for overweight Girls • Girls overweight at 5yrs, higher levels

restriction sig associated with higher EAH scores at 9 yrs* and higher increase EAH 5 to 9 yrs**

• ‘perception childs weight’ sig associated weight status*** and restriction*.

• ‘concern child overweight’ sig associated weight status*** and restriction* (modified by sig interaction**).

• Post hoc: girls > 75th % BMIz and mothers high restriction sig associated with mothers ‘concern child overweight’*

Campbell (Australia) 2010

N=392 2 age groups Base: 5-6yrs & 10-12 yrs Period: 3yrs

CFQ BMIz change (Measured)

• Parent educ • Mat BMI • Gender

(-ve) Restriction & BMIz Change • Restriction associated lower child

BMIz change (5/6yr to 8/9 yr), b = -0.014**, CL 95% [-0.024, 0.004] (unadjusted), b = -0.013*, CL 95% [-0.025, 0.001]) (adjusted).

(None) Restriction & BMIz Change • Restriction not sig. associated child

BMIz change (10/12yr to 13/14 yr), b = -0.002, CL 95% [-0.017, 0.014], (unadjusted), b = -0.004, CL 95% [-0.017, 0.009] (adjusted).

• For 5/6 year olds each unit increase on ‘restriction’ score (8-40, actual 20.7-33.26) decrease of BMIz 0.013

Faith (USA) 2004

N=57 (24) Base: 5yrs Period: 2yrs

CFQ BMIz Change (measured)

• Child BMI at 3 years

• Stratified ‘obesity risk’ group

• Mat BMI • Gender

(+ve) Restriction & BMIz Change (Only ‘high-risk’ of obesity group) • Restriction at 5 yrs sig. associated

with higher BMIz scores at 7 yrs for children at ‘high-risk’ of obesity (maternal obesity/overweight), only (β=0.55*).

• high-risk of obesity group remained sig. after adjusting for child BMI at 3 years (β=0.39*)

Farrow (UK) 2008

N=62 girls Base: 1yr Period: 1yr

CFQ Weight change (z-scores) (measured,1 yr recorded, 2 yr)

• Breast feeding • Birth weight • Child age

(-ve) Restriction & SD Weight Change • After controlling for standardized

child weight at 1 yr ‘restriction’ sig. predicted a lower standardized child weight at 2 yr (t45 = -2.66, β = -0.31*).

• No sig. correlations ‘restriction’ and child weight (SDSs) at 1 or 2 years.

• SDS weight at 1 year sig. predicted SDS weight at 2 years (F1,46 = 23.99, R² = .34***)

*p < .05. **p < .01. ***p < .001

262 Appendices

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other associations with restrictive feeding

Gregory (Australia) 2010a

N=106 Base: 2-4yrs (mean 3.3 yrs) Period: 1yr

CFQ (6) BMIz Change (Reported) Food Responsiveness (CEBQ)

• Mat age • Mat BMI • Mat educ • Child age • Gender

(None) Restriction & BMIz & BMIz Change • Restriction not sig. correlated with

BMIz cross-sectionally (at 3 & 4 years) or cross-lag correlations, r = 0.10 not sig.

(+ve) Cross-sectional Restriction & Food Responsive** (None) Longitudinal Restriction & Food Responsive Change • Restriction correlated with child food

responsiveness (at 3 & 4 years) cross sectionally, but not sig. for longitudinal change in food responsiveness, β = 0.06 not sig. (adjusted).

• Higher BMIz associated with higher child food responsiveness.

• Child BMIz at 3 years only independent predictor child BMIz at 4 years. Only 25% variance explained by covariates. Environmental factors play a key role.

Gubbels (Netherlands) 2011

N=1819 Base: 5yrs Period: 2yrs

CFQ BMIz change (Measured)

• M&F BMI • M&F Educ • M&F employ • M&F COB • Mat age • Gender • Birth wt • Hungry eater • Picky eater

(None) Restriction & BMIz Change • Restriction not sig associated child

BMIz change (5-7 years) (but was cross-sectionally associated at 5 years – see previous table)

• Moderation: Restriction associated with increased energy intake for children with Hungry eating style ᶢ, β=0.18* but not sig for normal appetite

• Restriction cx associated with higher baseline BMI at 5 yrs (β=.10***)

• Restriction cx associated with higher maternal BMI at (r=.10**)

• Restriction cx associated with higher hungry & picky eaters at 5 yrs (r=.14*** & r=.21***)

Holland (USA) 2014

N= 170 Base: 7-11 yrs Obese or overweight Period: 16 wks

CFQ score change

Following 16 week weight loss program (FBT) • BMIz change

(Measured) • Change in daily

energy intake (kj) • Change in %

energy from fat • Change in %

energy from protein

• Child age • Gender • Child ethnicity • Child BMIz base • CFQ score base • Child intake

base • Family income

(+ve) Reduction restriction score & reduction child BMIz (p < 0.05) (+ve) Reduction restriction score & reduction child daily energy intake (kcals) (p < 0.05)

Note: Weight loss program included < access to palatable foods at home, parent modeling eating > healthy foods at home. • Reduction in child daily energy intake

mediated the association between reduction in parent restriction and reduction in child weight.

• Single mediation models: change in daily energy intake (kcals), % protein intake, % added sugars were significant mediators of the association between change in parent restriction and change in child BMIz (p < 0.05)

Jansen (Australia) 2015

N = 388 Base: 2 yr Period: 1.7 yr

FPSQ Overt & Covert restriction scales

Eating behaviours (CEBQ)

• Mat age • Mat BMI • Mat educ • Child age • Gender • Child BMIz

Restriction & Eating behaviours (+ve) Overt Restriction Satiety responsiveness (β = .118*) (None) Covert restriction & Food responsiveness

• (-ve) Overt restriction & enjoyment of food (β = -0.092*)

• (None) Covert restriction & satiety responsiveness, emotional overeating, enjoyment of food

* p< .05, ** p< .01, *** p< .001

Appendices 263

Author/Year Sample/Age Restriction measure

Outcome measure

Other covariates Restrictive feeding results (predictor & outcomes)

Other associations with restrictive feeding

Montgomery (UK) 2006

N=40 Base: 3-5yrs (mean 4.6 yrs) Period: 2yrs

CFQ BMIz Change (Measured) Energy intake (KJ/kg)

• Gender • Mat BMI • Child age

(None) Restriction & BMIz Change • Restriction not sig. associated with

BMIz change or total energy intake (overall)

(+ve) Restriction & Energy Intake • Restriction sig correlated with energy

intake for boys only, r=.35* NB. Stated sample ‘underpowered’ to determine differences exist.

Rollins (USA) 2014c

N = 180 girls Base: 5yrs Period: 2yrs

RAQ (Fisher & Birch, 1999b) four parent profiles

Change EAH protocol (Fisher & Birch, 1999b) change BMIz Change (measured) 5-7 years Child inhibitory control and Approach (measured by CBQ).

• Child BMI 5 yrs • Mat education • Mat BMI • Family Income

(+ve) Restriction (RAQ profile) & EAH Change • Higher levels of restriction at 5 yrs sig

predicted higher change in EAH (5-7 yrs) for girls with low inhibitory control only*

(-ve) Restriction (RAQ profile) & BMI % Change • Lower levels of restriction (unlimited

access, limits access but not restrict at home) at 5 yrs sig. predicted higher change in % BMI (kg/m²) (5-7 yrs) for low inhibitory control only*

• Parent profile (limit access + restricts all 7 snack foods) significantly associated with higher parent CFQ (Birch, 2001) restriction scale scores* and girls reports greater access to 7 snack foods.*

Spruijt-Metz (USA) 2006

N=120 Base: 7-14yrs Period: 2.7yrs

CFQ TFM (Measured) change 2.7 yr period

• SEG • Ethnicity • Gender • Total Fat Mass

at Baseline

(None) Restriction & TFM Change • Restriction not sig associated with

change TFM overall, b = -0.01, p ns (adjusted).

• Non-sig trends r=-.13 (white popn) r=+.14 (African American popn)

• Study concludes: parental concern over child weight (CFQ, Birch et al., 2001) only consistent association with BMIz and energy intake. Results are given separately for boys & girls (not provided for combined gender).

Webber (UK) 2010b

N=113 Base: 7-9yrs Period: 3yrs

CFQ BMIz change (Measured)

Fat Mass Index

Waist Circumference

• Mat educ • Ethnicity • Child age • Gender • Mo BMI ᵇ

(None) Restriction & BMIz Change • Restriction not sig. associated with

change BMIz (unadjusted or adjusted), b = 0.128 ns.

• Restriction not sig. for Fat Mass Index and waist circumference.

Stability of feeding practices • Paired sample t-tests showed sig. decrease

in restriction from baseline to follow-up ***

Note. Maternal/Paternal BMI covariates were reported values unless otherwise stated.CFQ = Child Feeding Questionnaire, 8-item restriction scale (Birch et al., 2001); CFQ (6) = Child Feeding Questionnaire, 6-items from restriction scale (Birch et al., 2001); excluding 2 items referring to food rewards; RAQ = Restricted Access Questionnaire (Fisher & Birch, 1999b); FPSQ = Feeding Practices and Structure Questionnaire: overt and covert restriction scales (Jansen et al., 2014); CEBQ = Child Eating Behavior Questionnaire (Wardle et al., 2001a); CBQ = Child Behaviour Questionnaire (Rothbart et al., 2001); EAH = Eating in Absence Hunger (Fisher & Birch, 1999b); TFM = Total Fat Mass. Four parent restrictive feeding profiles. First differentiated between unlimited (one profile) and limited (three profiles) access to seven snack foods (four items in RAQ referring to limit buying, limit when and how much). The three profiles (of limit access) differentiated by levels of response to keeping numbers of snack foods (of seven snack foods) out of the child’s reach (1 item in RAQ). Seven energy-dense snack foods: popcorn, pretzels, chips, fruit-flavoured chewy candies, chocolate, chocolate chip cookies, ice cream. ᵇ Examined separately. Not significant, so total sample was retained for analysis. *p < .05. **p < .01. ***p < .001.

264 Appendices

Appendix C

Potential effect modification by sample characteristics

Child age

Only studies using BMIz as the child outcome measure were sufficient in

numbers to consider findings by child age. Whilst Campbell et al.’s (2010)

longitudinal study suggests that child BMIz associated with restrictive feeding may

be moderated by child age their findings may have been distorted by other factors

related to study design (see section 2.3.2.4). Evidence from the combination of

studies available to date is less convincing. Whilst no cross-sectional studies using

the CFQ (Birch et al., 2001) showed positive findings for children under 4 years of

age (Gregory et al., 2010b; Powers et al., 2010) other studies reporting no

association included older children of the same age as studies showing positive

associations (Wehrly et al., 2014; Sud et al., 2010; Hennessy et al., 2010). A time

lag between child eating habits manifesting into distinguishable weight gain may be

a factor but the combination of these studies does not provide a definitive finding

supporting effect modification by age. In addition, unanimous positive findings, using

the CFPQ restriction for weight control (Musher-Eizenman & Holub, 2007) spanned

child ages from 2 to 11 years old and the two negative findings for an association

between covert restriction and child BMIz (Brown et al., 2008; Jansen et al., 2014)

included child ages from 2 to 7 years old. Studies included in this review do not,

therefore, provide clear evidence of a differential effect of parent restrictive feeding

by child age.

Child gender

The determination of a difference in child gender responses to parent

restrictive feeding was based on one small study with a female gender subsample

of 22 (Fisher & Birch, 1999b, n = 42, 3-6 years). Interestingly, the same study only

found a gender specific correlation between higher maternal restriction and higher

BMIz for boys, consistent with Montgomery et al.’s (2006) findings of higher daily

energy intake (kilojoules) for boys only (n = 22, 3-5 years). However, both studies

involved small samples and did not control for covariates. Birch et al. (2003) and

Rollins et al. (2014c) examined EAH in relation to parent restrictive feeding for

samples of girls, with no further clarification of an effect modification by gender

Appendices 265

included in these larger studies. Other studies, including some with large samples

and inclusion of covariates, have failed to find an effect modification by child gender

(Harris et al., 2014, n = 37; Campbell et al., 2010, n = 392; Spruijt-Metz et al., 2002,

n = 120; Gubbels et al., 2009, n = 2578). Overall, evidence does not therefore

suggest differential effect of parent restrictive feeding by child gender.

Child weight

With the exception of Holland et al. (2014), study samples were not

recruited on the basis of child or maternal weight or concern about weight. The

majority reported that the average BMI scores in their sample were similar to the

general population for both children and mothers. However, Gregory et al. (2010b)

and Powers et al. (2010) reported slightly above average child BMIz scores than the

general population for their samples and Gubbels et al. (2009 & 2011) reported

slightly below average child BMIz scores than the general population for their

samples but this variance did not appear to modify study findings. Only a few

studies included child birth weight or younger age weight as a covariate but

adjustment for this variable did not appear to influence findings (Farrow & Blissett,

2008; Gubbels et al., 2011; Faith et al., 2004). These studies included children of 1

to 2 years old (Farrow & Blissett, 2008), and children of 5 years old (Gubbels et al.,

2011; Faith et al., 2004). However, Birch et al.’s (2003) study showed a prospective

association between higher parent restrictive feeding (measured by the CFQ

restriction scale, Birch et al., 2001) and greater EAH amongst a subgroup of

overweight girls, with no effect for the subgroup of healthy weight girls. This

suggests that parent restrictive feeding may only be harmful for overweight children

or the CFQ restriction scale is insufficiently sensitive to other differentiating factors

between these subgroups (see section 2.4.2). These findings suggest a potential

effect modification by child weight of the association between restrictive feeding and

EAH.

Risk of obesity (measured as maternal BMI)

Maternal BMI has been found to be independently associated with child

BMIz (Spruijt-Metz et al., 2002; Hennessy et al., 2010; Sud et al., 2010; Gibson et

al., 2007), so higher maternal BMI contributes a risk factor for a child to develop

obesity independently of restriction. Furthermore, evidence of an association

between restrictive feeding and maternal weight is not convincing, with mixed study

266 Appendices

findings. Whilst some studies have reported a positive effect modification by higher

maternal BMIz on the association between parental restrictive feeding (CFQ, Birch

et al., 2001) and child BMIz (Faith et al., 2004, n = 57, 5 years; Powers et al., 2010,

n = 296, 2-5 years; Costa et al., 2011, n = 109, 6-10 years), others have found a

negative effect modification (Gubbels et al., 2011, n = 1819, 5 years; Ystrom et al.,

n = 14122, 3 years) or no effect modification by maternal BMIz (Sud et al., 2010, n =

70, 4-6 years; Campbell et al., 2010, n = 392, 5-12 years; Spruijt-Metz et al., 2002,

n = 120, 7-14 years). Therefore, findings to date do not provide clear evidence of an

effect modification by maternal weight and findings are conflicting regarding the

potential direction of such an effect modification.

Summary of effect modification by sample characteristics

Whilst some studies have suggested that child gender (Fisher & Birch,

1999b), child age (Campbell et al., 2010) or maternal weight (Faith et al., 2004;

Powers et al., 2010) may modify findings, overall evidence from the studies

reviewed did not support effect modification by different sample characteristics. No

studies found had specifically examined whether child birth weight or earlier weight

modified findings. This variable had only been included in studies as one of a

number of covariates and did not result in consistent findings. In conclusion, the

combined evidence to date does not suggest effect modification by sample

characteristics of child age, child gender, child risk of obesity measured by higher

maternal BMI. This does not mean that characteristics of child age, child gender and

higher maternal BMI do not modify the effects of parent restrictive feeding just that

evidence to date does not suggest this. Whilst studies also reported no effect

modification by child weight for children under 5 years (Farrow & Blissett, 2008;

Gubbels et al., 2011; Faith et al., 2004, Birch et al., 2003), Birch et al.’s (2003) study

suggested effect modification between EAH and restrictive feeding by child weight

for girls over 5 years. However, this is just one study and further studies are

required to clarify such effect modification for older children.

Appendices 267

Appendix D

Qualitative studies examining restrictive feeding

Authors: Baughcum et al. Year: 1998 Country: Cincinnati, Ohio, USA Study features Findings Purpose To identify maternal beliefs and practices about child feeding that are associated with the development of obesity Theoretical perspective None stated Discipline: Dietetics/Psychology/Paediatrician Sampling • Dieticians and mothers of children (12 to 36 months). • low income families (< $29,693 pa 1997 level) • Not selected on the basis of mother or child weight Method Four focus groups • Dieticians, 16 participants • Two groups non-teenage mothers, 2 X 3 mothers (16-34 years) • Young mothers, eight mothers (14-21years) Data collection & analysis • Prompting questions used with focus groups • Focus groups audio and video taped. Audio tapes transcribed • Seven reviewers – codes by recurrent themes and extracted related

quotes • Coding sheets consolidated –major themes Conclusion Professionals should avoid implying that infant weight is a measure of health. Parents using food to satisfy child emotional needs or promote good behaviour may promote obesity. Interventions to alter feeding practices should include education of grandparents. (Note. It is unclear how first two points relate to findings).

Three major themes emerged. Themes 1 and 2 were not relevant for this study, so have only been reported briefly. Findings for theme 3 (using food to shape behaviour), was relevant and has been outlined in more detail. There was strong convergence between the three groups of mothers. • Theme 1: A bigger infant is a better infant – mothers believed that a heavy infant was a healthy infant and the result of

successful feeding and parenting. • Theme 2: My baby is not getting enough to eat – mothers frequently perceived that their infants were not satiated and

introduced cereal earlier than recommended, believed to assist with babies sleeping longer at night. • Theme 3: Using food to shape behavior

– Mothers frequently used food to reinforce appropriate child behaviour and good conduct - Mothers frequently used food to quiet a fussy baby, calm a toddler’s temper tantrum – Mothers used favourite foods as treats or rewards when children cooperated in various settings - Mothers almost unanimously called the use of food a bribe – sometimes it works sometimes it doesn’t – If the child was demanding a particular food the mothers were likely to give it to the child “..if they‘ve got their mind set on that one hot dog that they want… they’re going to scream and cry and kick and everything else until they get it. If you don’t have any [hot dogs] in the freezer, then it’s like, let’s run to the store real quick.” (p. 1013)

Additional findings • Mothers in this study set few behavioural limits on eating for their children. Children were often permitted to eat what

they wanted, as much as they wanted and when they wanted. (Note. This is related to lack of restriction but was included within theme 2)

• Mothers reported that they mainly fed their children foods they themselves liked. (Note. This is related to child and mother preferences but was included within theme 2)

• Almost all mothers said their main source of feeding information was from their own mothers (Note. This is related to influence grandmothers but was included within theme 2)

268 Appendices

Authors: Carnell et al. Year: 2011 Country: London, UK Study features Findings Purpose Overarching goal was to generate a comprehensive picture of parents’ perspectives on feeding behaviours and motivations that could potentially inform interventions. Theoretical perspective None stated Discipline: Nutrition and Dietetics Sampling Fourteen (interviews) and 22 (diaries), mothers of 3-5 year olds Four Pre-schools, volunteers previous community survey Four children overweight/obese, one third mothers University educated Method Fourteen Telephone interview and/or Twenty-two, two-day diary Data collection Interview • Topic guide with key questions and probes • Questions outlined in paper. • Interviews transcribed Diary • Diary to complete one weekday and one weekend day. • All food and drink related interactions. • Four columns: time, food/drink involved, what happened, why child

behaved in way reported

Data analysis (interview and diary) • Thematic framework of categories of parental feeding behaviour –

nine categories • Sub-themes developed in a ‘bottom-up’ fashion based on in-depth

analysis of five interview transcripts. • Scoring ‘all-or-nothing’ method – one subtheme mentioned at least

once – zero if sub-theme not mentioned. • Two researchers scored interview transcripts (88% inter-rater

reliability) and diaries (81% inter-rater reliability). • Full coding scheme available from the authors.

• Pressure and restriction used together to achieve a balanced diet. Restriction • Strategies to restrict intake

− limit availability or access to restricted foods (100% I, 57% D) by keeping foods out of reach, only available with permission, serve small amounts, limit intake to certain times, buying small portions

− verbal discouragement (50% I, 27% D) simple forms: stop eating, refuse request. Some offered reasons e.g. previous days intake or not need the item. Few parents discussed negative health effects, simply thought of the foods as ‘bad’.

− bargaining or negotiating acceptable eating (32% I, 30% D): negotiating compromises, offering a healthy substitute. • Motivation to restrict intake

– practical reasons, mostly time, hungry enough to eat a meal (61% I, 27% D) − health, balance or variety (71% I, 36% D) − weight concerns (25% I, 2% D) - concern about weight gain was rarely sighted as a reason for restriction, although

weight concerns may have been implicit concerns long-term health − cost (7% I, 0% D) rare − personal belief what acceptable to eat (54% I, 11% D) – language: health related reasons e.g. protect teeth but more often implicit unhealthy e.g. ‘junk’ ‘rubbish’. – dietary element implicit undesirable e.g. salt, preservatives – Striving for long-term ‘balance’ – decision based on overall food consumption for the day.

Pressure • Strategies to promote intake

– modifying food preparation (72% I, 23% D) egs. combining liked and disliked foods, soup or sauce form, preparation in favourite way. − presenting food in attractive way (54% I, 20% D) e.g. playing eating games, attractive arrangement of food − verbal encouragement (86% I, 61% D) e.g. direct exhortations/instructions to eat, telling good for you or health benefits

(healthy bones) – physical encouragement (54% I, 27% D), exposure and repetition (54% I, 20% D) e.g. spoon feed child – providing a structured feeding environment (54% I, 11% D) e.g. sit down to eat, not watch TV.

• Motivation to promote intake − practical reasons (57% I, 27% D) e.g. time pressures (finish before bed), manage appetite (ate enough before next meal) − trying to promote a healthy, balanced, varied diet (82% I, 34% D) e.g. adequate vegetables, fibre, calcium − trying to maintain or increase child weight (10% I, 0% D) − teaching child to enjoy variety of foods

• Instrumental feeding (food reward) – any kind of means-end contingency (64% I, 39% D) e.g. using food or non-foods as bribes for intake or good behaviour, withheld the reward – explicit emotional feeding (7% I, 4% D) to calm down, hurt ,bored

Appendices 269

Conclusion In order to engage parents of healthy weight children , obesity prevention advice should aim to satisfy parents primary motivations (practicality, health) and responding to different child characteristics.

– giving the child food to please them (82% I, 41% D) – many mothers reported giving treats (form of emotional feeding – giving food to avoid food-related conflict (29% I, 18% D) e.g. food given to prevent the child getting upset or having a tantrum

• Meal-time rules – socialize the child into normal ways, reinforce discipline, sit down while eating, family meals together, meals at a consistent time.

• Child involvement – choice what eat, buying, preparing from range options, desire to please (favourite), child have some control

• Flexibility – situational flexibility exceptions to restriction special occasions (weekends, parties, holidays), > flexibility grow older, achieving a balance rather than rigid pattern intake.

• Parental engagement with children’s eating behaviour - conscious awareness children’s appetitive styles and food preferences and how they relate to body weight – explicit responsiveness to child weight and eating behaviour (100% I, 98% D) – limiting access to less healthy foods otherwise eat to excess – remind child small appetite to eat

270 Appendices

Authors: Herman et al. Year: 2012 Country: Philadelphia, USA Study features Findings Purpose To understand the contextual factors that might influence how low income mothers felt about addressing behavioral targets for preventing obesity and mothers aspirations in feeding their children. Theoretical perspective No existing theoretical framework used Discipline: Nutrition, public health, pediatrics, sociology Sampling Thirty-two mothers of children 3 to 5.5 years old Predominantly African-American, low income (<130% federal poverty line), 80% unmarried, >½ obese. Method Seven focus groups (two to eight participants) Data collection & analysis • Focus group question guide (three domains) consecutive focus groups

until saturation • Digitally recorded and transcribed verbatim • Atlas.ti v 6 coding software • Inductive constant comparative method (Glaser & Strauss, 1967) • Three authors identified common themes and quotes • Two other authors verified themes and quotes Conclusion Primary aspirations of low income mothers feeding was not focused on child weight but these aspirations were compatible with obesity prevention strategies to limit child portion size and intake of fats and sugars.

• Despite opening the focus groups with references to feeding and child weight, mothers’ discussion of a connection between feeding and obesity was notably absent.

• Mothers described household contexts that presented challenges limiting sugar consumption, being nagged by children for sweets and snacks and undermined by other adults, as well as having bad childhood memories that made mothers feel guilty saying “no”.

Maternal aspirations – Three Themes • Preventing hyperactivity and tooth decay – Mothers expressed a strong desire to limit children’s sugar intake because of

concerns about sugar causing hyperactivity and tooth decay • Teaching life lessons to children

– setting limits and saying “no” to foods children wanted – hoped to teach important life lessons about not always being able to have what you want and when you want – saying “no”- hurting parent. “sometimes it hurts you as a parent more than the child when you say no. I don’t know why though. I don’t like my son looking all upset or crying…” (p. 5) “you might not like me right now… but you’ll love me later” (p. 6) – changed approach to children’s requests for food to teach them about working for things and earning them by being good – provide some structure by having rules about what and when they should eat “So I’ll give her that [peanut butter and jelly or chicken nuggets] but she has to eat a vegetable… it has to balance out.” (p. 6)

• Being responsive to children – responsive to children’s mealtime eating patterns, know how much food to serve by observing children’s eating patterns. – children unique food preferences – belief that adults should set limits with sweets and snacks, yet experience it as a major challenge

Challenges in achieving aspirations – Three Themes • Being nagged by children for sweets and snacks – Mothers struggle to say “no” to frequent requests for sweets or

snack foods – exasperated by children’s nagging and frustration with themselves for “giving in” to nagging – being firm, when you say “no” it should be “no” – Mothers described children being clever in the ways they convinced other adults to give them sweets and junk food.

• Being undermined by other adults in the family – Instead of providing support to mothers around rules and structure in feeding children, other adults tended to undermine the mothers’ authority – mothers frustration at being undermined – especially grandparents. – most challenging issue for mothers was that other adults offered children junk food throughout the day – grandmother spoil children by feeding sweets

• Having bad memories from childhood makes it hard to say “no” – Mothers described having few choices and almost always being told “no” about foods “I didn’t have it so I wanted him to have it” (p.8) – felt guilty about saying “no” “…I feel bad after I tell my kids no because I was used to me being told no, no, no, no when I was little…” (p. 8)

Appendices 271

Authors: Martinez et al. Year: 2014 Country: California, USA Study features Findings Purpose To explore the attitudes and behaviours of Latino mothers around feeding their children. Theoretical perspective None stated Discipline: Nutrition and Dietetics Sampling Forty-one Latino mothers of elementary school-age children (age not reported) Mothers mostly born in Mexico Method Focus groups (Ten to eleven participants) Data collection & analysis • One facilitator/one note taker • Question guide • Audio tapes transcribed verbatim • Video tapes reviewed for physical responses • 1st investigator applied microanalysis (Corbin & Strauss, 1990), to

create a preliminary coding scheme. 2nd investigator applied coding scheme to transcripts, codes refined by both investigators.

• Emergent themes by constant comparative method • Consensus code definition and application • Software Atlas.ti v 6.1 Conclusion These findings increase our understanding of the traditional role of Latino maternal role to feed children and can help to inform more culturally appropriate research to effectively address nutritional issues and obesity prevention in Latino children.

Note. Only findings related to feeding practices of interest reported here (i.e. restriction, pressure, reward) • Mothers appeared to be conflicted, as they felt responsible for having well-fed children, but realized they did not

always provide them with optimal choices. • Reinforcement strategies

– unhealthy food often used as motivator for child to eat something healthy – allowed their child to eat something unhealthy if they ate something healthy eg. fruit and vegetables – unhealthy treats given as rewards in exchange for child eating something healthy of finishing a meal – several mothers used ice cream, candy and fast foods as treats – several mothers rewarded their child at the end of the week by taking out to fast food outlets – non-food reinforcements to eat healthy food include video games, computer time, TV during dinner – half mothers used punishment or taking away privileges when their child did not eat – several mothers used verbal fear tactics eg get fat or diabetes, one mother reported ineffective and now uses encouraging verbal support to get child to eat less junk food

• Behaviours to support eating well – most mothers thought it was important to role model healthy eating but revealed that very few do – used persuasion tactics for motivating child to eat well – appealed to their children to eat vegetables by linking eating them with being popular, pretty or superheros – food rules in the house – difficult to get children to try new foods – several mothers reported setting limits on what and how much food their children ate – some limited the quantity of some food e.g. tortillas and bread, but not limit fruit and vegetables – several mothers did not buy cookies, chips, sodas or junk food – did not allow or limited (special occasions or once a week) candy, sodas and sweetened beverages in the home.

272 Appendices

Authors: Moore et al. Year: 2007 Country: Cardiff, Wales, UK Study features Findings Purpose Explore the extent to which parents employ feeding strategies and within what contexts to encourage or discourage consumption of familiar and novel foods. (Note. not clearly stated) Theoretical perspective None stated Discipline: Health Psychology Sampling Twelve mothers of children 3-5 years (four girls/eight boys) Snowballing technique from contacts of the author. Method Interviews Data collection & analysis • Semi-structured interview – four main questions • Invited to talk through actions at four types eating occasions.

− Reluctant to eat familiar foods − Presented with novel foods, − Discouraged from eating undesirable foods − Strategies not involving child interaction

• Probe questions to elicit more detail • Interviews recorded, transcribed and concurrent coding. • Coding manifest and latent (meaning inferred) levels. • Counted types of strategies (eight groups) used for three different food

scenarios – encouragement of familiar or novel foods and discouragement (restriction). Restriction identified as just one group

Conclusion Demonstrated the diverse range of strategies used by mothers involving: modeling, pressure, restriction, rewards, repeated taste exposure and attempts to influence attitudes and norms.

• All mothers reported using strategies to encourage eating familiar and novel foods and discourage [restriction] eating undesirable foods.

• Mothers’ concept of a well balanced diet – included fruit and vegetables but limited amounts of sugar and processed foods.

• Most dominant outcome sought by mothers was to establish eating behaviours associated with a well-balanced diet rather than increasing liking for particular foods.

• Persuasion: encouragement paired with comments “tasty food” • Dissuasion: teeth suffer if ate poor foods • Individual mothers used extensive repertoires of feeding strategies (range 13-30, mean =19). 126 different strategies – 51

unique to mother-child pairing. • Strategies selection based on: child temperament and eating status, avoid creating distress or conflict, short-term goals (e.g.

avoid going to bed hungry) and longer-term goals (e.g establishing varied and balanced diet. If one strategy failed try another one e.g. persuasion → reward → punishment.

• Restriction: not buy foods (n=7/12), avoid taking to fast food outlet (n=3/12), food reserved for special occasions e.g. weekend (n=2/12), negotiate a healthy substitute for an undesirable food (n=5/12). Spoke about “moderation” or “explanation” to temper restrictive practices.

• Modelling: encourage consumption familiar foods (n=12/12), novel foods (n=5/12), paired with comments “tasty food” • Pressure: firmly insist (n=6/12), mild threats (n=8/12), punishment (n=3/12), commonly removal of rewards. Indirect

pressure strategies: serve preferred foods, food presentation/preparation, mash liked/disliked foods together or chop up food.

• Food Rewards: contingent finishing or eating some of a meal (n=8/12) – reward a standard feature mealtimes rather than a temporary incentive. Most common reward was dessert (n=6/12), activities like watching TV (n=2/12) 2 mothers rejected used of reward.

Appendices 273

Authors: Moore et al. Year: 2010 Country: Cardiff, Wales, UK Study features Findings Purpose Explore the feeding goals sought by parents of preschool children. Theoretical perspective None stated Discipline: Health Psychology Sampling As above Method As Above Data collection & analysis As above Differentiated mothers’ reports of the child being a ‘good’ or ‘bad’ eater. Conclusion Parents do not target child food likes as a direct outcome of feeding strategies.

This study was an extension of the study outlined above using the same study findings. Where findings were a repeat of those already outlined in the previous study paper (see above) they have not been repeated here. • Mothers of good eaters spoke of long-term goals to establish varied, well balanced and healthy diet. Avoid the child

becoming a fussy eater. “Moderation” was an important factor. • Mothers of bad eaters spoke of short-term goals on a meal by meal basis, allowing the child to consume anything they

were willing to eat. • Mothers’ food choices – most popular reasons – balanced diet (n=10/12), child likes/dislikes (n=10/12), mothers childhood diet

(n=5/12). • Mothers information sources. Most commonly intuition, experience, own childhood experiences. Formalised advice mostly

sought in cases of problem eaters.

274 Appendices

Authors: Nielsen et al. Year: 2013 Country: Copenhagen, Denmark Study features Findings Purpose Investigate differences in parental concerns during early and later phases of complementary feeding. Theoretical perspective None stated Discipline: Clinical Nutrition Sampling Forty-five Mothers of children aged 7 & 13 months Groups segmented by • high educated mother /child 7 months • low educated mother / child 13 months • high educated mother / child 7 months • low educated mother / child 13 months

Method Eight Focus groups Data collection & analysis • Interview guide followed • Digital/video recording • Transcribed verbatim • Software: Atlas 6.2 • Analysis: deductive application RQ pre-determined codes. Followed

by inductive data derived coding for additional themes • Group validation – tested significance of concerns deducted with

participants. • 2nd and 3rd authors consulted on theme definition and data analysis Conclusion Mothers concerns and feeding practices varied considerably between early and late phases of complementary feeding.

No differences between different mother educational backgrounds. Four themes emerged Serving healthy food • 7 months - avoidance sugar, eating vegetables. • 7 months - suspicious nutritional quality ready-made foods, acceptable if not contain sugar. • 7 months - concern to satisfy hunger- priority give food child would eat Integration family and social food environment • 7 months –separate meals - choice healthy/unhealthy foods straightforward decision. • 13 months – eat as family. Engage limiting or increasing intake specific foods ensure healthy diet – focus on sugar, fruit

and vegetables. Secure variety – establish healthy eating habits/minimize fussy eating. Managing family relations and everyday life • Life pressures, time constraints impact food priority more when return to work (>13 months). • 13 months – need to negotiate child and friends/family of what offered. Sugar containing foods now tolerated. Teaching

rules intake confectionary, fizzy drinks and cake concern of mothers. Use of public nutrition guidelines • 7 months – dietary guidelines closely followed – safety rather than healthy eating • 13 months – relevance of guidelines diminished – few consult printed material – no need special advice. Milk given as per

family rather than guidelines skimmed milk.

Appendices 275

Authors: Sherry et al. Year: 2004 Country: Pennsylvania, USA Study features Findings Purpose To explore maternal attitudes, concerns and practices related to child feeding and perceptions about child weight in different ethnic groups. Theoretical perspective None stated Discipline: Dietetics Sampling One hundred and one mothers of children 2 to under 5 years old Method Twelve focus groups by ethnic group (five to ten participants) (Three White, three African-American, three Hispanic-American low income, three White middle income) Data collection & analysis • Structured focus group guide • Audio-taped and transcribed • Four co-authors identified key themes from transcripts • Two co-authors coded transcripts • Master table display for comparisons Conclusion The common use of strategies that may not promote healthful weight suggests work is needed to develop culturally and socioeconomically effective overweight prevention programs.

Findings were reported as themes. (Note. Only themes related to controlling feeding practices were reported here i.e. restriction, pressure, reward) Category - Maternal goals and beliefs good nutrition • All groups did not want children to eat too many sweets; Hispanics were concerned about processed foods; middle income

whites were concerned about high-fat foods. • Strategies for controlling intake of foods they did not want children to eat excessively included

– not purchasing – hiding – controlling portions – giving an approved form of food e.g. fruit-flavoured gelatin versus candy

Category – Maternal strategies used to persuade their children to eat • All groups child likes and dislikes when planning meals • All groups encouraged their child to eat • Food and non-food bribes and rewards or games commonly used to attain desired behaviours such as finishing a meal • Special snacks or treats used as rewards, bribes and pacifiers. Common foods: ice cream, fruit-flavoured gelatin,

popcorn, cookies and fruit (All Hispanic- American groups only) • African-American mothers did not offer snacks/treats when children were bored. • Middle income white used sweet or salty foods as a pacifier in the car or shopping Category – Maternal concern about weight • All low-income groups concerned underweight. All white and one African-American group concerned about overweight.

African-American groups generally believed children would outgrow overweight or high weight in childhood healthy. • Hispanics believe good health and what their child ate more important than weight. • Middle income white groups also concerned about eating disorders and developing good eating habits.

276 Appendices

Authors: Ventura et al. Year: 2010 Country: Philadelphia, USA Study features Findings Purpose To describe the feeding practices and styles used by a diverse sample of low-income parents of pre-school age children. Theoretical perspective None stated Phenomena of interest: feeding practices and styles low-income parents preschoolers. Discipline: Clinical Nutrition Sampling Parents of 3-5 year old children residing in a low-income neighbourhood or accessing services targeting low-income families (Seventeen black [African American], nine Cambodian/Vietnamese, three Hispanic, three White [Caucasian]) Method Mixed methods Thirty-two parents Interviewed Thirty-two parents, two questionnaires data collection & Analysis

Interview • Semi-structured interview script. Recount own and child actions

and experiences during meals and several specific feeding situations.

• Analysed iteratively following a thematic approach.

Questionnaires • Feeding Demands Questionnaire (Faith, Storey, Kral &

Pietrobelli, 2008) • Caregiver Feeding Styles Questionnaire [CFSQ] (Hughes et al.,

2005) Conclusion Low-income parents are a heterogeneous group with multiple rationales for a diverse array of feeding practices and feeding styles were not related to qualitative responses. Tailor nutrition education programs to meet diverse needs of this target audience

Pressure/encouragement • Uses verbal force • Reasons or bargains with the child • Verbal reasons given: ‘good for your health’, ‘help you grow’, ‘it is yummy’. • Offers rewards for eating - food rewards and non-food rewards • Offers preferred food items in exchange for eating • Imposes punishment for not eating - takeaway preferred activity, sit at table until eats Substitution • Offers a healthier food when child requests an unhealthy food Restriction • Limits child intake to address concern about weight (6/17 black (African American) participants) • Limits on preferred food items so child eats less of them • Many parents use both overt and covert restriction to limit intake of discouraged foods • Covert restriction – not buying, not keeping in the house (junk food, desserts, candy) • Overt restriction – not allow child to consume certain foods items kept in the house Modeling • Demonstrates consumption and acceptance Modifying • Adds sugar, butter or sauces • Mixes refused food with a preferred food • Hides refused food within a preferred food • Offers food in a different form Problem avoidance • Gives in to child demands/refusals • Does not discourage any foods • Does not present or encourage novel or disliked foods • Make separate meal – offer familiar/liked foods only Decision-making process: child-centred • Listens to child expression of hunger/fullness • Listens to child expression of what/how much • Only gives child his/her favorite or accepted foods • Determines portion based on what child ate previously Decision-making process: parent-centred • Limits child’s intake when he/she perceives child is eating too much • Provides a variety of foods that he/she perceives to be healthy • Serves the portions of foods that he/she perceives to be appropriate • Decides what/how much he/she wants to eat

Appendices 277

Cultural • The family eats traditional, cultural foods Concerns for child • No concerns for child • Child refusal to eat certain foods • Child has an overall unhealthy diet • Child underweight • Child Overweight Questionnaires CFSQ (Hughes et al., 2005) • Authoritative and authoritarian feeding scales combined for analysis due to low numbers (reason- both high demandingness).

(Note. not appropriate to do this) • Parents categorized as having similar feeding styles were not homogeneous groups in relation to qualitative responses,

especially parents perceiving an existing problem of concern with their child’s eating behaviours or weight status. • The group of four indulgent parents did not perceive any problems with child feeding. These parents were all of East Asian

origin and were using child-based decision-making processes with very few feeding practices, all of which were problem-avoidance practices. These parent’s scores below sample average for demandingness and anger/frustration. However, parents reported their child typically consumed energy-dense snack food or fast food.

278 Appendices

Appendix E

Participant invitation letter and enclosures

Appendices 279

280 Appendices

Appendices 281

Appendix F

Information for interview participants

282 Appendices

Appendices 283

284 Appendices

Appendices 285

Appendix G

Commencing and final interview schedules

Start interview protocol 25-7-14

1. Are there any particular foods that you don’t like [NOURISH child’s name] to have or

have too much of? Follow-up Questions (if required) What about drinks, any particular drinks you don’t like [NOURISH child’s name]

have or have too much of? Which types of foods and drinks does this include? (Refer ‘food and drinks’ list) If no – Have you deliberately not given or limited any particular foods or drinks in

the past? If still no – Go to Qu 5.

2. What are (were) your main reasons for not wanting [NOURISH child’s name] to have these foods/drinks? Follow-up Questions (if required) Do you not like [NOURISH child’s name] to have [these foods/drinks] because you

think there might be short or long term effect on him/her? What effect would this be?

What about weight, are you concerned about [NOURISH child’s name] weight at all?

Are there any other reasons for not wanting [child’s name] to have these foods/drinks that you haven’t mentioned so far?

(If more than 1 reason) Are there different foods/drinks associated with different reasons?

3. Can you tell me what do you do to reduce [NOURISH child’s name] exposure to or

consumption of these foods/drinks? Follow-up Questions (if required) Do you say anything to [NOURISH child’s name] about these foods/drinks? Tell

me what you say. Do you say this when the food is available or at another time? Do you have these foods/drinks in the house/buy them? How do you manage

these foods/drinks in the home? What do you say to [NOURISH child’s name]. Thinking about when you go out and different situations: the supermarket, a party,

friends or family get-togethers, eating out. Do you use different approaches in different situations? Tell me what you do? What do you say to [NOURISH child’s name] in these different situations?

What situations have you found to be most challenging? Do you let [NOURISH child’s name] have any of these foods/drinks at specific or

special times - ? Which specific foods/drinks? When? (ie. ‘treats’).

4. Has your approach changed from when [NOURISH child’s name] was just a toddler until now? Follow-up Questions (if required) How has your approach changed? What factors have influenced these changes?

5. What advice would you give to new mothers about the best ways to limit or not expose

their child to undesirable foods or drinks? Follow-up Questions (if required) What has worked well for you? What in your experience led you to choose these as the best approaches?

286 Appendices

6. If you could go back in time to when [NOURISH child’s name] first started on solid food, would you do anything differently? What would you do differently? Follow-up Questions (if required) Have any of the foods or drinks you gave [NOURISH child’s name] when he/she

was younger become an issue now? In what way are they a problem?

7. Are there any particular foods you encourage [NOURISH child’s name] to eat or drink more of? Follow-up Questions (if required) Which foods/drinks? Reason/s? (Are these the same as ‘restriction’ or different?) How do you encourage [NOURISH child’s name] to eat/drink these foods/drinks?

8. Do you give [NOURISH child’s name] any particular foods or drinks as a reward, for

say: eating up healthy foods, good behaviour or doing well at school? Follow-up Question (if required) In which situations do you give these rewards? Which specific foods/drinks? Link to specific reason/s? How do these vary from foods/drinks you give as treats on special or specific

occasions? Are there any situations when you might not give [NOURISH child’s name] the

reward or treat? Which situations?

Final Questions I have got to the end of my questions. Do you have anything you would like to add

or questions for me? What should I have asked you that I didn’t think to ask?

Appendices 287

Final interview protocol 28-8-14

1. Are there any particular foods or drinks that you don’t like [NOURISH child’s name] to have or have too much of? If no – Have you deliberately not given or limited any particular foods or drinks in

the past? If still no – Go to Qu 5.

2. My next question is: What are (were) your main reasons for not wanting [NOURISH

child’s name] to have these foods/drinks? Follow-up Questions (if required) What about weight? Are you concerned about [NOURISH child’s name] weight in

any way ? Any other reasons? (If more than 1 reason - foods/drinks associated with different reasons)

3. What do you do to stop [NOURISH child’s name] having (too much of) these

foods/drinks? Follow-up Questions (if required) say what do you say to [NOURISH child’s name]? When ? (note WORDS used for

restricted foods desirable/undesirable) do you say why it is ‘sometimes’ food? when/amount When does [NOURISH child’s name] have these foods/drinks? Do you limit the amount [NOURISH child’s name] has?

modelling Do you have these foods/drinks with them or at another time?

at home Do you buy these foods/drinks to keep at home? (at all or limited times?) Where do you keep these foods/drinks in the house? Does [NOURISH child’s name] know where these are kept? When does [NOURISH child’s name] have these foods/drinks - when /amount/with

who? Going out What about when you go out? What do you do when you take [NOURISH child’s name] to a party? What do you say to [NOURISH child’s name]? before or at the party? What about other social occasions like get-togethers with family or friends ? What

do you say? Do you visit grandparents? What happens then? What about eating out ? what do you say? what about when shopping or visits to the supermarket? what do you say? what about school lunches – canteen/tuckshop? school food culture?

Final Are there any other situations inside or outside the house that we haven’t

discussed yet? What situations have you found to be most challenging in or out of the house?

Prompts

Tell me more about that? Give me an example?

4. What about TREATS? (Only if mentioned) Which foods/drinks do you give [NOURISH child’s name] as treats? When do you give these? Which specific occasions? Does [NOURISH child’s name] have a favourite food or drink?

288 Appendices

I am wondering what the reason for a treat might be? (Difference HOME Vs SOCIAL)

What are you referring to when you said ‘not missing out’ (or similar)? Do you have these with them – or at another time? When? Own treats?

5. My next question is: Has your approach to this CHANGED from when [NOURISH child’s name] was just a toddler until now? Follow-up Questions (if required) When ? age first had? What has influenced these changes? How has what you say to [NOURISH child’s name] about these foods and drinks

changed? Reasons? Does [NOURISH child’s name] ask for these foods/drinks? When did they start

asking for them? (approx. age first asked) Has this influence your response?

6. With your experience now and the benefit of hindsight, what advice would you give to a new mother about the best ways to limit or not expose their child to undesirable foods or drinks? What works well? Follow-up Questions (if required) Would this be different at different ages? What about when you go out to a party?

7. What would you tell a new mother to avoid doing? What doesn’t work well?

Follow-up Questions (if required) Have any of the foods or drinks you gave [NOURISH child’s name] when he/she

was younger become an issue now? (In what way?)

8. Are there any particular foods you encourage [NOURISH child’s name] to eat or drink more of? Follow-up Questions (if required) Which foods/drinks? Reason/s? How? What say?

9. Do you give [NOURISH child’s name] any particular foods or drinks as a reward, for

say: eating up healthy foods, good behaviour or doing well at school? Which specific foods/drinks? (link to specific reason/s) Which situations? Are there any situations when you might not give [NOURISH child’s name] a

food/drink as a reward or treat? Which situations? If mentioned treats You mentioned treats. What are the differences between a treat & a reward for you? Which foods/drinks given as ‘treats’ ? Does [NOURISH child’s name] have a favourite food/drink?

Final Questions I have got to the end of my questions now. Just to finish, what should I have asked

you that I didn’t think to ask? Do you have anything else you would like to add or questions for me?

Appendices 289

Appendix H

Record of main changes to the interview schedule as the study progressed

28-7-2014 (After 3rd interview)

• I took out a number of superfluous sub-questions to make the questioning

more open and allow more flow - reducing me talking/leading. In retrospect,

I realized some of the sub-questions were not relevant to the way

participants were responding or seemed impossible to answer.

• Qu 2. Reduced sub-questions to just probing about weight if not mentioned

because this has received so much emphasis in relation to restriction of

foods amongst the dietician community. Mothers tended to freely talk about

other reasons.

• Qu 3. Changed from Can you tell me what you do to reduce your child’s

exposure to or consumption of these foods or drinks? to Can you tell me

what you do to stop [child’s name] having (too much of) these foods and

drinks?

• Qu 3. Sub-question about whether mothers thought there was anything

specifically about their child that means they need to be careful (suggested

by supervisor). Didn’t need to ask this question because child eating

behaviour revealed by participants responses to other questions. It also

seemed difficult to answer and vague and didn’t seem appropriate to ask in

the interviews so far.

• Qu 3. Added a sub-question on which foods given as treats/special occasion

foods and when – if the word ‘treat’/special occasion foods mentioned.

• Qu 3. sub-question added on about when ‘limited’ foods were given and

whether the amount was limited.

• Qu 7. Changed from ‘would you do anything differently’ to ‘what would you

tell a new mother to avoid doing’ because minimal responses were given to

this question or a firm ‘no’.

• Took out sub-question on ‘reasons’ from Qu 8 & 9 (encouragement &

reward) same answers as ‘reasons’ Qu 2 + not focus of study.

4-8-14 (After 5th interview)

• Qu 3. Sub-question – situations most challenging not really useful – most

participants not find challenging as such – only asked if seemed relevant

from examples given by participant.

290 Appendices

• Reduced some more superfluous follow-up questions or merged/simplified

eg ‘say’ in Qu 3

• Qu 7. I was amazed at how well the previous change worked. This resulted

in much longer and revealing responses about their negative experiences. I

started to just combine this with the advice question – what to do and what

to avoid.

22-8-14 (After 13th Interview)

• Qu 6. Advice to new mothers - sub-question added – ask whether they

would give different advice at different ages of the child

23-8-14 (After 14th interview)

• Qu 8. (rewards). Added sub-question – what participants see as the

difference between a treat and a reward – only asked if participant

mentioned treats regularly.

20-9-14 (After 27th Interview)

• Qu 6. Advice to new mothers - sub-question added – ask whether different

advice for different situations (e.g. kids party vs home).

Appendices 291

Appendix I

First cycle main group and sub-group codes

Table I.1 Main Group Codes and Definitions

No Main Group Code Definition 1 Foods & drinks restricted Food and drink items mothers said they did not let their child

have at all or restricted intake in moderation. 2 Reasons Reasons mothers said they restricted certain foods and/or

drinks 3 How ‘At Home’ How mothers said they restricted their child from consuming

certain foods and drinks in the home environment. 4 How ‘Going Out’ How mothers said they restricted their child from consuming

certain foods and drinks when they went out of the house and at social gatherings.

5 Talk (incl. overt, covert) Whether mothers verbally communicated to their child that they were restricting certain foods or drinks and if they did, what they reported saying to their child.

6 Role modelling Whether children saw their parents consuming foods or drinks restricted from the child and associated parent communication.

7 Food descriptions The words mothers used to describe restricted foods or drinks in the interview conversation.

8 Rewards & Treats

Whether mothers reported giving foods or drinks as rewards for conditional child behaviour and/or as unconditional treats.

9 Exposure & Child preference Child preference for restricted foods or drinks associated with familiarity.

10 Changes over time Mothers’ reports of their changes to restrictive feeding practices over time.

11 Advice & Avoid Mothers’ advice to a new mother of successful restrictive feeding practices and which practices to avoid.

12 Encourage/pressure Foods and drinks mothers report encouraging their child to consume and how they encourage them to consume these items.

13 Other: Sibling comparisons Mothers reported differences in child reponses to restricted food and drink items between the study child and younger siblings and what mothers believe might be the cause of any differences.

292 Appendices

Table I.2 First Cycle Main Group and Sub-Group Codes

No. Main group code Sub group code Summary of data elements included

1. Foods/Drinks Restricted

Level of restriction (applied to foods and drinks)

- Not at all - Allowed in moderation

Soft drinks

- Carbonated sweet drinks - Sports drinks

Other sweet drinks

- Cordial - Juice - Milkshake/smoothies

Sugary foods generally - Unspecific reference to high sugar or sugary foods Confectionary

- Lollies - Chocolate - Bubble/chewing gum

Savoury snacks - Chips - Savoury biscuits

Cakes and biscuits

- Homemade - bought

Other sweet snacks

- muesli bars - fruit bars/straps - LCM bars

Desserts

- Ice-cream - yoghurt

Preservatives/additives - any reference to food preservatives or additives Highly processed foods - reference to processed foods or drinks Fast foods

- MacDonald’s, Hungry Jacks, KFC - Other take away - Greasy foods

Sweet cereals - Coco pops - Nutrigrain - Fruit loops

Other - Salt 2. Motivation Healthy diet

- Avoid ill health

Balanced diet

- Sufficient good nutrients - Depends on amount ‘bad’ foods eaten - Not spoil appetite before a meal

Form good eating habits

- Taste for ‘healthy’ food - Small amounts of ‘unhealthy’ foods - Develop a dislike of ‘unhealthy’ foods

Behaviour

- Sugar related behaviour change - Additive related behaviour change

Tooth decay - Tooth decay - Rot teeth

Weight - Prompted - Unprompted - Family history

Other - Variety - Keep as a treat - Sometimes food - Party food - treats

3. How: family controlled environment

Limit coming into the house

- Don’t buy - Buy limited amount - Buy social occasions - Bought in by visitors

Limit by where kept in house

- Not kept in house - Not know where kept - Out of reach - Out of sight - Treat box

Control what is given

- What is offered (healthy options) - Out of sight – forget – throw away

Appendices 293

No. Main group code

Sub group code Summary of data elements included

3. How: family controlled environment (Continued)

Limit when given

- Never give at home - Not before meals - After meals - Need to ask/can help self - Eat healthy foods first - At set times/No set times

Limit amount given

- Balance overall amount - day or week - Feed ‘good’ food before going to a social occasion ‘fill

up’ - restrict quantity

- amount given (half, small packet, 1 or 2 pieces) - Say ‘no’ (when enough)

4. How: managing social influences’

Kids Parties - Free rein (not often) - More lenient than at home - Peer/social pressure (not the only one/can’t control/not

miss out) - Tell/ensure balance healthy/unhealthy foods - Monitor – when enough direct to alternative healthy

food/activity - Most challenging

Other Social occasions - Less problem than parties - Healthier food than parties - Limit amount - share - Play dates/sleepovers, can’t control

Grandparents & relatives

- Bake together - Spoil - Give lollies/sweet foods – to gain favour - Conflict - ask – follow our rules - Accept – no rules - spoil

Supermarket/Shopping

- Avoid taking child - Avoid aisle - Pictures on packets attract - Ask for foods – known or seen at school - Buy a treat (exchange good behaviour or habit)

Eating out

- More lenient - limit frequency - Not often – expensive & difficult - McDonalds most common – play ground – happy meal

(toy attracts) - Select healthier take away options eg. pasta, pizza,

Thia, Indian - Feed before go. - Feed healthy food that day to compensate

School

- Teaching about healthy foods – start to discuss at home (+ve)

- See what other kids have in lunchboxes and want to try - Want lunch orders –choose unhealthy like other kids - Want to buy lollies, iceblocks, sweet foods from

tuckshop - ‘Treat’ in lunch box

Most challenging - Kids parties - Grandparents - Home - Supermarket - None challenging

5. Mothers’ communication

Totally restricted items Partially restricted items Unrestricted ‘healthy’ items

- Don’t say anything – child unaware - No ‘label’ – no concept. - Focus on talking about healthy foods (+ve reinforce) - Discuss not healthy before faced with food/drink - Explain not healthy – when faced with food/drink - Explain why ‘sometimes’ food - Tell to eat good food first - Tell to stop when had enough/direct to healthy foods - Say ‘no’/that is the rules/no negotiation - Convince child that they don’t like this food/drink - Make negative comments about restricted foods - Discuss healthy/unhealthy foods when not available

(educate) - Different at home/social occasion

294 Appendices

No. Main group code

Sub group code Summary of data elements included

6. Role modelling

Negative modelling - Eat with children - Eat in front child – child not allowed - Other relatives: Grandparents/relatives/husband - Model indulgent overeating

Avoiding Negative modelling

- Eat out of sight - child not aware - Tries to eat out of sight - child sees

Positive modelling - Eat with children Mother’s preferences/restraint

- Don’t keep in the house – I (mother) will eat

7. Descriptions of restricted foods and drinks

Descriptions restricted items

- Descriptions of totally restricted foods & drinks - Descriptions of partially restricted foods & drinks - Descriptions of unrestricted ‘healthy’ foods & drinks

Key terms used - ‘treat’ - ‘party foods’ - ‘sometimes foods’ - ‘not miss out’

8. Rewards and ‘treats’

Which foods/drinks - Same foods as partially restricted - Different foods from partially restricted

‘Treats’: when, why, talk - When - give every now and then - Party – social ‘norm’ - Link back to parents habits/likes - What is said to child – label ‘treat’, party foods,

sometimes foods - Don’t buy because mother will eat.

Food given as a reward

- Dessert after meal - To negotiate good behaviour - Toilet training - To go to bed - To go to school - Withhold – bad behaviour - Don’t give food as a reward – give activity or toy as

reward Difference ‘treat’ & reward

- ‘Treat’ no reason – special times - Reward for doing something promised

9. Exposure & child preference

- Child preference towards familiar foods: home & social - Child preference towards familiar partially restricted

foods: home & social - Child preference towards unfamiliar foods at social

occasions - Child preference towards totally restricted foods at

social occasions 10. Changes over

time - Restricted more when younger

- Restricted the same over time (might have bigger portion)

- Restricted more as older 11. Advice &

Avoid

Advice to new mums - Don’t Buy or give to them - Let them have these foods ‘in moderation’ otherwise

they will want them more. - Don’t eat/drink it in front of them - Okay to have grown up foods and eat in front of child - Explain ‘sometimes’ or ‘special treat’ food - Say ‘no’ – don’t give in - routine

What to avoid - Introducing restricted foods - Giving in when child asks - Don’t make negative comments about healthy foods –

they will dislike too. - Don’t ‘label’ the food– concept won’t exist in child’s

head. 12. Encourage/pre

ssure

Encourage which foods/drinks

- Fruit & vegetables - Water - Milk - Meat - other

How encourage - Verbally encourage to try/eat amount: ‘good for you’ - Rule - meal before dessert - Make food attractive - Hide or disguise in other food - Don’t provide other choices

Appendices 295

No. Main group code

Sub group code Summary of data elements included

13. Other: Sibling comparisons

Sibling differences

- Younger siblings exposed earlier – desire restricted foods more

- Younger siblings less exposed - less desire for restricted foods

- Younger siblings different personality – associated with eating behaviour

296 Appendices

Appendix J

Sample of summary table

Table J.1 Example of Summary Table Used for Analysis of Data. ID Number XXX XXX XXX XXX XXX

Gender Child Male Male Male Male Male

Mother Uni/Non-Uni Uni Uni Uni Uni Uni

Date Interview 6/8/14 11/8/14 20/8/14 22/8/14 4/9/14

Loc/Wave Bris (wave 1) Bris (wave 1) Bris (wave 1) Ade (wave 1) Bris (wave 1)

Siblings Girl 5 yr Girl 4 yr Girl 5 yr Girl 3 yr Boy 18mths

1. FOODS/DRINKS RESTRICTED (What say 1st 2nd 3rd)

Soft drinks (incl Sports drinks) No soft drink at all (1st) Don’t have soft drink at all (e.g. 2nd )

1st No sports drinks Soft drink – not too much

2nd No cola or sports drinks (doesn’t like soft drink – would allow lemonade if out)

1st Limit overly sugary drinks

Other sweet drinks

• No cordial or juice in house • Flavoured milk rare • Popper school lunch 1 X

day – big treat

Rarely Cordials (e.g. 3rd) Dilute juice Milkshake – bike ride (out)

2nd Flavoured milk, juice, cordial – not too much No vit C syrups

3rd Limit juices, cordial, milk 1st Limit overly sugary drinks

Sugary foods generally 1st High sugar foods (Not mention sugar) 2nd Limit overly sugary foods Confectionary

Not much lollies & chocolate - treats

Lollies (e.g. 1st) Lollies, choc – not too much 4th Lollies, choc – small amounts – no fixed rules

Savoury Snacks

Not much chips – treats Pretzels okay (P4)

No chips in house

Cakes and sweet biscuits - homemade - bought

4th Biscuits – small amounts

Other sweet snacks Desserts

- Ice-cream - yoghurt

Ice cream – bike ride (out) 6th desserts – ice cream, jelly, custard – every 2nd night

Preservatives/additives • Limit numbers and Es • Not overly salty – don’t add

Appendices 297

FOODS/DRINKS RESTRICTED (Contn)

XXX XXX XXX XXX XXX

Highly processed foods 2nd Highly processed Avoid overly processed Fast foods

- eg. MacDonald’s 3rd Fatty & Takeaway foods

Hot chips – bike rides Don’t know McDonalds, KFC, Hungry Jacks (P1)

NO fast foods – Never been to McDonalds, hungry jacks etc

5th McDonalds – rule 1 X month (Never been KFC, Hungry Jacks)

Sweet cereals Limits – holidays/camping treat (Nutrigrain)

Other (Nil or Limit) Drinking for the sake of drinking

School tuckshop: Special homemade hamburger offer at school (+ milkshake, cookie) – he liked it & raved about it for days (P9 Qu) (mo excited about this but bans McDonalds e.g. similar foods)

1st Food – everything in moderation ex fruit, veg & meat.

• Avoid foods made China –methods/standards

• Hard to avoid completely – treats, parties

• Take batter off fish – so not filling up on.

3. HOW ‘AT HOME’ (Family) XXX XXX XXX XXX XXX SAY 1st

1st talk about healthy eating (p2) – intro Kindy – sometimes food

1st talk about: Sometimes food, special treats. not healthy – nutritious/not nutritious

1st Don’t buy it.

Limit coming into the house

Not in the house Only buy/have - people coming over. - Birthday etc (homemade banana bread, P4) Not in house – can whinge & cry – not there (P15) Cakes, biscuits – not limit because not in house. (Qu P6 EXPOSURE?)

Take health snacks out with us. Hide party bags (p1+2) – top of fridge (out of sight) had enough sugar at party. A treat a day – throw half away Don’t buy lollies. Have juice of yoghurt as treat Every day life Try to keep reasonable – a treat a day (p4) He will ask for dessert – if choc biscuits that day – no dessert - balance (p4). Been to a party – don’t need more that day – no dessert (p5) Don’t have crisps in house – I will eat them (p7)

Talk – seem really yummy but not add to our diet – not nutritious Talk: concentrate on sugar - not talked about fats great deal. We oversee what he eats Offered by us or he asks Fruit platter – need to ask Special treat box (Buy muesli bars, chips, tiny teddies). When - Can have eg. been good, eaten fruit When - had one day not the next BUT not set in stone. Limit - Choose one Ask for a treat – 2 X week, (weekend or after school). Only set time – after Jiu Jitsu 1 X week – BUT occasionally fruit – cause bit consternation(dismay) Don’t have biscuits in the house.

Lollies & choc – buy when shopping. Not interested in sweet drinks – happy with water & warm milk 2 X day. Don’t have soft drinks at home.

Don’t buy it. (but say buy choc) Talk – about why don’t eat certain things (-ve) - what good food and bad food can do to you (+ve & -ve) See obese aunts – eat the wrong foods – see KFC & Coke – lived example. hard to stop any bad food occasionally bend the rules Don’t have dessert – yoghurt 2-3 X week or fruit

298 Appendices

HOW ‘AT HOME’ (Contn) XXX XXX XXX XXX XXX Limit coming into the house (Contn)

Homemade cakes – not often eg. birthday

Don’t buy cakes often – husband buys doughnuts

Limit by where kept in house

Rubbish in pantry - kids know but don’t help selves (P4)

Special treat box

Lollies & choc - Out of reach (up high) - Out of sight - Knows where are - Asks – not help self

Control what is given/offered (Eg. only offer healthy options)

Not help himself - Controlled - Says hungry – give healthy

options

Eat school lunchbox leftovers for afternoon tea

Eat the healthy stuff first

Never go to McDonalds

Limit when given

Set meals – no continual grazing

Space stick –after school (choc) not in shop (previously said no choc. in house)

Social occasions 1 X week – lollies, choc, chips

(Naughty food tonight – eat healthy this morning.) Feed before go out & tell eat healthy first when there.

Full good food eat less rubbish out (P7)

Treats – try in morning or after school - not affect dinner/bedtime. Don’t tend to have dessert as family – might have 2 or 3 times a week (p6)

When - Can have e.g. been good, eaten fruit When - had one day not the next BUT not set in stone. Ask for a treat – 2 X week, (weekend or after school). Only set time – after Jiu Jitsu 1 X week

Lollies & choc - After school or dinner - More at weekends - Rarely in house Depends on if he has had anything that day or even previous day. Desserts – every second night More relaxed on weekends – but Breakfast before choc biscuits at weekend (savoury before sweet) (EXP too)

Limit amount given

Popper ltd school lunch 1 X day – extra popper weekend

Social occasion – Monitor – limit amount little packets

Allowed Couple lollies at party – not generally in home

Only budgeted for one each (P6)

Went for second cupcake – tell one’s enough (P7)

Ice cream – 1 small scoop + few smarties/ sprinkles – miserable little piece of ice cream (P7) Dilute sugary yoghurt with plain yoghurt – reduce amount sugar (P7)

Limit - Choose one Cakes - Allowed one, not two

Give limited amount - less because will ask for

more - give one or two more

portions - he pushes boundary - I give in - depends on

mood/patience (inconsistent)

Do buy chocolate – limited amount – 2 pieces (Don’t give to younger sibling – give fruit) Not that often – not routine

Appendices 299

Appendix K

Final second cycle codes: modified main group and

additional complex sub-group codes

Table K.1 Final Second Cycle Codes: Modified Main Group and Additional Complex Sub-Group Codes

No. Modified main group codes

Final second cycle additional sub-group codes

1 Foods and drinks restricted

n/a

2 Motivation for restrictive feeding

- Balance between restricted and unrestricted foods - Restrictive feeding intentions: totally, “in moderation”, inadvertent - Not restrict totally otherwise will want more. - Form lifelong habits - Relative Nutritional Values (three groups of comparison) - Future concern about child weight (related to parent experiences)

3 How mothers restrict foods & drinks: restrictive feeding practices

- Don’t buy: avoid “giving in” to child demands - Supermarket - Flexible judgement: balance gauged over day or week - Rules or Routines - Avoiding access: out of sight - Avoiding access: offer alternative “healthy” foods - Social inclusion - Bribe to eat school lunch - Restricted item in the school lunch box - School Canteen/tuckshop money - Grandparents and relatives - Emphasising little amounts and not often - Mother’s contrasting descriptions restricted and unrestricted foods - What mothers say to children about totally restricted foods - Mothers descriptions of “treat” foods. - Mothers descriptions of foods and drinks restricted in moderation - Mothers descriptions of foods and drinks totally restricted - Parents own preferences for foods and drinks restricted in moderation - Parents lack of preference for totally or inadvertently restricted foods

and drinks - Mothers beliefs about the desirability of restricted foods - Avoiding negative role modelling - Negative role modeling

4 Relationship between restrictive feeding, pressure & reward

- Encourage: focus on healthy diet. - Encouraging variety of foods - The reward dilemma - Difference between “treat” and reward - Dessert or “treat” dependent on eating a healthy meal - Not overtly mention dessert associated with dinner or as a reward - Food reward for good behaviour - Withholding food rewards

5 How restrictive feeding has changed overtime

“‘No concept”: child unaware of restricted items when younger - Reduction in restriction influenced by child maturity and expanding

social world - Stricter as older due to other family members’ dietary needs

6 Mothers’ experiences of restrictive feeding practices

- Child interest associated with familiar foods - Not exposed/not interested - Comparative sibling exposure experiences - Introduced a restricted food – wanted it more - Age dependent: “not offer” to “in moderation” - Don’t need to restrict at parties - “Rules” and routine experiences - Child behaviour associated with “giving in” or giving inconsistently - Good intentions are hard to achieve - Emphasise minimal amounts - Feelings of “guilt” - Social norms, “like all kids”

300 Appendices

Appendix L

Variables selected for analyses

Table L.1 Variables Included in Descriptive Analysis and Binary Logistic Regression

Variable Source Items Scale included Rationale

Child selected restricted drinks ‘Intake Frequency’

Scale developed by NOURISH survey staff (Daniels et al., 2009)

Qu: How often does your child currently have the following non-milk drinks? Please circle only one option per row. 1. Fruit juice drinks 2. Fizzy or soft drinks e.g. lemonade, coke

5 pt scale (Never, >1/week, 1-3 times/week, 4-6 times/ week, once a day or more)

Drink intake frequency provides an indication of the parental pattern of restriction associated with selected items. Items selected were based on findings of commonly restricted drinks reported in the qualitative study. Gubbels et al. (2009) also found soft drinks to be the most common drink or food item parents restrict.

Child selected restricted foods ‘Intake Frequency’

Child Dietary Questionnaire (Magarey et al., 2009) included in NOURISH survey

Qu: Please circle the number of times your child had the following food in the past SEVEN days. Please circle only ONE response per row. 3. Sweet biscuits, cakes, muffins, doughnuts or fruit pies 4. Potato chips/crisps or savoury biscuits 5. Lollies, muesli or fruit bars 6. Ice-cream/Ice blocks 7. Takeaway (e.g. McDonalds, KFC, Fish & Chips/Chicken shop).

7 pt scale (Nil, once, twice, 3 times, 4 times, 5 times, 6+ times)

Food intake frequency provides an indication of the parental pattern of restriction associated with selected items. Items selected were based on findings of commonly restricted foods reported in the qualitative study.

Child selected restricted food & drink ‘Liking’

5pt food & drink liking scale (Wardle et al., 2001a). Never tried category added as 6th point (Daniels et al., 2009) included in NOURISH survey

Here, we would like to know about your NOURISH child’s likes and dislikes. Please indicate how much your child in general likes each of the following foods by circling only ONE number per row in the table below. Even if you do not give your child a food or they no longer eat a food, please tell us how much they like or dislike the food or mark “never tried”. 1. Fruit Drink 2. Soft drink or fizzy drinks e.g. lemonade, coke. 3a. Sweet biscuits e.g. plain or chocolate. 3b. Cake, doughnuts, buns, pastries 4a. Potato crisps e.g. corn chips, Twisties, Thins, Burger rings. 4b. Savoury biscuits e.g. Jatz, Shapes. 5. Lollies 6. Ice-cream 7. Fast foods e.g. KFC, McDonalds

5 pt preference scale (Likes a lot, Likes a little, Neither likes/dislikes, Dislikes a little, Dislikes a lot) Never tried category coded as missing data.

Food & drink liking provides an indication of what a child might choose in the absence of parental control. Items selected were based on findings of commonly restricted food and drink items reported in the qualitative study.

Note: items 3a & 3b matched with food intake item 3 above. Items 4a & 4b matched with food intake item 4 above.

Appendices 301

Variable Source Items Scale included Rationale

Child selected restricted food & drink ‘Never Tried’

5pt food & drink liking scale (Wardle et al., 2001a). ‘Never tried’ category added as 6th point (Daniels et al., 2009) included in NOURISH survey

Here, we would like to know about your NOURISH child’s likes and dislikes. Please indicate how much your child in general likes each of the following foods by circling only ONE number per row in the table below. Even if you do not give your child a food or they no longer eat a food, please tell us how much they like or dislike the food or mark “Never tried”. 1. Fruit Drink 2. Soft drink or fizzy drinks e.g. lemonade, coke. 3a. Sweet biscuits e.g. plain or chocolate. 3b. Cake, doughnuts, buns, pastries 4a. Potato crisps e.g. corn chips, Twisties, Thins, Burger rings. 4b. Savoury biscuits e.g. Jatz, Shapes. 5. Lollies 6. Ice-cream 7. Fast foods e.g. KFC, McDonalds

Exposed = 5 pt preference scale (Likes a lot, Likes a little, Neither likes/dislikes, Dislikes a little, Dislikes a lot) Not exposed = Never tried category

Taste liking are strongly influenced by exposure between 0-2 years (Cooke et al., 2007). The qualitative study also indicated a potential relationship between early exposure and child liking for restricted items. Measurement at 14 months or 2 years (depending on the item) provided a proxy for ‘early exposure’.

Maternal selected restricted food & drink ‘Liking’

5pt food & drink liking scale (Wardle et al., 2001a). ‘Never tried’ category added as 6th point (Daniels et al., 2009) included in NOURISH survey

Please indicate how much YOU like the following drinks or foods by circling only ONE number per row. If there are drinks or foods you like but don’t usually drink or eat, please still circle as either ‘Likes a lot’ or ‘Likes a little’. 1. Fruit Drink 2. Soft drink or fizzy drinks e.g. lemonade, coke. 3a. Sweet biscuits e.g. plain or chocolate. 3b. Cake, doughnuts, buns, pastries 4a. Potato crisps e.g. corn chips, Twisties, Thins, Burger rings. 4b. Savoury biscuits e.g. Jatz, Shapes. 5. Lollies 6. Ice-cream 7. Fast foods e.g. KFC, McDonalds

5 pt preference scale (Likes a lot, Likes a little, Neither likes/dislikes, Dislikes a little, Dislikes a lot) Never tried category coded as missing data.

The qualitative study and literature (Howard et al., 2012) indicated a potential relationship between maternal and child liking and child intake of restricted items.

302 Appendices

Appendix M

Frequency and percentage of data for child exposure, intake and liking.

Table M.1 Original NOURISH Data: Child Weekly Frequency (Valid %) of Intake of Selected Food and Drink Items Sweet drink categories n

Frequency (valid %) of current child intake frequency per week Never < 1 1-3 4-6 >6

Soft drink 193 116 (60) 65 (34) 11 (6) 1 (1) 0 (0) Fruit drink 191 60 (31) 98 (51) 20 (11) 10 (5) 3 (2)

Food categories n

Frequency (valid %) of child intake frequency in past 7 days n/a 0 1 2 3 4 5 6+

Sweet foods Sweet biscuits/cake 191 n/a 16 (8) 34 (18) 48 (25) 36 (19) 25 (13) 16 (8) 16 (8)

Lollies 192 n/a 60 (31) 36 (19) 40 (21) 36 (19) 11 (6) 9 (5) 0 (0) Ice cream 194 n/a 53 (27) 60 (31) 40 (21) 20 (10) 11 (6) 8 (4) 2 (1) Savoury foods Takeaway 194 n/a 113 (58) 69 (36) 9 (5) 2 (1) 1 (1) 0 (0) 0 (0) Chips/savoury biscuits 193 n/a 50 (26) 57 (30) 40 (21) 26 (14) 11 (6) 7 (4) 2 (1)

Examples included: McDonalds, KFC, fish & chips, chicken shop. Missing data: 8.1-9.5%.

Table M.2 Original NOURISH Data as Shown in Figure 5.1: Child Weekly Frequency (Valid %) of Intake of Selected Food and Drink Items.

Sweet drink categories n

Frequency (valid %) of current child intake frequency per week

Never < 1 1 2 3+ Soft drink 193 116 (60) 65 (34) 4 (2) 4 (2) 5 (3) Fruit drink 191 60 (31) 98 (51) 7 (4) 7 (4) 20 (11)

Food categories n Frequency (valid %) of child intake frequency in past 7 days

n/a 0 1 2 3+ Sweet foods Sweet biscuits/cakes 191 n/a 16 (8) 34 (18) 48 (25) 93 (48) Lollies 192 n/a 60 (31) 36 (19) 40 (21) 56 (30) Ice cream 194 n/a 53 (27) 60 (31) 40 (21) 41 (21) Savoury foods Takeaway ᵇ 194 n/a 113 (58) 69 (36) 9 (5) 3 (2) Chips/savoury biscuits 193 n/a 50 (26) 57 (30) 40 (21) 46 (25)

Frequencies for soft drinks and fruit drink were collected as one category for 1-3/week. These data have been evenly split between 1, 2 and 3/week categories to provide consistency with data collected for food categories. ᵇ Examples included: McDonalds, KFC, fish & chips, chicken shop.

Appendices 303

Table M.3 Frequency (Valid %) of Child Sample who had ‘Tried’ Selected Food and Drink Items by Stated Years old.

Food/drink item 14 months 2 years 3.7 years 5 years

n (sample) % n (sample) % n (sample) % n (sample) % Soft drink 17 (198) 9 68 (183) 37 115 (184) 62 143 (192) 74 Fruit drink 36 (198) 18 99 (184) 54 134 (184) 73 169 (193) 88 Sweet biscuits 139 (195) 71 182 (185) 98 184 (184) 100 191 (193) 99 Cakes 130 (197) 66 175 (185) 95 184 (184) 100 193 (193) 100 Lollies 31 (197) 16 128 (185) 69 180 (184) 98 193 (193) 100 Ice cream 119 (199) 60 169 (185) 91 182 (184) 99 191 (193) 99 Fast foods 24 (197) 12 101 (185) 55 143 (183) 78 165 (192) 86 Savoury biscuits 104 (197) 53 174 (185) 94 182 (184) 99 191 (193) 99 Potato chips 60 (197) 30 153 (185) 83 177 (184) 96 191 (193) 99 Missing data n (%) 12-16 (5.7-7.6) 26-28 (12.3-13.3) 27-28 (12.8-3.3) 18-19 (8.5-9.0)

Note. Tried = all responses to 5 points (likes a lot to dislikes a lot) on 6 point preference scale. Reference group = 6th point never tried. Valid Percentage.

Table M.4 Frequency (Valid %) of Child Sample With a High Liking (Likes a Lot) for Selected Restricted Foods and Drinks.

Food/drink item 14 months 2 years 3.7 years 5 years

n (sample) % n (sample) % n (sample) % n (sample) % Soft drink 6 (198) 3 35 (183) 19 70 (184) 38 76 (192) 40 Fruit drink 19 (198) 10 55 (184) 30 95 (184) 52 118 (193) 61 Sweet biscuits 99 (195) 51 134 (185) 72 157 (184) 85 167 (193) 87 Cakes 77 (197) 39 116 (185) 63 144 (184) 78 161 (193) 83 Lollies 16 (197) 8 85 (185) 46 141 (184) 77 158 (193) 82 Ice cream 79 (199) 40 133 (185) 72 168 (184) 91 181 (193) 94 Fast foods 8 (197) 4 27 (185) 15 80 (183) 44 102 (192) 53 Savoury biscuits 71 (197) 36 130 (185) 70 145 (184) 79 161 (193) 83 Potato chips 31 (197) 16 109 (185) 59 138 (184) 75 154 (193) 80 Missing data n (%) 12-16 (5.7-7.6) 26-28 (12.3-13.3) 27-28 (12.8-13.3) 18-20 (8.5-9.0)

Note. High liking = 1 scale point likes a lot. Reference group = non- high liking = responses 2nd to 5th scale points (likes a little to dislikes a lot) and 6th point never tried. Valid Percentage

304 Appendices

Appendix N

Data characteristics of dichotomised groups

Child Intake Frequency

Table N.1 Dichotomised Data Used for Analysis of Child Intake Frequency

Drink & food categories Valid percentage of child weekly intake frequency Never < 1 1 2 3 4 5 6+

New label 2 1 Soft drink 60 41 Fruit drink 31 69 New label 2 1 Takeaway ᵇ n/a 58 43 New label 2 1 Sweet biscuits/cake n/a 26 73 Lollies n/a 50 51 Ice cream n/a 58 42 Chips/savoury biscuits n/a 56 46 1 = high child intake frequency (reference group); 2 = child non-high intake frequency. ᵇ Examples included: McDonalds, KFC, fish & chips, chicken shop.

Child Early Exposure

Table N.2 Dichotomised Data Used for Statistical Analysis of Child Early Exposure (Valid %) Food/drink item Child age

data Tried Never tried

Original scale 1-5 6 New label ᵇ 1 2 Sweet drinks Soft drink 2 years 37 63 Fruit drink 2 years 54 46 Sweet foods Sweet biscuits 14 months 71 29 Cakes 14 months 66 34 Lollies 2 years 69 31 Savoury foods Fast foods 2 years 55 45 Savoury biscuits 14 months 53 47 Potato chips 14 months 30 70

1= likes a lot; 2= likes a little; 3= neither likes/dislikes; 4= dislikes a little; 5 = dislikes a lot; 6 = never tried. ᵇ 1 = child tried (reference group); 2 = child never tried.

Appendices 305

Child Liking

Table N.3 Relabelled Dichotomised Data Used for Analysis of Child Liking (Valid %) Food/drink item Child liking at 5 years Never

tried Original scale 1 2-5 6 New label ᵇ 1 2 Missing Sweet drinks Soft drink 40 35 26 Fruit drink 61 27 12 Sweet foods Sweet biscuits 87 13 1 Cakes 83 18 0 Lollies 82 19 0 Ice cream 94 6 1 Savoury foods Fast foods 53 33 14 Savoury biscuits 83 16 1 Potato chips 80 19 1

1= likes a lot; 2= likes a little; 3= neither likes/dislikes; 4= dislikes a little; 5 = dislikes a lot; 6 = never tried. ᵇ 1 = child high liking (reference group); 2 = child non-high liking.

Mothers’ own Liking

Table N.4 Original Data Frequency (Valid %) of Mothers’ Sample With a High Liking (Likes a Lot) for Selected Restricted Foods and Drinks, When Child was 2 Years old.

Food/drink item Mothers’ high liking

n (Sample) Valid % Sweet drinks Soft drink 44 (184) 24 Fruit drink 36 (184) 20 Sweet foods Sweet biscuits 103 (185) 56 Cakes 106 (184) 58 Lollies 65 (185) 35 Ice cream 126 (185) 68 Savoury foods Fast foods 49 (184) 27 Savoury biscuits 91 (185) 49 Potato chips 102 (185) 55 Missing data n (%) 26-27 (12.3-12.8) Note. Non- high liking = responses 2nd to 5th scale points (likes a little to dislikes a lot) and 6th point never tried. High liking = 1 scale point likes a lot (reference group).

306 Appendices

Table N.5 Relabelled Dichotomised Data Used for Statistical Analysis of Mothers’ own Liking (Valid %) Food/drink item Mothers’ own liking

(child 2 years) Never tried

Original scale 1 2-5 6 New label ᵇ 1 2 Missing Sweet drinks Soft drink 24 75 1 Fruit drink 20 78 2 Sweet foods Sweet biscuits 56 44 0 Cakes 58 41 1 Lollies 35 64 1 Savoury foods Fast foods 27 72 1 Savoury biscuits 49 51 0 Potato chips 55 45 0

Original scale: 1= likes a lot; 2= likes a little; 3= neither likes/dislikes; 4= dislikes a little; 5 = dislikes a lot; 6 = never tried. ᵇ New scale: 1 = mothers’ own high liking (reference group); 2 = mothers’ own non-high liking.

.

Appendices 307

Appendix O

Covariates included in binary logistic regression

Table O.1 Covariates Included in Binary Logistic Regression Variable Source Scale Reference/Direction Rationale

Maternal education level

NOURISH survey (Daniels et al., 2009)

Dichotomised: University educated (yes/no)

Reference: University educated

Lower used of food restriction in higher educational groups (Blissett et al., 2008). Higher prevalence obesity in lower educational groups (Gibson et al., 2007).

Maternal age

NOURISH survey (Daniels et al., 2009)

Continuous Direction: Older maternal age

Higher use of food restiction by younger mothers (Blissett & Farrow, 2007).

Child gender NOURISH survey (Daniels et al., 2009)

Dichotomised: Male/female

Reference: Male Some studies indicate child outcomes associated with food restriction vary by gender (Fisher & Birch, 1999b; Montgomery et al., 2006)

Maternal BMI (kg/m²)

NOURISH survey (Daniels et al., 2009)

Continuous Direction: Higher maternal BMI

Higher maternal BMI associated with child obesity risk (Hennessy et a.l, 2010; Sud et al., 2010; Gibson et al., 2007)

Child birth weight z-score

NOURISH survey (Daniels et al., 2009)

Continuous Direction: Higher Child weight z-score

Heavier child birth weight associated with later obesity risk (Yu et al., 2011)

Breast feeding duration

NOURISH survey (Daniels et al., 2009)

Continuous - duration breast feeding (weeks).

Direction: Longer duration breast feeding

Early taste exposure via breast milk influences taste liking (Schwartz et al., 2011). Breast/bottle feeding influences taste acceptance (Mennella, Forestell, Morgan, & Beauchamp, 2009). Lower use of food restriction associated with breastfeeding (Blissett & Farrow, 2007).

308 Appendices

Appendix P

Findings for regression analysis for prediction of child liking for restricted foods and drinks

Table P.1 Logistic Regression Findings: Child High Liking for Fruit Drink Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Soft Drink (n= 127) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 2.56 (0.44) 35.22 12.94 (5.56, 30.13) .000 .380 2.40 (0.47) 25.85 11.06 (4.38, 27.93) .000

.387

Child Early Exposureᶜ 1.17 (0.37) 10.02 3.23 (1.56, 6.68) .002 .105 0.17 (0.47) 0.14 1.19 (0.47, 3.00) .713

Mothers’ Own High Liking 0.94 (0.45) 4.38 2.56 (1.06, 6.18) .036 .048 0.59 (0.53) 1.22 1.80 (0.63, 5.12) .269

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ No covariates remained after backward selection. ᶜ Exposed by 2 years. Table P.2 Logistic Regression Findings: Child High Liking for Fruit Drink Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Fruit Drink (n= 148) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 0.94 (0.40) 5.60 2.55 (1.18, 5.54) .018 .052 0.91 (0.42) 4.74 2.47 (1.09, 5.59) .030

.145

1.02 (0.43) 5.48 2.76 (1.18, 6.47) .019

Child Early Exposureᶜ -0.34 (0.37) 0.85 0.71 (0.34, 1.48) .358 .008 -0.70 (0.40) 3.05 0.50 (0.23, 1.09) .081 -0.69 (0.41) 2.76 0.50 (0.22, 1.13) .097

Mothers’ Own High Liking 1.47 (0.57) 6.75 4.35 (1.44, 13.20) .009 .081 1.55 (0.58) 7.08 4.72 (1.51, 14.80) .008 1.70 (0.60) 8.14 5.47 (1.70, 17.58) .004

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ Covariates included: maternal BMI, child gender. ᶜ Exposed by 2 years. Table P.3 Logistic Regression Findings: Child High Liking for Sweet Biscuits Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Sweet Biscuits (n= 165) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 1.51 (0.49) 9.40 4.53 (1.73, 11.91) .002 .104 1.58 (0.50) 9.79 4.84 (1.80, 13.02) .002

.134

1.67 (0.52) 10.38 5.31 (1.92, 14.67) .001

Child Early Exposureᶜ -0.26 (0.55) 0.22 0.77 (0.27, 2.26) .637 .003 -0.50 (0.58) 0.75 0.60 (0.19, 1.89) .386 -0.23 (0.60) 0.15 0.79 (0.24, 2.56) .697

Mothers’ Own High Liking 0.62 (0.48) 1.65 1.85 (0.72, 4.75) .198 .019 0.77 (0.51) 2.28 2.15 (0.80, 5.83) .131 0.82 (0.52) 2.54 2.82 (0.83, 6.28) .111

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ Covariates included: maternal age. ᶜ Exposed by 14 months.

Appendices 309

Table P.4 Logistic Regression Findings: Child High Preference for Cake Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Cake (n= 165) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 0.72 (0.45) 2.57 2.05 (0.85, 4.93) .109 .025 0.56 (0.47) 1.43 1.75 (0.70, 4.37) .232

.101

0.60 (0.47) 1.63 1.82 (0.73, 4.58) .201

Child Early Exposureᶜ 0.40 (0.43) 0.84 1.48 (0.64, 3.46) .361 .008 0.14 (0.46) 0.10 1.15 (0.47, 2.81) .758 0.25 (0.46) 0.29 1.28 (0.52, 3.18) .589

Mothers’ Own High Liking 1.24 (0.45) 7.76 3.45 (1.44, 8.25) .005 .083 1.19 (0.45) 7.00 3.29 (1.36, 7.96) .008 1.34 (0.46) 8.30 3.80 (1.53, 9.43) .004

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ Covariates included: maternal age. ᶜ Exposed by 14 months. Table P.5 Logistic Regression Findings: Child High Preference for Lollies Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Lollies (n= 171) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 0.56 (0.41) 1.83 1.75 (0.78, 3.93) .176 .018 0.45 (0.42) 1.14 1.57 (0.68, 3.61) .287

.038

Child Early Exposureᶜ 0.39 (0.42) 0.82 1.47 (0.64, 3.38) .364 .008 0.26 (0.43) 0.34 1.29 (0.55, 3.02) .557

Mothers’ Own High Liking 0.71 (0.47) 2.28 2.02 (0.81, 5.05) .131 .024 0.54 (0.48) 1.27 1.72 (0.67, 4.44) .259

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ No covariates remained after backward selection. ᶜ Exposed by 2 years. Table P.6 Logistic Regression Findings: Child High Preference for Fast Food Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Fast Food (n= 148) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 0.35 (0.34) 1.04 1.42 (0.73, 2.76) .309 .009 0.16 (0.37) 0.19 1.18 (0.57, 2.40) .659

.110

0.10 (0.38) 0.06 1.10 (0.53, 2.31) .800

Child Early Exposureᶜ 0.38 (0.35) 1.22 1.47 (0.75, 2.88) .269 .011 0.19 (0.37) 0.27 1.21 (0.59, 2.47) .607 0.09 (0.38) 0.06 1.09 (0.52, 2.29) .811

Mothers’ Own High Liking 1.42 (0.44) 10.52 4.12 (1.75, 9.70) .001 .108 1.33 (0.45) 8.86 3.77 (1.57, 9.05) .003 1.57 (0.48) 10.87 4.79 (1.88, 12.16) .001

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ Covariates included: child birthweight z-score, breast fed duration. ᶜ Exposed by 2 years.

310 Appendices

Table P.7 Logistic Regression Findings: Child High Preference for Savoury Biscuits Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ own High Liking for Savoury Biscuits (n=166) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 0.20 (0.41) 0.24 1.23 (0.54, 2.76) .624 .002 -0.06 (0.44) 0.02 0.94 (0.40, 2.21) .885

.075

-0.16 (0.45) 0.13 0.85 (0.36, 2.05) .724

Child Early Exposureᶜ 0.67 (0.42) 2.61 1.95 (0.87, 4.40) .106 .026 0.52 (0.44) 1.46 1.69 (0.72, 3.96) .228 0.82 (0.46) 3.11 2.27 (0.91, 5.63) .078

Mothers’ Own High Liking 1.05 (0.45) 5.49 2.86 (1.19, 6.91) .019 .059 0.99 (0.46) 4.72 2.70 (1.10, 6.62) .030 1.01 (0.46) 4.71 2.73 (1.10, 6.78) .030

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ Covariates included: maternal age. ᶜ Exposed by 14 months. Table P.8 Logistic Regression Findings: Child High Preference for Chips Associated With Predictor Variables: Child High Intake, Child Early Exposure and Mothers’ Own High Liking for Chips (n= 166) Predictor Variable

Raw Bivariate Models Predictor Model Adjusted Covariate Model ᵇ B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p R² ᵅ B (SE) Wald OR (95% Cl) p

Child High Intake 0.12 (0.40) 0.09 1.13 (0.52, 2.44) .766 .001 0.05 (0.41) 0.01 1.05 (0.48, 2.31) .908

.053

0.06 (0.41) 0.02 1.06 (0.48, 2.36) .885

Child Early Exposureᶜ 0.25 (0.43) 0.32 1.28 (0.55, 2.99) .572 .003 0.09 (0.45) 0.04 1.09 (0.46, 2.61) .846 0.26 (0.46) 0.32 1.30 (0.53, 3.20) .570

Mothers’ Own High Liking 0.95 (0.41) 5.46 2.58 (1.17, 5.71) .019 .053 0.92 (0.41) 5.06 2.51 (1.13, 5.61) .024 0.95 (0.41) 5.24 2.58 (1.15, 5.79) .022

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. ᵅ = R² for 3 predictors together. ᵇ Covariates included: maternal education. ᶜ Exposed by 14 months.

Note: Adjusted covariate models only include the covariates remaining in the final adjusted models following the backward selection procedure. This means that different covariates remained for different foods and drinks. Covariates excluded provided minimal or no effect.

Appendices 311

Appendix Q

Adjusted predictions including characteristic covariates

Table Q.1 Adjusted Prediction of Child High Liking by Child High Intake Frequency, Mothers’ own High Liking and Child Early Exposure for Eight Selected Restricted Food and Drink Items at Child Aged 5 Years

Food or Drink n Child intake frequency Mothers’ own liking Child early

exposure OR (95% CI) OR (95% CI) OR (95% CI)

Sweet food & drink items

Soft drink 127 11.06*** (4.38, 27.93) 1.80 (0.63, 5.12) 1.19 ᵇ (0.47, 3.00) Sweet biscuit 165 5.31*** (1.92, 14.67) 2.82 (0.83, 6.28) 0.79 (0.24, 2.56) Fruit drink 148 2.76* (1.18, 6.47) 5.47** (1.70, 17.58) 0.50 ᵇ (0.22, 1.13) Cake 165 1.82 (0.73, 4.58) 3.80** (1.53, 9.43) 1.28 (0.52, 3.18) Lollies 171 1.57 (0.68, 3.61) 1.72 (0.67, 4.44) 1.29 ᵇ (0.55, 3.02)

Savoury food items

Fast food 148 1.10 (0.53, 2.31) 4.79*** (1.88, 12.16) 1.09 ᵇ (0.52, 2.29) Savoury biscuit 166 0.85 (0.36, 2.05) 2.73* (1.10, 6.78) 2.27 (0.91, 5.63) Potato chips 166 1.06 (0.48, 2.36) 2.58* (1.15, 5.79) 1.30 (0.53, 3.20) Note. OR = odds ratio. CI = 95% confidence intervals of OR. Adjusted prediction model includes three predictors and characteristic covariates remaining after backward selection. aChild had been exposed to the item by 14 months. ᵇChild had been exposed to the item by 2 years. *p < .05. **p < .01. ***p < .001.

Table Q.1 shows that odds predicted for sweet biscuits, fruit drink, cake and fast

foods were slightly higher with the additions of characteristic covariates.There were no

notable reductions in odds predicted with the addition of characteristic covariates. The

following associations between covariates and prediction of child preference for the

restricted foods and drinks examined were found (B change > 20%).

• Higher child birth weight z-score had a stronger and significant association with

high child preference for fast food than lower child birth weight z-score.

• Female child gender had a stronger but not significant association with high child

preference for fruit drink than male gender.

• Mothers with a lower BMI had a stronger and significant association with high child

preference for fruit drink than for mothers with a higher BMI.

• Older mothers had a stronger and significant association with high child preference

for savoury biscuits than younger mothers, as well as a stronger but not significant

association with high child preference for sweet biscuits and cake.

• University educated mothers had a stronger but not significant association with

high child preference for chips than non-university educated mothers. For NOURISH trial (Daniels et al., 2009) participants included in the sample,

anthropometric measurements were completed at local child health clinics by trained

312 Appendices

assessors. The initial child birth weight was obtained from hospital records. Measurement at

clinics included infant naked weight and recumbent length (average of two measures) and

weight in underwear when children. Maternal height and weight (shoes removed) were

measured.

Appendices 313

Appendix R

Early exposure: bivariate models and models adjusted for child intake

Table R.1 Logistic Regression Findings: Early Exposure Predicting Child High Preference for Food and Drink Items, raw Bivariate Models and Models Adjusted for Child Intake.

Food or drink item n Raw bivariate models Models adjusted for child intake

B (SE) Wald OR (95% Cl) p R² B (SE) Wald OR (95% Cl) p

Soft drink 127 1.17 (0.37) 10.02 3.23 (1.56, 6.68) .002 .105 0.23 (0.47) 0.25 1.26

(0.51, 3.15) .615

Fruit drink 148 -0.34 (0.37) 0.85 0.71 (0.34, 1.48) .358 .008 -0.47 (0.39) 1.49 0.62

(0.29, 1.33) .222

Sweet biscuits ᵇ 165 -0.26 (0.55) 0.22 0.77 (0.27, 2.26) .637 .003 -0.36 (0.57) 0.41 0.70

(0.23, 2.11) .520

Cake ᵇ 165 0.40 (0.43) 0.84 1.48 (0.64, 3.46) .361 .008 0.29 (0.44) 0.44 1.34

(0.56, 3.18) .507

Lollies 171 0.39 (0.42) 0.82 1.47 (0.64, 3.38) .364 .008 0.34 (0.43) 0.65 1.41

(0.61, 3.26) .421

Fast food 148 0.38 (0.35) 1.22 1.47 (0.75, 2.88) .269 .011 0.33 (0.35) 0.86 1.39

(0.70, 2.76) .354

Savoury biscuits ᵇ 166 0.67 (0.42) 2.61 1.95 (0.87, 4.40) .106 .026 0.66 (0.44) 2.38 1.94

(0.84, 4.47) .123

Chips ᵇ 166 0.25 (0.43) 0.32 1.28 (0.55, 2.99) .572 .003 0.24 (0.44) 0.30 1.27

(0.54, 2.97) .586

Note. OR = odds ratio; 95% Cl = 95% confidence intervals; R² = Nagelkerke. Exposed by 2 years. ᵇ Exposed by 14 months.

EXPLORING THE RESTRICTIVE FEEDING

PHENOMENON AND THE POTENTIAL

IMPACT ON CHILD FOOD PREFERENCES

ADDENDUM 4.1

ADDITIONAL SUPPORTING QUOTES

KIM JACKSON

MSc (Health Planning & Financing), Postgrad. Diploma (Health Visiting), BN (Bachelor of Nursing)

Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy

Queensland University of Technology Institute of Health and Biomedical Innovation (IHBI)

School of Exercise and Nutrition Sciences Faculty of Health

2018

Addendum 4.1 1

Box 1 – Child interest associated with familiar foods

Because once they’ve had it then they’ll just want it all the time. And I mean it’s the same with like fast food. Like he’s had McDonalds but he’s never had Hungry Jacks or KFC or you know other fast food because once he’s had it he’ll always want it and so I mean I guess you know we gave in one day and he had McDonalds and now he always wants it. So we just stick to that one. (Melissa, 4:6)

Miles would sit down and eat a whole tub if he was left to himself... his morning tea at school, is usually yoghurt... So after dinner he’ll say “I’m hungry, can I have yogurt?”, and he’ll have, you know, maybe half a cup of yoghurt, and then he’ll say “I’m really hungry, I need more yoghurt”, I’m like “Ok, well it’s time for an apple” “Oh no I’m not actually hungry after all”. (Pip, 3:56)

[most challenging situation] ...probably at home more so because yeah I mean when like I said when you’re at parties you know he doesn’t like a lot of the food that’s there anyway. So yeah I mean probably being at home because he’ll repeatedly ask. ...he’ll just keep asking... he will just want a lot of bad food I guess. (Melissa, 3:73)

...we try and you know limit him often because then they often say oh we want McDonalds, we want McDonalds. They seem to like the chicken nuggets and the happy meal type thing and I think if you have it more often then they keep asking for it. (Joanne, 1:16)

...she loves the chocolate... For her night time sweets it’s usually ice cream with a little bit of topping and it might be six smarties. You know those M’n’M chocolate... the smarties, they’ve had them so often and so long on their ice cream... (Karren, 2:10 & 3:13)

When she was little, she enjoyed sweets, but because I’d, I would only offer it to her out of the blue, she appreciated it. But as she’s got older, it’s been, when she started learning, earning her own pocket money, that, it became quite obsessive... And so she’d get her twenty cents and want to take it to school and buy a lolly, or a sweet treat for school... what’s valuable at her age right now is sweets. She doesn’t care so much about buying other things like stationary, or dolls, or anyth ing else. (Karren, 8:16, 20 & 22)

..if they see the McDonalds sign, then they always want to go there... I’m not saying that we’re like super strict, because we do allow them to have it... Maybe once a month... it’s one of my super lazy days that’s the problem. It’s like when we’re time stressed (Melanie, 3:140-156)

...at the moment I don’t know, it’s just driving me nuts. She just seems to get her fair share [lollies] from wherever else she’s been going to that many parties and things, and having that many. So I just think she doesn’t need any more... I encourage her not to have them, but she still wants them, and that’s fine (Rebekah, 3: 24,4-10)

He definitely has a sweet tooth, he likes all those things, as probably most kids do... that’s a treat group food, and you know you can have two blocks of chocolate today, but that’s all your having today. And of course he’ll ask for more, because he likes it... (Kate, 3:14,6).

...if I had a packet of biscuits and I hid it in the pantry, they’d find it. They’d, I shoved the family assorted biscuits right at the back at the top, and Ben found them yesterday, and I can’t believe he found them... It’s like little crows, foragers, anything that shines they find. Little rat bags... now that I’ve put biscuits in the house, they’re not going to have fruit if there’s biscuits are they?... But I mean they’re kids. If I left, if I left a whole big packet of biscuits out there, they would eat them all. No doubt about it, little rat bags... it was only until mid-year, I realised you can put junk food in their [school] lunch box. That’s when I started putting the biscuits in, or tiny teddies... The LCM bars, I just thought maybe that’s a good snack for school, but once again, if I buy them a pack of eight. The next day they could all be gone, and then I’ve got nothing for the school box... Yeah, so I’ve got to hide them (Penny, 2:24,28 & 3: 142,42,44)

...as he grows up he’s going to have that opportunity to buy himself lollies and chocolates and the drinks he wants later. So if I can minimise it now, have that control now... hopefully it will train him that a little bit, if he needs something sweet a little bit is enough... a couple of times we were out at parties or he was at a party obviously lots of sweets and lots of lollies and chocolates and all that and he does go a little bit crazy... if he feels that he hasn’t had something sweet or he really feels like having something he will stop me and he will sort of say look I really wouldn’t mind having something. You know something like a YoGo or a lolly and he might have one of those I don't know milk bottle lollies and that’s enough for him... a couple of years ago, I think he was about four. He just, there was a bowl of I don't know lollies as in you know the milk bottles and those teeth lollies… and yeah he just kept eating them and eating them... (Veronika, 2:2-14 & 3:4,96)

I remember that he didn’t even like chocolate at all. He had tried chocolate when he was young, and didn’t like it at all, and I think it was when he was three that he actually worked out that he likes chocolate. So there were things that like he didn’t have for many years, you know, and then he was introduced to it, and worked out that he liked it. (Tara, 4:6)

...we do go to McDonalds on occasion, which I know is rubbish, and I usually tell her that when we’re going. You know, she likes it... (Helen, 3:102)

Addendum 4.1 2

Box 1 – Child interest associated with familiar foods (continued)

...particularly with drinks. She might whinge and complain a bit. She’s like “But I want more soft drink” like “I want another drink” and, but yeah, and sometimes I might give in. “Ok well last one, don’t ask me again”. But yeah, you know and then it’s just “Well no, it’s just water now, that’s it. You’re done” and you know she’ll whinge and complain sometimes, but eventually she’ll get over it. (Jasmyn, 3:28)

Box 2 – Not exposed - not interested Soft drink

They gave it [soda] to her by mistake, you know, once, and she’s like, “I didn’t like it” and I said, “That’s ok. You don’t have to”, you know. If she doesn’t like it I’m going for it. (Helen, 2:17)

He doesn’t like soft drink. He’s tried soft drink before at a party... he wanted to try soft drink like all his mates... he just said “I don’t like it”. (Natalie, 3:143)

...he hasn’t actually had any soft drinks before or the sport drink. So he’s never had a taste of that and he’s never really, we’ve been lucky he’s never really shown any interest. (Joanne, 2:12,14).

He doesn’t drink soft drink, there’s only once that he drank soft drink... that was all that was available so he had soft drink... then he goes back to drinking his normal stuff... because he’s now six you know he kind of got used to the juices, the water, everything is flat as opposed to the bubbly. (Veronika, 3:74-88)

I don’t allow her to have soft drinks... When we go anywhere where there’s an offer of other children drinking soft drinks she always asks for water. (Joanne J, 1:2 & 3:10)

We actually never told them that they’re not allowed to have it [soft drink]... they’ve never asked. They just prefer to drink their water. (Melanie, 3:48)

...we had a friend over and he says “Does Ben want soft drink?” and I kind of whispered “No, no, no” and he just goes “No, I’ve just got my water”... I’ve never given him any. I reckon even if I poured some on a cup and go “Here, taste that” he’ll go “No, I don’t want to”. (Penny, 3:65,67)

he has never had soft drink ever and so if it is put in front of him he doesn’t even look at it because it’s not part of his diet you know he just goes I don’t drink soft drink I will have a water so and its working so far (Kylie, 2:23)

Fast Food Outlets

...if they weren’t exposed to it, they wouldn’t know about it, you know, in those younger years... for a long time, all McDonalds was to my daughter was this big M, and the playground out the front. (Margot, C:2)

...when he was quite young he noticed that there was a playground in McDonalds or Hungry Jacks, or one of them, and he said “Can we go and play in the playground one day?”... you basically had to say to him “No, the health, the food that they serve in there isn’t very healthy... it sort of became known in our family as a fat shop... he knows that they’re unhealthy and he never asks to go into them. (Natalie, 4:12,14)

We don’t really go to fast food restaurants, mainly because we don’t want to eat it, so we don’t go with them. I think they’ve tried Macdonald’s once. They didn’t like the burgers, so I was like ‘oh good’ that helps... (Erin, 3:47,49)

...we don’t have any fast food at all. So the kids don’t even know what McDonalds looks like, and they’ve got no concept at all about Hungry Jacks or KFC... (Pip, 1:14)

Other foods and drinks

As far as cordial, we’ve been to parties, but because we’ve never had it before he doesn’t like the taste of it, and he won’t drink it, if that makes sense. (Heidi, 2:2)

he won’t really eat anything he hasn’t eaten before. And yeah things like parties not really an issue because there’s usually only limited things that he would eat. ...So it sort of makes it quite easy. (Melissa, 3:32)

...the teacher provided them with afternoon tea, and so she provided little poppers and muesli bars, and he picked a milk drink in a popper, and he must have had about three or four, it was a chocolate milk, three or four sips and no, didn’t like that either. (Natalie, 3:147)

...he’s not terribly interested in cakes. We don't buy them... if we did have it in the house... I would have to ask him if he wanted it first because a lot of the time he would say no. (Tegan, 3:32)

...my husband’s German, he likes his cake. So that goes in the cupboard and the kids know that’s his. They’re not particularly interested because they’re not allowed to have it... (Karren, 3:18)

She has had sherbet... because it came in a party bag I didn’t say no, but it’s not something I’d buy for her. She has tried it, she wasn’t really that big a fan of it fortunately... she had a mouthful of it and said “No, I don’t like it Mummy”, and she gave it back. (Karren, 3:38)

Addendum 4.1 3

Box 2 – Not exposed - not interested (Continued)

People will from time to time give him lollies... he might ask for them for a few days and then he just seems to forget about it. I don’t think it’s his absolute favourite thing. (Claire, 3.2,14)

[At parties] ...she often actually, even one of the cakes and things, she won’t eat, she’ll have a mouthful and then leave because I think she’s just not used to it... because I don’t, we don’t have it. (Rebekah, C12,16)

I’ve never been a big soft drink drinker or never a big sweets eater so I just tend not to buy it. I tend not to buy biscuits and that sort of thing either. And if we have chips or something like that it’s usually because we’re having a party… I’m not sure if it’s affected anything but I’ve noticed at parties that... she’ll have a little bit, and then she moves on. You know she might eat half a piece of cake and give it over to me, and say you know ‘I’ve had enough’... (Erin, 3:4,8)

I always make sure he has whole grain bread, I won’t give them white bread... I have only given it to him so he doesn’t know the difference and he doesn’t ask for white bread because he doesn’t know it is any different (Kylie, C1,3)

I’ve never exposed them to white bread, so they don’t, they might have had it at parties and just gone “Ugh, this is disgusting bread” “Yes, fantastic” fight against white bread. (Pip, 3:44)

I wish they liked nuts, that would have been good. But of course the, I think the schools with the no nut policy type thing puts kids of liking nuts these days... Yeah, it’s a bit of a bummer, but you’d think that you know, if they can’t have them at school, then they’d like them more at home. But no, that hasn’t worked. (Penny, 3:32,34)

Dissenting Quote

...my husband occasionally will have a thing of Coke, I don't drink pretty much any soft drink unless it’s got alcohol in it... But she did try a mouthful of Coke and she was just like oh my God that is so good. I said yeah that’s the last sip you’re having of that ever. (Victoria, 3:76,78)

However, mother said child never has soft drink or cordial and then later said she has cordial & juice at parties. She also said that she got stricter as her child got older because of increasing desire for sweet foods/lollies. It is possible that soft drinks were accessed at a younger age too. Fizzy water is given to the child at home via a soda stream. If carbonated drinks were not familiar why would this be given at home? She said ‘...it’s been quite a good way for us to sort of get around that fizzy drink thing.’ (Victoria, 3:76,78)

Box 3 – “Balance” between restricted and unrestricted foods.

You know, I want them to have a very good basis, a healthy relationship with food. I want them to be able to have those treats. Like yes we talk about not having them, but I try not to overdo that, because I want them to appreciate that they can have treats sometimes as well, and that they can have a balanced life. (Tara, 2:6)

...I think you know, if you didn’t allow your child to have anything at all then they would be wondered “well why, why can’t I have this?” I think if there’s limitations and you can back up the reason as to why... everything in moderation. (Joanne J, 5:2)

...I don’t want her missing out, but I don’t want to have it as an everyday, that’s why we call them treats, you know. It’s not an everyday food. (Karren, 2:6)

That the good stuff goes in first... the other stuff is not good and we don’t need it but acknowledging that it’s nice to have occasionally. (Narina, 3:4)

I believe everything is in moderation. She certainly hasn’t missed out on having lollies, or having potato chips or anything. (Lisa, 1:6)

...because he eats really well, and a variety of good and healthy foods, and lots of fruits and veggies and things, then it’s ok in my mind to give him treats every now and then. (Pip, 4:20)

I don't mind him having some you know like the odd you know chips or biscuits and that. So I’m not going to completely limit it. But I think yeah the balance is the main thing. (Joanne, 2:34)

I’m not too bothered if she’s having it at a party, because I know that the rest of her diet is quite good. (Erin, 3:17)

...I want him to understand that they are just food to eat sometimes. And I keep them as a treat so he doesn’t expect that he will get them all the time... (Tegan, 2:2)

Addendum 4.1 4

Box 4 – Not restrict totally otherwise will want more.

I don’t want her missing out either because then she’ll probably want it more... (Karren 2:6)

...you see some parents that are like “No they can’t have any cake, or they can’t have any chocolates” and the kids are having a nervous breakdown seeing all these other kids having it, and it seems kind of cruel... everything in moderation, and I think getting too fanatic about it is just as bad. You know, you don’t want to be depriving them, you don’t want to be you know, they’re missing out. Because then they’re just going to want it more and they’re going to resent it... (Jasmyn, 6:2,10)

My parents were extremely strict... I think that lead me, when I was an adult, to take, you know, make bad food choices, because I could, and so I’m hoping that we are a little bit more relaxed about lollies... than my own parents were. So I’m hoping that he’ll just be able to pick up where we leave off... Rather than suddenly going, “Wow! I can actually have all these amazing foods” and spend his time eating all of that when he becomes a young adult. (Pip, 2:12,14)

I’m not going to not give them any because then as soon as they go to someone else’s house and they get it, they’ll, then it’s exciting... the stricter I am, it’s going to work against me. So I think... everything in moderation... if I say nothing, that’s not going to work in my favour a long time, so I just do it a little bit. (Penny, 2:18)

...they [mothers] actually get quite upset about it... Yeah they can’t say you know you’re not meant to eat that and their child goes oh okay and goes away. It’s like they have to actually physically take them away so that the kid focusses on something else rather than eating. We did use to have little friends that used to come over as well who weren’t allowed to have sugar... if you know there was lollies around the place... he would actually steal them and hide them in his pockets and that kind of thing. So just seeing that I think well I would rather just my kids have one lolly every now and then so that they get them, they know what it’s about rather than seeing them you know steal hand fulls of them to stash away. Like because they never get it. (Tegan, 5:8)

Box 5 – Form lasting lifetime habits. a. No “need” for totally restricted foods and drinks

But the soft drink I just yeah I just don't think he needs that at all... (Joanne 2:34)

I don’t think she needs that type of thing [soft drink] at her age. So why give it to her? (Helen, 2:23)

...soft drink, just the sugar content, and we just don’t see the point to it. There’s absolutely, like no nutritional value, it makes, it’s full of sugar. (Heidi, 2:2)

[Mother in law said in relation to soft drink] “oh gosh, you know a bit of soft drinks not going to hurt him, it hasn’t hurt us.” So I probably have relented a bit and on those occasions let him have soft drink, when it’s not something I really ever thought he needed to have or wanted him to have. (Narina, 3:54)

[Cola] I sort of don't see the need for children to have caffeine at all so I wouldn’t allow you know cola drinks at all. (Melissa, 1:10).

...I just don’t think – at the age of 5 and 6 that that’s something that that aged child needs. (Joanne J, 3:2)

I don’t know why I’ve got this thing against soft drink. I really, I think we don’t need it... “She doesn’t need it”. (Karren, 3:36).

I would never provide soft drink at a party for children myself. Because I just don't think it’s necessary for them. (Victoria, 3:86)

b. Small amounts of foods and drinks in moderation

I think for me mostly it’s just that I don't want, I want him to get used to small amounts of not necessarily good food and larger amounts of good food. And I just want him to get used to that balance. (Veronika, 2:20)

...at least she knows. Like, it’s not a good thing to have a lot of it. Yeah, so I’m hoping that it stays that way. (Melanie, 4:14)

I’d like her to probably end up like I have. We understand what’s healthy. We know what we’re supposed to be eating, and I hope that she likes that. So, yeah, by restricting the junk, but not making, not letting her miss out completely, I’m hoping that she’ll realize which path to take, maybe. (Lisa 2:8)

I don’t want them to grow up loving all the sweet stuff... I don’t want them to get used to it. So when they’re thirty they’re addicted to chocolate... Some people would say, have one Tim Tam, they have the whole lot, I don’t want them to end up you know, being that sort of person... (Penny, 2:18,28)

Addendum 4.1 5

Box 6 – Relative “nutritional values”

a. Different types of sweet foods

...if you’re going to give them a treat, we’d prefer it to be something, you know, like a little, like yeah. Something like a cupcake or a muffin, or some ice cream. Whereas we just don’t see the point at all at his age, having soft drink. (Heidi, 2:2)

...there’s some things like flavoured milk that obviously aren’t great but... it’s got some calcium in it. You know other stuff like lollies you just think well it’s got absolutely nothing. (Claire, 3.168)

[Halloween trick or treating] ...I generally throw out all of like the rubbishy lollies and things. If they put like a nice little chocolate in it, like a Freddo Frog or something like that I’ll let them have that. (Tara, 3:4)

I say grab a yoghurt which has still got sugar and that in it but I guess it’s, you feel it’s a bit better than some of the other stuff... (Joanne, 7:4).

...at least chocolate’s got cocoa. It might be a little bit better [comparison with lollies] (Penny, 3:48)

...we’ll sub in a chocolate milk instead of a soft drink, which obviously is still high in sugar but I feel that the children are getting something out of the milk. (Kate, 3:46)

b. Savoury better than sweet foods

...I had to laugh at myself saying “Casey if you don’t eat your nuggets, you won’t get ice cream” and I went “Oh my god, did you just hear what I said? I said if you don’t eat that junk food you don’t get that junk food” (Penny, 3:79)

...make sure that he has something that’s I guess savoury before he can then have you know something that’s sweet (Melissa, 3:26)

...if there’s you know, little frankfurts or something, I’d say, “Mate have a couple of them first, before you move onto like the dessert type things... if the frankfurts come out hot, or as I said the sausage, pie and sausage roll. Not that they’re much better, but they’re a lot better than all the sugar... we just try and make sure he has that savoury first, so that there’s not quite enough room to fit in fourteen cupcakes. (Heidi, 3:58 & 60)

lunch packed for Audrey is all savoury and then if I know that she’s done well with all those then I don’t mind a little bit of sugar now and again. (Joanne J, 2.24)

I know that, you know he’s going to get a little bit of a sugar high later on, and I try to just get him to eat sort of half, savoury half sweet. So that’s at a party... So when we have morning tea after church I say he has to have something savoury, and then something sweet... So that he’s balancing it out... (Pip, 3:8)

c. Homemade (and less processed) better than bought processed foods

...minimise everything packaged as much as possible. So I try to cook as much as I can from scratch... we try to minimise the boys eating typical ice creams, because the ingredients list is, you know, a mile long ... I can make the boys a version of ice cream in the Thermomix. (Tara, 1.4,11).

...if he’s doing fine with you know, the stuff we’re giving him, I’d rather it stayed the sort of, you know the clean sort of food stuff rather than get to that sort of processed stuff... if we have cakes, it’s been homemade... (Carolyn, 1:18 & 3:32).

So he doesn’t have any of like the McDonalds, KFC, Hungry Jacks, he’s never been to any of them... But like we’ve turned down birthday party invites and stuff because I’m just not doing it. ...at school on a Friday they had a special hamburger offer, like homemade hamburgers... But you know, having him appreciate a homemade burger, in a proper bread roll with salad and a nice homemade beef pattie, that was a bit win for me. (Carolyn, 1:10 & 4:2,4)

...Grill’d burger place, and I usually let them just have a kids meal there and that’s pretty reasonable. Yeah, again as a one off it’s not an unhealthy meal I don’t think... we don’t ever go into McDonalds or anywhere that I think is going to be selling us very unhealthy food. (Pip, 3:72)

She has pretzels, but I don’t really consider that too bad. You know, like there’s flavoured crackers and potato chips and stuff, we just don’t have in the house. (Helen 3:18)

...we’ll bake fruit scones or like we made muesli slice last week and that kind of thing rather than buying packets of donuts and chips and I don't know roll ups and muesli bars and that kind of thing. (Tegan, 3:22)

...we’ve made homemade pizzas last night, that was a bit naughty, but it’s homemade so it’s better (Penny, 1:20)

I mean, it’s hard to avoid it completely, so there are treat times, like at parties and stuff. But yeah, in general our family food is generally less processed, as least processed as possible. (Natalie, 1:10)

[school tuckshop] ...she brings up that... “You can get a sausage roll”, and I’ll say, “Well one day we might attempt at making sausage rolls”. (Lisa, 3:143)

Addendum 4.1 6

Box 7 – Future concern about child weight

a. Prompted - weight not a prominent reason

I think it’s more just I want to see my children grow into healthy adults, you know, healthy bodies, not being concerned about, you know, not having to think, actively think about weight and that sort of stuff, that it all just comes naturally to them. You know, they, they’re born and they’re perfect, and you know, it just seems like a lot of the time it’s just downhill from there. (Carolyn, 1:8)

Not at all... So I grew up with a few issues about body image as a child... It’s about being strong and healthy. It’s not being about slim, it’s about being about strong and healthy, and as long as you’re active, and you have sometimes food sometimes, that’s ok. (Heidi, 2:20)

‘Not really no... it’s not a factor in Michaela’s life’. (Kerryn, 2:4,8)

No he’s very active and he eats well, so I think he’s quite balanced, yeah I’m not worried about his weight. (Kate, 2:6)

Darcy actually has never been a big eater. So it’s… so she’s always been more of a concern as to regards of weight. We’ve always been trying to put weight on. (Erin, 2:16)

Not her at all but I just feel sad when I see little kids that are quite heavy... And I just want Neve to be off on a good track... Wanting to be healthy and active (Mhari, 2:28,30)

No, no he’s and he’s pretty I mean he’s kind of heavy but he’s lean at the same time. Yeah he’s, I’m not concerned about it at all. (Tegan, 2:14)

No. Not at all… She’s pretty healthy (Margot, 2:6,8)

Umm no I think he’s fairly slim. If you know if he was bigger then you know I might be even more conscious of what he eats. (Melissa, 2:12)

No. Not at all (Veronika, 2:16)

I haven’t worried about both of their weights, ever really. (Penny, 2:16)

Well I guess that’s part and parcel with her, or wanting her to eat healthier I suppose. I mean I don’t have any worries with her weight at the moment. But it’s more about, you know, I mean you can eat healthy and still be big, some people. So it’s not, yes, like I’m more worried about her just generally eating healthy... Yeah I mean, I don’t, my husband’s side, they do have more weight problems, but I haven’t really, that sort of hasn’t bothered me as much. I’d rather just have them sort of get used to a healthy lifestyle, instead of worrying about, yeah, weight. Because if she’s healthy, eating healthy, then that should sort of hopefully be part and parcel of, yeah. (Rebekah, 2:8,10)

No... No, they’re both really healthy range. (Carolyn, 2:16)

No... And that’s probably a big thing too I guess maybe the size of the child too. You know if they start getting bigger as well then you may be really need to start to watch their diet perhaps I don’t know the answer. He’s a very active child too. (Joanne, 2:42,45)

No. I’m not concerned about weight. She’s in the normal range, and in our genes, I don’t worry too much about weight. I can eat whatever I want and I’m underweight and I’ve been eating. So it’s not about getting fat or anything. (Racy, 2:36)

...um I do get a bit concerned that he is a little bit on the small side because he is quite thin... That is also why I make sure that everything that goes into his body is worthwhile because he doesn’t have a lot of it so I don’t want the small amount going in not to be rubbish. (Kylie, 2:8)

No he’s as skinny as a rake. He’s some skin stretched over a bit of bone. (Claire, 2:6)

Not at all, no. If anything, well, well certainly I guess with the first thing I always think of when someone says concern about weight, is I always think about overweight. I suppose you could be concerned about underweight as well. He is a little waif, like he’s a thin, little slight boy. Like, he’s definitely, there’s no overweight problem. I don’t think I’m particularly worried about him being underweight at the moment. Even though he is quite thin, because he’s just so active. I mean, so incredibly active. So I know he’s just burning off everything that he puts into his mouth. So yeah, no probably not, no. Not worried about that. (Tara, 2:4)

b. Unprompted – future concern about child weight

...subconsciously I think for myself I don’t want them to have weight issues but I don’t mention that to the children obviously. I don’t want them ever feel that they can’t eat something because it’s going to make them fat or overweight or anything like that... I wouldn’t want them to associate sugary foods with being overweight because I don’t think that it necessarily happens like that. And there’s different reasons that people are different weights. So I know that with children you’ve got to be very careful when you talk about things like that. So it’s never a conversation or it’s never something that I would bring up with them. (Joanne J, 2:6,8).

I guess basic reasons anyone would say, you know, health, weight, diet, teeth, behaviour, all those things that I think food can contribute to. You know, not that I’m saying weight’s an issue of course. ...I don’t see weight as an issue, but it’s something that you obviously, you know you want to be conscious of, you don’t want to over feed your kids and make them overweight. (Jasmyn, 2:4,6)

Addendum 4.1 7

Box 7 – Future concern about child weight (continued)

...and we want him to be a healthy weight, and a healthy, sort of, active kid and not too sort of up on, you know, sugar highs and sugar lows and those sorts of things. [concern about his weight?] None at all, no, that’s fine... Oh I just don’t want to have a fat kid, you know like, I think, I mean mostly I’d like him to be fit and active, but I think also, you know, you see a lot of kids who aren’t fit and active and do have bad looking diets... So he’s stocky, like he’s a broad, stocky kid but he’s not, there’s no fat on him at all. (Pip, 2:2,6,8)

The health consequences, I guess that they’re, the high sugar, I think, you know, given the weight consequence to kids, and not that he, fortunately he’s very active, so it doesn’t have, show any previous disposition to that. (Narina, 2:2) She hasn’t got a weight issue, and she’s very active anyway. But it is a conscious thought that, I mean we don’t really need sugar in our diet. (Karren, 2:6)

c. Unprompted - future concern associated with own/relative weight or eating problems

Obesity and all those sort of things. We’ve got my husband’s got obesity on his side of the family, he’s not obese, he’s within his normal range, but he’s got two very obese sisters. So we’re, you know, I’m conscious of the genetics there. (Natalie, 2:11)

You know I could do with losing probably you know five kilos. You know like I don't ever want my kids to be obese or you know I don't want them ever to have to deal with that. (Victoria, 2:6)

So, yeah, my big thing is, everybody on my side of the family is very, very slender, and my husband’s side of the family not everybody is slender, and I really, really don’t, probably because she’s a girl more than a boy as well, that I don’t want anything to be in her genes to encourage her to end up in the larger department. Because I don’t think that’s the healthy way to go. (Lisa, 2:2).

I’m afraid if she has them she’ll have just way too much of it, and obviously some of them do taste good... not that I’m specifically concerned with her weight, but I don’t want her to have that as in issue as she gets older... if she’s eating reasonably healthy now, then hopefully she’ll stay that way and when she gets older, she won’t want all these things, and won’t have to worry about weight... I find with certain things if I have a little bit, then I have, you know, way too much. So if I have none I’m ok, but if I have. So I think she has in some ways sort of that same kind of, you know, I don’t know, it’s not a personality, but a certain thing... (Helen, 2.2,13)

Box 8 – “Don’t buy”: avoid “giving in” to child demands

...try not to have that stuff here, at home, so it’s not something that’s in the cupboard that he opens and constantly nags about, you know, that on those days when you’re just sick of saying no, that you give in, so if they’re not here, they’re not having it... (Narina, 3:2)

What we have in the house is up to us. So if it’s not there, then she can’t have it. (Margot, 6:8)

...sometimes dessert will be fruit, but sometimes it also depends on, like I said, a lot of time I don’t have stuff in the house. So if it’s not here then, it’s not here and she can’t have it... (Helen, 3:14,16)

so what’s in the house is what they get to eat... get a packet of biscuits or whatever for the week that’s it I’ll you know I’ll say well that’s your lot for the week. (Joanne, 3:8,10)

...we don’t have regularly in the house. So things like lollies and chocolates, and yeah, anything like that. We try to keep that to a minimum... trying to give him some balance, where maybe he is able to have some of those things... outside of the home, but we try to keep what’s inside of the home as healthy as possible. (Tara, 1.2,24)

Box 9 – Supermarket a. Avoiding the supermarket aisles that stock restricted foods

I don’t take Michaela down that aisle or the soft drinks. Because you’re going to look down that aisle, bang, they’re going to ask you “Oh Mum, can I have this one?”... and they put you on the spot and you think “Oh well, I did take her down the aisle, I did bring you to the shop. You know”. You feel bad to say “No, you can’t have it”. So if you want to limit it, just don’t take them near it. (Kerryn, 5:2)

I pretty much walk quickly past the things that I know attract his attention... I don’t need to go down the soft drink and chips aisle. If we did that might cause a problem (Pip, 3.4,68)

...she does badger me about buying junk food at the shops. I tend to avoid the aisle that has that food in it when I have them with me... (Victoria, 3:112)

Addendum 4.1 8

Box 9 – Supermarket (continued) b. Say “no” to requests but “give in”

...she may be like other kids and pester, you know, “I want a lollipop” or, “Can we buy potato chips” or something. But as soon as you say no, she moves onto something else... I’m very lucky that she’s not a food pesterer... my word is law, so once I’ve said no, that’s the end of it. I mean, she can keep asking if she wants... my husband and I are very, we’re very firm... if we’re going to back down, we need to both agree on it. (Lisa, 3:5,11)

They’ll ask, you know, “Can we get a packet of biscuits?” or “Can we” you know. Whatever, this that and the other stuff. The majority of the time the answer will be no. If it’s not something we’ve come for, generally the answer is no. But that’s not to say that there aren’t time when I say “Ok, well yeah it’s been a while since we’ve had a packet of biscuits in the house, so yeah let’s go and we’ll choose one together”. (Carolyn, 3:52)

...they’ll say can we have a Kinder Surprise or something like that. And I’ll say no we’re not going to get one of them today...on occasions like if I think or if I, I mean I don't really have to have a reason to buy them a treat. (Tegan, 3:12).

c. Avoid taking to the supermarket

...if I have them with me, and we’re walking down the aisles, they will convince me to buy certain things sometimes. So I’ve been convinced to buy, you know, little squeezy yoghurts, and I’ve been convinced to buy Tiny Teddies, you know. I can be swayed sometimes. If I’ve got two little boys, you know, batting their eyelashes at me, and begging me for things, sometimes I say, “Oooh ok, ok we’ll get it as a treat” But I’m much better about not bringing it to the house when I’m shopp ing by myself. (Tara, 3:42)

...with the biscuit aisle and he’ll just be wanting to put the cream you know cream biscuits in and you’re fighting with him to put them back out again. And the Shapes and he wants you know…so he’ll just be putting lots of those sorts of things in. So it’s that much harder to shop and I guess yeah they just eat what you get at the end of the day, in the house. So if you avoid taking them it makes it a bit easier. (Joanne, 3:118)

...I shop online... so I don't kind of have that issue with them you know begging for something. (Tegan, 3:12)

Box 10 – Flexible judgement: balance gauged over day or week

So if he does have a little bit more while we’re out he won't have as much while we’re at home or you know bit of a balancing game I suppose... So I kind of work out how much he’s had before during the day... I have to sort of weigh up that he’s eaten something else or he’s been maybe at my mum’s house and my mum has given him something for afternoon tea or you know whatever it might be. (Veronika, 3:148 & 7:14)

...constantly say “You’ve got to eat your healthy stuff first” (Jasmyn, 3:2)

...trying to give him some balance, where maybe he is able to have some of those things... outside of the home, but we try to keep what’s inside of the home as healthy as possible. (Tara, 1.24)

“Well actually we’ve already had a treat today, because Charlie brought his chocolate biscuits over to share, so we don’t need dessert... “If they’ve been to a party, and they don’t need their party bag that day” or if they’ve had morning tea at church, we don’t have to have dessert that night... (Pip, 3:20,28)

...I try to keep it in the early part of the day, and you know they often wake up and say “Can I have that little Mars bar from my party bag?” Like “No, not until you’ve had breakfast, at least” I try and string them out until morning tea. Yeah, so on a weekend I think morning tea’s a good time, and then they can run it off in the park, or go for a bike ride or something, and then get that out of their system. (Pip, 3:32)

“You’re going to have some naughty food tonight, so this morning we’re going to eat healthy... (Heidi, 3:36)

[Going to a Party later] So a lot of times we’ll feed him first, and then when we’re out we’ll say, “Well mate, if you have a piece of bread, then you can have, like, your chips or your, you know, your popper later”... See if he can be full, it’s, then you don’t have to stress too much about getting him to eat properly and having an argument, and then secondly, he’s probably not going to eat as much rubbish, because he’s got a bit of a full tummy. That’s how we sort of justify it I suppose for ourselves. (Heidi, 3:36)

... it depends you know if you, well if he’s had anything that day that’s not good food or …and even you know the previous day... I would allow lemonade. But I wouldn’t have it in my home for him to have it all the time. But if we were out at a party then he could have it (Melissa, 3:12,36)

Addendum 4.1 9

Box 10 – Flexible judgement: balance gauged over day or week (continued)

I won’t fill her up on the treat before a meal time. But I won’t say no either... if she was sitting at the dinner table with her lunch in front of her, and she wanted to try a mouthful of her chocolate, I’ll let her try it, but I won’t let her have the whole thing... I’d rather her put good food in her tummy, and then use that as a finishing really, than just filling up on it. (Karren, 3:26)

...If it’s a day where yeah, we have had pizza and stuff like that, then no, they won’t ever have a lolly or stuff like that, because they’ve already had something that’s not so good... if they eat well during the day then they can have a, you know like a lolly, like a gum or something, you know... it’s usually after dinner. (Melanie, 3:12 & 8:2)

...if we’re out at a party... She can have food or whatever, and then I won’t necessarily give her a whole bunch of crappy stuff before we go... we won’t come home and then have more junk. (Helen, 3:34,82)

...maybe twice a week, or once on a weekend of whatever, once after school, we might say, if they say “Mum, can I have a treat?” it’s like “Yes, you can have something out of the special treat box”... if they asked for it again the next day it would be “No, you had something yesterday”. (Carolyn, 3:14)

...if they’ve only had a small handful [chips] I might give them a bit more... it kind of depends on the day and what else they’ve eaten. (Tegan, 3:28)

I think well he has had a couple of packets full of crap you know even if there is a nutritional value its always got preservative in it so I will make sure the rest of the day is a lot of whole foods. (Kylie, C:5)

Box 11 – “Rules” or Routines

...we do have a rule on like fast food. Yeah I mean McDonalds is sort of his favourite so we, that’s really the only one we have so yeah that’s once a month. (Melissa, 3:2)

In the case of Easter, she can go for her life, for the first twenty four hours. I don’t care if she eats it all day. She can have it for breakfast, lunch and dinner. But the next day it goes away and she can only have it for sweets (Karren, 3:24)

If we do go out and say there’s chips as part of a meal... the rule is he has to eat his meat and the vegetable or the salad, and then he can eat the chips. (Natalie, 3:88)

.. after dinner he might be allowed to have a few. (Claire, 3:16)

So he knows, so Monday night he does get ice cream, but that’s the standard routine. (Heidi, 3:94)

...if she has a hot chocolate, she’ll have it, it’s usually her and her dad’s treat. So that’s usually like Tuesday nights. But she knows that, that’s when it is (Helen, 3:4)

...I do want them to be responsible for taking and not taking the lollies. And they always ask and Liam is probably the best one at it. But always asks and if I say no that means no. so they don't go in there and take any. If I say yes then that’s fine they know they can take one or two or however many I’ve said. (Veronika, 3:8)

The rule is he has to eat his lunch, that’s the main thing otherwise he gets no sweets in his lunch box... (Veronika, 3:130)

.. if he doesn’t finish his tea then he doesn’t get anything else... (Tegan, 8:12)

...she knows she won’t get dessert unless you eat the dinner... it’s you know, the rules, like. (Jasmyn, 8:2 & 13)

The only sort of regimented time that they know that the can choose something out of the box and put in their bag is for after Jiu Jitsu.’ (Carolyn, 3:14)

...our nanny on a Friday, they have an ice cream with her, and that’s it for treats on a Friday. So where other children will have, like, a muffin or a jelly cup or something at school on a Friday for tuck shop, Miles has sushi and popcorn, and then he has his ice cream. So it’s a big treat day on Friday, but he doesn’t have anything too treat like, because I know the ice cream’s coming, and so does he. (Pip, 3:32)

So he knows, so Monday night he does get ice cream, but that’s the standard routine. (Heidi, 3:94)

Addendum 4.1 10

Box 12 - Avoiding Access: “out of sight”

...chocolate and lollies and things we do keep them up higher. So that’s out of reach and also out of sight. (Melissa, 3:2)

...I do have them in the house, things like the chocolate eggs, they stay up in the top of the cupboard and they don’t see the light of day... (Karren, 3:13)

People will from time to time give him lollies and I tend to put them in a box and put them out of sight and then he can have them occasionally. I find if he can’t see them he doesn’t really ask for them... he might ask for them for a few days and then he just seems to forget about it. (Claire, 3:2,14)

[party lolly bags] So you kind of just put it away in a place where it’s not visible and then they just forget about it. (Victoria 3:58)

...we’d get the lolly bags home and put them up in that cupboard... they forget about them... I do go through the cupboard and just chuck a whole lot of it out. (Tegan, 3:20)

[Halloween trick or treating]... I basically throw half of it away before they have a chance to even look at it... I might leave some of the nicer chocolates or something for them... (Tara, 3:4)

Box 13 - Avoiding Access: offer alternative “healthy” food

...and if you’re still hungry we can have an apple. Or drink your milk or something like that instead”.

(Pip, 3:20,28)

...you had a muffin yesterday, mate. We’ll just have a piece of fruit today” (Heidi,5:3)

...he asks me again sort of like just after he’s had the biscuit ‘can I have two more biscuits?’ and I’ll say no you’ve just had two biscuits, how about you have a banana or a yoghurt or something like that normally. (Joanne, 3:10,33)

If I don't want them to have any more I’ll just offer them another alternative. Like I’ll say oh no there’s no more chips but why don't you have an apple... (Tegan, 3:28)

...if I’ve made cupcakes I’m not going to let him sit down with three cupcakes for afternoon tea. He can have one and it needs to be accompanied by cheese and crackers, and fruit. (Kate, 3:78)

...if I know they love something, so like the ice cream, or like you know, cakes or muffins or things, I can play around with healthier versions of things at home, and try to make a better option for them. (Tara, 3:2)

Box 14 – Social Inclusion

I just don’t want to be the mum yelling at my child ... and that’s about my relationship with him ...just enjoy the day I suppose. Otherwise I think the day gets a bit ruined. (Tara, 5:7)

I don’t want them to miss out on the fun. I mean, occasional food’s called occasional food for a reason... the reality is, is that you know, you want to allow them to participate in what everyone else is doing I guess. (Karren, 3:38 & 4.6)

...where there’s twenty kids running around, you know hoeing into stuff, and it’s very hard to go, “Oh no, my child won’t have that”... I’ve even had his little friends come up to me and say, “Is it true Vin can’t have soft drink until he’s ten”, I say “Yeah”... I say “Am I a mean mummy?”, and they’re like “Yeah”... (Heidi, 3:30 & 5:3)

...a big part of his age group, his peers and you know I just let him go along with what the others are doing at parties. (Claire, 3:82)

...he turned to me and said oh, you know, Kristin is having coke, can I have coke?... And I think I let him have lemonade, so guessing it was that little bit of added peer pressure, because normally I would have just said an apple juice... (Narina, 3:46)

...I’m not going to stand there and say, “She can’t have this, she can’t have that”... (Helen, 3:96)

...he can see everybody is having it. You know and I certainly don't want to be a nasty parent so I’ve got to kind of balance that saying yes or say no. (Veronika, 3:148)

I generally just let him have what he wants. Because ... I don't want it to be a huge issue... (Tegan, 3:44)

...we’ve just had to give in to the parties, and just deal with it... (Natalie, 3:203)

...she doesn’t want to feel out of it... I just make sure she doesn’t have too much. But yeah, I don’t like to be the nasty mother either, that’s hovering over and you know... (Rebekah, C12,16)

...they’re not going to choose water if all your friends have got Coke or something... you don’t want to make a miserable life just because you know we don’t drink it any other day... we did like earlier but not now... I don’t see the point of fighting (Kerryn, 3:56,58).

It’s not really fun for them if you’re nagging them anyway. So I don’t bother, and then it’s not a stress. (Margot, 3:90)

...we have had to be a bit more lenient I suppose in that sort of situation like if he has a friend over or something you know so he doesn’t look like the kid that only eats grapes and apples you have to throw a few more sort of treats in there... (Kylie, 4:2)

Addendum 4.1 11

Box 15 – Bribe to eat school lunch

it’s been a battle just to get her to try and eat at school at all... you start giving them things that you know they will eat... “I’d rather you eat that, than not eat at all, or throw it away”. (Jasmyn, 4:4,8)

I’ve never bribed with food, but I bribe with tuckshop on Friday... if you eat well Monday to Thursday. (Narina, 3:86)

So he has to have his sandwich and the fruit and if he hasn’t eaten those then he doesn’t get the lollies and the Freddo Frog the next day... fifty cents every day that he’s eaten everything... get himself an ice block... a handful of lollies... whatever he wants is fine, he’s done well he’s ate his lunch. (Veronika, 3:130,142)

I’ve given in a little bit with him because once a week he has tuck shop if he has a great week at school. (Tara, 3:25)

Box 16 – Restricted item in the school lunch box

In her snack box at school, we do have a dried fruit strap... Occasionally she might get a little jam sandwich as a treat. Something different from the ham and salad... I don’t pack cakes or biscuits, otherwise it’s expected, you know. I treat her once and it’s like “Mum”, it’s for the next three weeks she’ll be asking for it again, so I’ve learnt not to do that... Or sultanas, just a little handful to after, sort of in with her lunch box. So once she opens it up at lunch time, she’ll have it after her lunch, as a little sweet treat. (Karren, 2:10 & 3:58)

...he has a popper in his lunch box... that’s his big treat for big school. That’s lucky... He loves his popper, and I’m sure that gets drunk very early in the day. (Heidi, 1:12,14 & 3:86)

...very occasionally, like yesterday just as a treat he was allowed to, I gave him two dollars fifty and he went and got a frozen nudie juice, and that’s an absolute treat for him (Carolyn, 3:62)

...I do buy the mini packets of tiny teddies, and I halve each packet. So that she’ll, say, have one packet of tiny teddies, and it will go over the two days. But she’ll only have two of them for the week... (Lisa, 3:133,143)

...he has the sandwiches and the fruit and I’ll put some biscuits in there like Tiny Teddys. (Joanne, 3:129)

And he will have maybe a couple of lollies or I might put in there a small you know freddo frog chocolate or something small just enough for him... (Veronika, 3:130)

Lunch he’ll just have either a ham and cheese sandwich or a wrap. And then usually something like… some biscuits. So sometimes savoury say just like Salada biscuits or Jatz biscuits and sometimes sweet like teddy biscuits. And maybe a fruit bar like an apple bar. (Melissa, 3:53)

...we’ll pack her, her two fruits, and like a sandwich, and then she’ll either get something like, they’re like oat biscuits, or a you know like shapes? Shapes... Yeah, so she’ll get one or the other, and that’s what she gets as her extra. (Melanie, 3:128,130)

So you can have like a homemade, like a fruit scone or a homemade muesli slice or something like that. It’s kind of like a sweet you can sort of get away with... (Tegan, 3:10)

Fruit Juice I would prefer we weren’t having that everyday, although I have ended up putting a popper in his lunch box because that seems to be a compromise to him getting some form of fruit outside of the house, but you know, I’m obviously trying to buy the fruit juice rather than the fruit drink... (Kate, 3:76)

Box 17 – School Canteen/tuckshop money

She was spending half of her recess time lining up at the canteen... she was getting an ice block at recess time, which I thought was once a week, and she was doing a couple of times a week. (Karren, 3:56)

...she just wants to buy what the other kids have ...she’s being punished at the moment because she was supposed to buy something healthy, or one thing, and she went and she spent a heap of her money on just junk. (Melanie, 4:22,28)

I think her dream would be if we gave her pocket money to buy stuff from the canteen... I wouldn’t trust giving her money to buy, to spend at the canteen. Because if I did, I would suspect that she would buy lollies (Margot, 6.8)

...you see all the kids competing about wanting canteen money, and you know, I’ve found, like kindy was so much easier in that they very much had this healthy eating policy. (Jasmyn, 4:4)

I gave him two dollars fifty and he went and got a frozen nudie juice, and that’s an absolute treat for him... I said “Ok, that’s two dollars fifty. Do you want me to put it in a bag, and order if for you? Or do you just want to go up the tuck shop and get it?” and he said “Well don’t put it in the bag, I’ll just go up to the tuck shop, and then if I change my mind, I might get something else”... “Well hang on, no, no, no, that’s not how it works” You know “I’m giving you two dollars fifty for a frozen nudie juice... he’s seeing what his friends are doing, and that’s starting to influence what he wants to do. So I’m not sure how I’m going to manage with that moving forward. (Carolyn, 3:62)

Addendum 4.1 12

Box 18 – Grandparents and relatives

a. Conflict

...we didn’t want him going to McDonalds. So we had to sort of re-educate her... while you’re his grandma, and you can spoil him, you can only spoil him in certain ways. [allow sweet foods] (Natalie, 3:100)

...they tried to give him soft drink one day, and Brad hit the roof. (Heidi, 3:68)

...my parents will get offended if I suggest they’re giving him things that perhaps aren’t good for him... my Dad gets a bit huffy...they sort of take the view that they’ve got the right to spoil the child if they want... (Claire, 3.146,150)

...there’s a bit of social family pressure [partner’s family]... “oh gosh, you know a bit of soft drinks not going to hurt him, it hasn’t hurt us.” So I probably have relented a bit and on those occasions let him have soft drink, when it’s not something I really ever thought he needed to have or wanted him to have. (Narina, 3:54)

I just find it annoying that every place she goes to, or whenever she sees those aunties and uncles, they’ve always got a, you know they always seem to like to give her chocolate and rubbish. But you know they, I’ve told them and it doesn’t make any difference. (Rebekah, 3:74)

The only thing I might struggle with is, my mum likes to treat the children. So if we go to Nanna’s house I might have to put my foot down and try and implement the rules we might have in our own house... I don’t mind them having a lolly there, so you know that’s not very different, but yeah, I definitely, soft drinks are for parties. So if it’s not a party at nannas, if it just a visit then I definitely do say something about that. (Kate, 3:34,36)

b. Tradition

...and I thought “Well that’s fine, you know, grandparents are grandparents” and they like to spoil their grandchildren. (Margot, 3:84)

“You’re at Nanny and Grandpa’s now. So you can do what you want”... (Jasmyn, 3:30)

Grandma’s time is Grandma’s time. So I’ve, I don’t have any rules as far as their eating goes, other than you know, the soft drink intake, and she knows I’m very strict about that... Grandma does spoil her... She does the typical Grandma stuff. They do cooking, and make chocolate treats... (Karren, 3.54)

Box 19 – Good intentions are hard to achieve

I just want to give him... the best start that it can have and if it means a few less preservatives in his system whether it makes a difference or not I don’t know, but it makes me feel better you know makes me sleep better at night to know that I tried. (Kylie, C5)

...and then at the end of the day you can hope that you know, what you’ve done has been the right thing... it’s so difficult that you know, you want them to be the best children that – best people that they can be and not only in relation to food. (Joanne J, 5:4)

[school lunches] ...the fatigue sets in, we might get a bit slacker. But yeah I think we’re going okay, I think there’s only been one week there where I was a bit disappointed in my efforts. (Kate, 3:66)

...I know it’s terrible... I know it’s one of my super lazy days, that’s the problem. It’s like when we’re time stressed and like we just, we need to eat something, and then we’ll go [to McDonalds].

So you know maybe once a month. (Melanie, 3:142, 156)

I blame myself for not being, you know, better at dinner time. So then I feel guilty and maybe I do fold because I feel sorry for them because they are hungry, because I should have done a better job Anyway, oh my god. Being a mother is so stressful... you put so much guilt on yourself. (Penny, 3:79,81)

Addendum 4.1 13

Box 20 – Social norms: “like all kids”

...she loves sugar like all kids love sugar. (Victoria, 3:8)

He definitely has a sweet tooth, he likes all those things, as probably most kids do. (Kate, 3:14)

So we don’t like her having it, and yeah she knows. But, in the end you know, she’s a kid and she

likes to have them when she gets the opportunity. (Rebekah, 3:10)

like all children they always ask, you know “Mummy can I have a sweet?”. (Karren, 2:8)

[at supermarket] ...she’s like every other kid, she still asks for stuff (Lisa, 3:151)

I mean they’re normal kids, if they’re hungry, when they get home from school, I’ll say get some yoghurt, or the nutritional stuff. They don’t want that, they want biscuits... We’re all the same, but

you know, I give them like two biscuits and they can sit there and watch telly whilst I do dinner type thing. But yeah so I don’t want them to get used to biscuits and chocolate, and all that type of thing. I mean we all do it. (Penny, 2:18)

But I don’t think there’s be many parents out there that are that perfect with their kids to say, “You

will only have great food in the house” I don’t know, how. If they could get away with that. (Penny, 5:8).

...if I sat there and looked at Kayla with a friend, that gets a lot of lollies, and a lot of bakery, and a lot of this. So I’m thinking, well there’s, you know there’s not many questions on my kid to say that your kid’s got the wrong amount of stuff, so. Yeah. (Kerryn, C2).

Box 21 – “Rules” and routine experiences a. “Rules” and routines

...it’ll take me a week just to get over it, and then she’d see him [ex.partner] again. So it was like this constant battle. Whereas now she just knows the routine... Like, she knows if she doesn’t eat her lunch or her dinner, that she won’t get a treat, and she knows she drinks water, and that treats are sometimes, and she’s just in that routine now... I am finding it’s getting easier (Jasmyn, 3:56,58)

He’s adopted that himself, and I can see him doing that when he hasn’t, when I’m not directly physically saying “That one, now have that one, that one now, that one”. He’s actually going and getting a tissue, you know, a serviette, and he’s putting one savoury on it, and one sweet thing, and going down and sitting out with the other kids and eating it. So he’s actually regulating it himself now (Pip, 3:8)

I think if they already know things like just one per person, so you’re only going to have one piece of cake, or you’re only going to take one piece of whatever, or a couple of lollies things like that. I think if they’re aware of the rule already, even by a young age they can usually self-monitor. (Erin, 5:21)

...he wouldn’t ask for one of the muesli bars unless we were camping, unless we were in the car going camping. Yeah, so he knows, yeah, that that’s what they’re for. (Natalie, 3:43)

The only sort of regimented time that they know that the can choose something out of the box and put in their bag is for after Jiu Jitsu. (Carolyn, 3:22)

b. “Habits” or “expectations”

So you know, if you pull up at a petrol station, you know, once or twice you can get something special. So, but now if we pull up at a petrol station she knows being, “I know that there’s lollies, and I know Mum can get them”, and it’s yeah, she knows that we usually do get them. So if we pull up at petrol stations, it’s been “Mum, can I have some lollies? Can I have this?” and its. Whereas before she’d just sit there and wouldn’t worry about it. It would be like “Oh wow!” (Kerryn, 4:10,12)

...think maybe when he’s out with his dad, one day, he had you know, a little kids burger and chip... that now, that’s a bit of an expectation... (Claire, 4:6)

...my husband, bless him, he’s grown up with having dessert after dinner... So when he’s at home which is probably about two thirds of the time he’s home for dinner, the kids will have a little bit of ice cream or an ice block. [On the nights he is not there] If they ask for it and if they push for it I might. Because I think it’s now become a bit of a habit that’s hard to break. (Veronika, 3:50)

I’ll always offer fruit first. Even though I know he expects a cake or a biscuit or something at morning tea I will offer a piece of fruit first so yeah I guess I try and encourage those... We’ll usually we compromise and I’ll say something like, if you could just eat your way around the apple once then you can have the cupcake. It doesn’t always work and I’m not going to fight him on it. But I’ll at least try (Kate, 7:2,4).

Addendum 4.1 14

Box 22 – Child behaviour associated with “giving in” or giving inconsistently

But Lily she’ll try it on and she’ll try and ask me and she’ll badger me you know and occasionally I

give in like okay yeah... It’s not an every time we go shopping. So and that’s yeah once again otherwise it’s not a special treat anymore if every time we go to the supermarket you get an ice block or a chocolate bar then it’s no longer a special thing you know. (Victoria, 3:114)

So my motto is always going the less the better and I always start giving them a little bit and usually that’s enough... as kids do they can come to me and ask for more... I pretty much say no and then later on I might decide that yeah okay they can have some. Look if they don't ask for sweets I usually don't give it to them... (Veronika, 3:36-44)

...by the time I’ve said “That’s enough” she’s probably had enough... She might whinge and complain a bit. She’s like “But I want more soft drink”... and sometimes I might give in. “Ok well last one... (Jasmyn, 3:28).

I know that he’s going to come back and ask for more. So I usually put less in the first instance and then maybe you know give him you know another one or two more afterwards... But he does try and push that limit as well I guess... Yeah I mean I guess he pushes my boundaries, basically my boundary and it depends on my mood and my patience sometimes whether I give in... (Melissa, 3:14,16)

...when we go to the mall, although she will ask for Boost, she likes Boost when we go to the mall... she will usually ask for it when we walk by, like we walk past it, and sometimes I’ll say yes, and sometimes I won’t... You know, she might grizzle a little bit. But she’ll probably grizzle a little bit more than anything I guess. (Helen, 3:137-140)

...like all children they always ask, you know “Mummy can I have a sweet?”. But I call them surprises, otherwise they’re called expectation... I treat her once and it’s like “Mum”, it’s for the next three weeks she’ll be asking for it again, so I’ve learnt not to do that... (Karren, 2:8 & 3:58)

Box 23 – Mother’s contrasting descriptions of restricted and unrestricted foods

We talk about how you know this is a good food because it’s going to give you the right energy and all the right nutrition and nutrients that your body needs to be healthy. And that yeah really high sugary foods, whilst they’re really yummy actually really do no good for your body. So that’s sort of how I tend to put things. (Victoria, 3:6)

...understanding what’s good and what does our body need, and the other stuff is not good and we don’t need it but acknowledging that it’s nice to have occasionally... talk to him about what food is for your body... why you need to eat the good stuff... the yummy stuff [chips, lollies, chocolate] was not so good. (Narina, 3:4)

“They’re things we just have sometimes because they taste nice. But they don’t give your body, you know, the energy and what we need to be healthy” (Tara, 3:25)

...he just knows that they’re treat foods and you don’t have them all the time, they’re something special... and how important it is not to fill up on those because then you don’t have room for your fruit and your veg, and that’s what makes you grow big and strong. (Kate, 3:2,14)

Box 24 – Mothers descriptions of “treat” foods.

So they’re special treats and you can have a little bit ... and it’s not, you know, very healthy... That would be sort of the lollies, and the chocolate, sometimes you know those really chocolaty biscuits, like Tim Tams and things like that. (Margot, 3:4 & 8:8)

...if he does have something with too much sugar in it or a chocolate or something, then it’s usually seen as a treat... (Natalie, 3:7)

...special treats... any sort of ice cream or anything that’s got chocolate in it. Yeah pretty much high sugar content. (Victoria, 3:10,14)

...so it fits into that high sugar, high processed food I guess. (Narina, 8:16)

As a surprise, she likes the kinder surprises. I don’t mind those so much because there’s hardly any chocolate and it’s all about the treat in the middle... twenty cent ice cream from McDonalds. What else? In her snack box at school, we do have a dried fruit strap... For her night time sweets it’s usually ice cream with a little bit of topping and it might be six smarties. You know those M’n’M chocolate… (Karren, 2:10,12).

Probably like your cakes and bickies would be a treat if we had them, and maybe a chocolate. We don’t have lollies, generally, in the house at all. Even as a treat... So yeah, definitely chocolate milk, definitely cakes, bickies... (Heidi, 3:90)

...when I’ve got you know my sister comes by or something. They’ll get them Kinder surprise. So that’s kind of would be probably a bit of a treat for them... I will stop at McDonalds for example as a treat for them... (Veronika, 3:152 & 8:10)

...I make kale chips at home. All of that, I don’t consider treats. Like that I consider, you know, good, healthy food... chips outside of the home, I would consider that a treat. (Tara, 3:54)

Addendum 4.1 15

Box 24 – Mothers descriptions of “treat” foods (continued).

You know they’ll be just little occasions where I might be “Alright, you know, have a treat” or sometimes when you’re out, and you know, I might get them, you know a little ice cream or treat here and there. So it’s just, yeah, just not too much, like, and even McDonalds, I often, you know they like to go to McDonalds for a play, and then get a happy meal and stuff, which I’m fine with, like as long as it’s not too often. (Jasmyn, 3:16)

Box 25 – Avoiding negative role modelling

My secret habit? Oh you know I might have something at work or something after dinner. I do feel guilty but I don’t give the kids chocolates all the time. Or, it's not a normal part of their day to have a chocolate after dinner or whatever like that. Even though I probably eat a bit too much of it myself. I don’t want them to be the same... Yeah that’s right and I don’t have enough self control of myself to say no you don’t need that. But I expect the kids not to have it. (Mhari, 2:10,14)

I’m terrible, don’t ask me, I sneak them at work. (Heidi, 3:38)

I think every mother I know will sneak in the Tim Tams or the chocolates after they’ve gone to bed. Or you know, when their kids aren’t looking. So it’s as much of a reflection, I think, of your own eating habits, as to what the children are exposed to. (Margot, C:2)

...usually when I guess I have a treat it’s usually after he’s gone to bed. (Melissa, 3:22)

...if a friend comes over they usually might bring a little treat from the cake shop... we try and gobble it all up before they get home from school (Natalie, 3:45)

after they’ve gone to bed my husband and I will sometimes have a bowl of ice cream or a couple of cookies (Victoria, 3:28)

I’ll eat chocolate when he’s not looking... I will occasionally buy it and hide it, it’s terrible and I’ll stand behind the fridge. (Claire, 3:116,118)

I have a craving for chocolate and then I hide it for myself, and don’t let her see it. But yeah, generally yeah. I would never buy them anyway, but yeah and if we did have them on the odd occasion we wouldn’t allow the kids to have them because I’m trying to encourage them not to have them. (Rebekah, C4 & 3:18)

...so like a chocolate bar like a Kit Kat or something is for me for my break, not for them... when they’re asleep or when they don’t see me eating it. There’s a secret place... They can’t find it and they don’t even know it exists. (Racy, 3:2,16).

...unless you go into the bathroom, have a chow down on a couple of biscuits and come back out and not tell the kids. I don’t know if you’d get away with that because my two kids, they can come around and they go, “Have you had chocolate?” and I say “No, no I haven’t had chocolate” and they go “Yes you have” and then that then, I can see my, their mind working, going “Where has she just come from? She’s come from the bathroom.” I’m giving away my tips aren’t I? And he’s run there and found the show bag that I hid in the bathroom, and then it was all over red rover. (Penny, 5:10)

I have a craving for chocolate and then I hide it for myself, and don’t let her see it. But yeah, generally yeah. I would never buy them anyway, but yeah and if we did have them on the odd occasion we wouldn’t allow the kids to have them because I’m trying to encourage them not to have them. (Rebekah, 3:18)

I’ve got such a false idea in my own head that, you know, if I’ve been busy at work all day I deserve a chocolate. I’m like “No you don’t. That’s ridiculous”. So I’m trying not to instil that in the kids as well. (Pip, 8:14)

Box 26 – “No concept”: child unaware of restricted items when younger

...the little treats that they have now, or that they’re aware of now... when they were at that age... they didn’t really notice... It wasn’t offered to them at all. (Carolyn, 4:10)

...when he was younger he would have just had what he was given... he wouldn’t have necessarily asked for things. Or been able to help himself to things whereas now he can obviously help himself (Melissa, p5)

...when he was a toddler he didn’t ask for food I mean it was given to him. Whereas now he’ll ask for it (Tegan, 4:2)

But I think a lot of it we justify by saying he doesn’t know. Like, he doesn’t know ice cream from yoghurt, so why give him ice cream?... He doesn’t know that soft drink’s this fabulous drink, so why give it to him... (Heidi, 4:2)

...when she was really little, I just didn’t give it to her, and she didn’t kind of know, because she was really little. (Helen, 5:4)

I guess when he was one he didn’t know anything other than what I’ve told him. And now that he’s more aware, he’s got his own little brain you know that works differently from mine sometimes. He does he is different and I have to adjust to that to a certain degree as well. (Veronika, 4:2)

...when she was younger it was easier to be stricter, like she didn’t have any chocolate until she was like 3 or something... she didn’t know about it so you didn’t give her any. (Mhari, 4:2)

Addendum 4.1 16

Box 26 – “No concept”: child unaware of restricted items when younger (continued)

...we didn’t have to do very much when she was a baby because she would, she was never around the food anyway. So she was pretty good, we didn’t have really any, you know, conversations. She actually didn’t have sweets and stuff until probably until she was two or three (Melanie, 4:4)

Box 27 – Reduction in restriction influenced by child maturity and expanding social world

We used to be worse when he was little, but yeah, now we’re probably a little bit more relaxed... he’s running in a bigger group, and more aware... so probably about the three and a half, four, I think we sort of went, “Oh we’ve got to let go, like just relax”, like if he’s running with a bunch of kids, and they have a little packet of chips each, is it so bad? (Heidi, 3:30 & 4:6)

a two year old, he wouldn’t have necessarily asked for things. Or been able to help himself to things whereas now he can obviously help himself to things so we sort of put boundaries there... as he’s gotten older he’s sort of… been able to eat more treats... I wouldn’t have allowed any you know chocolate or lollies hardly at all. Whereas I guess now I am a bit more relaxed on it... also at school I mean you know they have when it’s someone’s birthday they’ll have cake or lollies... (Melissa, 4:4,6)

...she has more stuff than she used to, you know. But that’s just getting older... her circumstances have changed... it’s probably broadened... she goes out more, and does more things that I’m not necessarily there for all of the time. Like school... (Helen, 4:2)

I started out with this “My child’s not going to eat sugar and she’s going to look eighteen until she’s sixty four”... It’s the reality... you want to allow them to participate in what everyone else is doing I guess. (Karren, 4.6)

...I’d say she probably does have more sweets now than she did as a toddler, just because at this age they are at that party stage and birthdays and this and that going on and at school... that’s just part of life isn’t it? (Joanne J, 4:4,6)

...as young babies, as young children, you have such a single minded focus on giving your child the healthiest food possible... Until they’re you know, two or three, and all of a sudden it becomes very easy to buy some packaged things, and you go to other people’s houses, and things slip into their diet, that previously you would never have let them touch (Tara, 1:24)

Once they get to school it’s different, and you know, they start watching more TV and they’ve got the ads on and everything. But for a long time, all McDonalds was to my daughter was this big M, and the playground out the front. (Margot, C:2).

...if he goes to someone’s house for a sleepover obviously I can’t control what’s happening there but I don't stress about it. (Tegan, 4:2)

...what’s worked in the past is changing a little bit now because he’s becoming older and a bit more confident, and you know he’s seeing what his friends are doing, and that’s starting to influence what he wants to do. (Carolyn, 3:64)

...he had yeah no exposure to those, probably for as long as I could you know manage that before he was seeing it at parties... and being aware that other kids were having it. (Narina, 5:10)

...he’s just a bit more aware of his surroundings, a bit more aware of how people operate. How other people have lollies and sweets. (Veronika, 4:10,18)

It was her sister coming along, but also sort of releasing her into the wild, having her go to Kindergarten (Erin, 4:2,7)

Yeah he was probably less aware of some foods before he was going to kindy and school because we just hadn’t had them in our house before, and he’s probably come across them outside of the home. And yeah so there’s probably just a few sort of lunch box type snacks that he wouldn’t have been aware of that he is now. (Kate, 4:8)

we have had to be a bit more lenient I suppose in that sort of situation like if he has a friend over or something you know so he doesn’t look like the kid that only eats grapes and apples you have to throw a few more sort of treats... because I don’t want him to be the only kid that’s not eating it and that’s not fair so I have had to just sort of but I will again I’ll limit it where other kids are going back for their third cup cake I will only let him have one. (Kylie, 4:2,10)

But as she grows older and she’s got friends and they have those foods I've realised you know you can’t be so hard lined about it it’s just a normal part of life that people eat those foods. So she’s going to be exposed to those foods and eat those foods it’s not reasonable to say, she can’t have any of that. I guess I’ve become just more lenient... (Mhari, 4:2)

...it was just gradual... she’s gone to birthday parties and had these foods and I guess I’ve just thought oh well it’s not a big deal she can’t have the ideal diet, I mean I don’t have the idea diet either. And so I've just sort of realised it is kind of normal for kids to eat these kinds of foods and not really that much of a big deal as long as we’re not scoffing it down all the time I guess. (Mhari, 4:6).

Addendum 4.1 17

Box 28 – Stricter as older due to other family members dietary needs

Tara - own health issues leading to greater understanding of healthy foods

Went from like really strict, and then some things slipped in... and then I started to get strict again... I’ve been on my own little journey with trying to educate myself about health and food over the last few years... with some mystery illness that no one seemed to be able to figure out... trying to make sure that everything that I ate, and the family ate was as healthy as could be... So that’s kind of what… Really started it... That was about ten months ago... Right before I gave birth to my third son ...with me being even stricter with myself, it means it’s even stricter in the household. (Tara, 4:4, 1:19, 20,22,24,26,28, 3:69)

Narina – younger siblings food intolerances lead to greater strictness for family

...probably only I guess slightly accentuated by his younger brothers intolerance... my attitude to all processed foods, high sugar, high salt, high caffeine, that kind of thing, has not changed, I guess maybe I may have managed it a bit more strictly in the last two years. (Narina, 4.2)

Natalie - gestational diabetes with younger sibling led to family diet improvements

I had gestational diabetes with [younger sibling]... So I became a lot more aware of my diet... I’m probably a little bit more hyper vigilant with him... we are on the fruit drive at the moment... it’s more about what we’re trying to reduce him [study child] eating in terms of the sugar stuff... (Natalie, 6:14,16 & 7:4)

Box 29 – Introduced a restricted food - wanted it more

...if you start giving them sweets from when they’re babies, then they’re going to get a taste for it... when I was a new parent, like we were told ...when they’re four months old and they start on solids and then you start them on like carrots and, you know you’ve got to give it to them a few times before they get used to the taste. It’s, I guess it’s the same with sweets, like if they don’t get a taste for it, they won’t want it as often... I just worked it out on our kids... once they’ve had it once they want to keep having it... I think it was a Kinder Surprise with a toy to try and keep him occupied during a long bus ride... (Melissa, 5:2-6)

...once they’ve had it then they’ll just want it all the time... like fast food. Like he’s had McDonalds but he’s never had Hungry Jacks or KFC... I guess you know we gave in one day and he had McDonalds and now he always wants it. (Melissa, 4:6)

...not getting them used to it at a young age, because I think once you’ve got a taste for something that’s overly sugared, or overly salted... they might develop a preference for it. (Natalie, 5:2)

I don't mind him having some you know like the odd you know chips or biscuits and that. So I’m not going to completely limit it... They get hooked yeah I think…and then they keep nagging you know wanting them all the time. He really likes the biscuits so he’ll keep asking me... So I try to yeah limit that... (Joanne, 2:34,51,53)

I don’t pack cakes or biscuits, otherwise it’s expected, you know. I treat her once and it’s like “Mum”, it’s for the next three weeks she’ll be asking for it again, so I’ve learnt not to do that. (Karren, 3:56)

He had tried chocolate when he was young, and didn’t like it at all, and I think it was when he was three that he actually worked out that he likes chocolate. So there were things that like he didn’t have for many years, you know, and then he was introduced to it, and worked out that he liked it. (Tara, 4:6).

Box 30 – Comparative sibling exposure experiences a. Sibling earlier exposure experiences

...you probably picked the right child to be asking me about. She’s not really a problem for that sort of thing... she’s pretty good... You’re lucky you’re not asking me about the others... as there’s been more children, I’ve probably got a little bit more lenient with each one... what I let Emerson eat now at six, I also... let Lexy eat it at three... (Lisa, 3:25,27,119 & 4:2,4)

And I suppose with her little sister coming along, it’s made me be a bit more relaxed about how you approach things… when I had Darcy younger, you felt like you could control almost everything, and another one comes along and you realise that you’re really not in control at all... Scarlet will demand to eat the entire lolly bag while it’s there and Darcy tends to forget she has one after she’s had one lolly from it. (Erin, 4:2,7)

Addendum 4.1 18

Box 30 – Comparative sibling exposure experiences (continued)

a. Sibling earlier exposure experiences (continued)

...Compared to my daughter he’s actually very good... And it doesn’t mean that we’ve never broken a rule, we’ve broken rules. Don't get me wrong, when my third one was born and he was three months old you know I certainly didn’t have the energy to fight with the kids. So I probably relaxed the rules a little bit because I didn’t have as much energy to say no. Or I needed a little bit more quiet so they’ve got a little bit more of what they wanted... it’s more my daughter that would do that [scream through supermarket] because she’s a lot more stubborn... He’d have a bit of a sook really that’s it. (Veronika, 3:148, 5:2 & 6:4)

...he’ll go off and play for the majority of the party, and then come, you know, come back a couple of times here and there. He’s not too bad. I know this is, this interview is probably about him, but my second son, he’s the real worry, because he will sit at the food table the whole party, and not walk away... But at a party he won’t leave the food table. He just eats, and eats, and eats, and I say to other people, “You would honestly think I don’t feed my child. You would obviously, you would think that he never has a treat” which is, you know, he does occasionally of course. He just sits and devours everything. (Tara, 3:17,21) [Younger sibling 4 years old].

...my daughter’s almost four and I mean she I guess she’s… oh she’s probably worse than Hayden that she would just eat whatever’s in front of her. (Melissa, 7:22)

b. Sibling later exposure experiences

...So if Finn [NOURISH child] gets a piece of chocolate, Miles [younger sibling] will get a mandarin... he’s [younger sibling] quite happy with his fruit... he’s [Finn, NOURISH child] never been a big fruit eater... I’m assuming I mustn’t have encouraged it, because we encourage it a lot more with our younger son, and he just goes for it... if I had my time again and we’re doing it with our one and a half year old, because he’s not had any sweet biscuits, or... chocolate, he gets something else [fruit]... hold off on introducing those sort of things as long as possible... Well I had gestational diabetes with Miles [younger sibling] as well. So I became a lot more aware of my diet. (6:14) (Natalie, 3:26 & 6:7,9,14).

...my son’s a great eater, whereas Kenzie’s always been difficult. She’s always been a challenge with food, and I put it, a lot of it I put down to him [Ex. Partner]... he’d be taking her in the bedroom and giving her chocolate before dinner, and he ate and drank a lot of soft drink... So I’d be encouraging her to drink water, but he would have a can of lemonade there, and be like “Here you go, have some lemonade”. So it took me a long time after we broke up to get her... off lemonade and drinking water... whereas my son, it’s been all me, you know I find him so much easier... trying to get her out of it at three, four was so much harder than what it would have been if she was younger. (Jasmyn, 3:42,44 & 5:2)

...I’ve tended to not have Lily with me when I do my shopping. My younger one is easier to control and she would go, and she’s just got more of a savoury tooth anyway she’ll go for the cheerio before the lolly at the birthday party. And she’ll stand in front of the cheerio bowl and just eat all the cheerios... Lily just is more difficult about it... she does want more sugar and she’s got a bit of a sweet tooth... I have had to become more strict about it. So that’s been my reaction to it, to limit it even further rather than give in. (Victoria, 3:128,130 & 4:6).

Box 31 – Age dependent: “not offer” to “moderation”

...they don’t understand at this point, and it’s not until they start seeing, understanding others, and questioning themselves that you’re then faced with that dilemma” Until you’re faced with that dilemma, why give them bad foods? (Jasmyn, 6:6)

Don’t bring it into the house and just don’t introduce it yourself. It will come in time but I think if you delay it perhaps they don’t know what they’re missing. And then introduce it I guess as something that’s a treat. (Claire, 5:2)

But I guess, in retrospect, if you don’t want them having too much of that or you don’t want them knowing what it is, just leave it as long as possible and they’ll find out when they go to school... I think everything in moderation, so yeah, that’s sort of what we try and do, that’s all you can do... (Kate, 5:4-10)

...so he had yeah no exposure to those, probably for as long as I could you know manage that before he was seeing it at parties and... being aware that other kids were having it. (Narina, 5:10)

But yeah, I’m still trying to learn how to completely discourage it... I don’t know, if it needs to be completely discouraged, I think it’s ok sometimes... I don’t want to be the mum that is, you know, that much of a party pooper. I just kind of think balance, you know, try to teach them balance (Tara, 5:2)

...as a first time parent, you have all these ideas of how you want to do things, and whether you actually stick to it or not is a different… it’s a different story. Because you don’t want to let them miss out on the joys of life, I guess. (Karren, 4:4,6)

Addendum 4.1 19

Box 32 – Encourage to eat: focus on healthy diet.

So just trying to make sure she gets enough protein in. She likes tuna, so we’ll give her tuna. (Margot, 7:2)

I might serve broccoli more often than say, green beans, because she likes broccoli better... (Helen, 7:11)

Like he doesn’t like banana, I won’t force him to have a banana... he’ll have the grapes you know or the strawberry or something else that he might like. (Veronika, 7:14)

You know if that’s the way that she likes it then that’s the way we’ll cook it... (Melanie, 7:16).

I give her the ones that she likes basically... she really likes carrots and apples so that’s what I give her most of the time... (Erin, 7:4)

I’m not going to have a fight with him every night if I’m serving five vegetables and I know he only likes two of them, ill only put the two that he likes on his plate. He’ll generally eat those, and he’s had some vegetables rather than making him clear the plate or anything. (Kate, 7:14)

Box 33 – Encouraging variety of foods

...and I just stick with one at a time, so at the moment it is, it’s capsicum, and I, you know I put it on their plate and I say, just have a little bit for me, and he has a little bit and says how disgusting it is, and then next time he knows that it’s going to be there again... (Carolyn, 7:2)

...serve the kids all types of foods and even if the first few times they say they don't like it then just keep serving it up to them because their tastes will change... some things that he’s telling us that he doesn’t like but we just keep saying you know just try it. (Tegan, 5:2 & 6:6)

So broccoli’s the first thing gone for her. She says, “Oh man” and then eats it. She gets it over and done with first, and then carries on. (Lisa, 3:85)

I have to say kind of say “come on you’ve got to eat your carrots”... Have a couple of your carrots.” (Joanne J, 7:8,14)

...even if I’ve done the same exact thing this week to last week, and he didn’t like it, I’ll still give him a little piece, and I’ll just say, “Try it again” I just keep trying to get him to try it. (Tara, 7:11)

...so often like they’ll dig their toes and go no I don't want to eat it, I don't want to eat it. I’m like well this is dinner... I’d like you to try it... we’ll just all sit there... and then they just start eating. (Victoria, 6:2)

Box 34 – The reward dilemma

...I think we’re sort of told not to use it as a reward, but then I know I do use it in certain respects as a reward… But you know, it works, so, when we’re onto something that works, I think you know you can’t really tamper with it too much. (Natalie, 8:2,29)

I’m conscious of not using food as a reward, that’s what I’ve read... When she was younger, and we were toilet training, we used food as a reward. (Margot, 8:4).

So I’ve never really used food as a reward. I don’t agree with the value, I guess, in that. Other than, I guess the you know the trap of using as a dessert to encourage her to finish her plate full of food... It’s a bit hypocritical saying that, isn’t it? But no, under no other instances, I don’t, I can’t recall using food as a reward... we do fairy rings occasionally... the fairies don’t come unless your bedroom is clean, and then obviously I’ll just chuck in a couple of chocolates... I don’t want her to be controlled by food, and I’ve been very careful about not using it as a reward (Karren, 2:20,24, 3:5 & 4:6)

...if we’re out together, I might purposefully, and that is almost a reward, because I say to him... because you’re so understanding of the fact that you’re brother has to miss out so you miss out, we’re going to go get an ice cream, well you can have that. So that’s sort of a little side reward he has. (Narina, 8:4)

[Response to whether give rewards for food or behaviour] No, he’ll sometimes get a milkshake if he’s been extra helpful doing the shopping. (Claire, 8:2)

...I actually don't really like thinking about them as rewards. I try to not say to the kids that if you eat

your dinner that your reward is... But I don't think the kids look at it as a reward. I think they just look at it l’m not going to have dessert unless I eat my dinner... more a rule rather than a reward... (Veronika, 8:2,4)

...we will say “Let’s go for a cycling trip today, and we might see if there’s a treat along the way”, and that’s about, you know, we don’t say “If you cycle without”, actually we do. We do say “If you cycle along without grumbling, then we’ll be able to stop at a café, and you know, have a chip or something”. But that’s really the only things that we run with rewarding, I think. (Pip, 8:2)

I think one night he gave her hot chocolate and decided this works so then that’s sort of, you know standing... I don’t usually use food as a reward, or punishment I guess, because I don’t necessarily think it’s the most effective. (Helen, 3:131 & 8:4)

Addendum 4.1 20

Box 34 – The reward dilemma (continued)

...But we do, do I guess well you know okay you’ve done all your homework and you’ve been a really good girl today then okay then you can have another piece of cake tonight. So sort of I try not to always obviously give food rewards because I think that’s once again a bad habit. So yeah but we do, special treats. (Victoria, 3:10-14)

...as far as rewards go, I mean I don’t tend to do it a lot... But we’re probably all guilty of going to the shops, and saying “Well if you behave yourself I’ll get you a treat at the end of it”... But it’s so easy to do sometimes. “I just want to get something done”. So you know I think I am a little bit guilty of that sometimes (Jasmyn, 8:4,6)

Box 35 – Difference between “treat” and reward

...a reward to me is something, like she’s obviously done something really good, or she’s, and she needs a reward for it. A treat’s sort of, you know if we were out for an outing or something and we all had an ice cream, well that would be a nice treat for all of us, and that’s different. Like, she doesn’t have to do something good to have got that. (Rebekah, 8:5)

In our house a treat is just a sometimes food, it’s just a food that we would probably limit it and it’s a way of explaining a food that you can have a little bit of because it’s in the house at the moment, but you can’t go to town on it... probably the only reward for effort, that you know you’ve given your dinner a go and getting a bit of dessert. But, yeah, I can’t think of an occasion where he’s done something good and we’ve gone that’s great we’ll buy some food (Kate, 8:10,12).

I guess a treat is something you don’t necessarily have to earn, so like if it’s someone else’s birthday you’ll get treat food but you didn’t actually earn that you just turned up, if that makes sense? Where as a reward to me is probably behaviour based, so it is like helping with the shopping and that kind of thing. (Claire, 8:22)

But the treats are what she’d have regardless... as far as rewards go, I mean I don’t tend to do it a lot... But we’re probably all guilty of going to the shops, and saying “Well if you behave yourself I’ll get you a treat at the end of it”. (Jasmyn, 8:2,4)

...because I work full time we don’t spend a huge amount of time together... I’ll offer just out of the blue, even if they’ve been a little bit naughty in the car or something, I might not be in the best of moods, but she doesn’t need to be good, if you know what I mean... for no reason I’ll just say, you know, “Come on, let’s go and get us a treat”. (Karren, 2:36)

It’s the same thing, isn’t it?... It depends if you want to call it a reward or a treat but it’s the same thing really. I would have thought, yeah I wouldn’t say, “Oh you can have a Tim Tam as a reward or a treat.” I’d just say, “You’ve done really well with your dinner, would you like a Tim Tam?” (Joanne J, 8:12)

Box 36 – Dessert or “treat” dependent on eating a healthy meal

a. Dependent on eating a healthy meal

...if he’s eaten pretty much all his meal, he’s allowed to have his dessert. (Heidi, 3:72)

I mean not so much in terms of a reward, it’s more like he has to eat his dinner before he gets dessert. But the dessert is not a reward for eating the dinner... you know you’ve got to eat a balanced diet. And you’ve got to eat the good foods before you can get you know a treat. (Melissa, 8.2, 8:8)

...I’m not going to give her a massive amount of dessert if she’s eaten nothing. (Helen, 8:4)

we’ve got really to the point of if you don't finish your dinner then you don't get any biscuits... cottoned right onto it now, he’s eating his dinner quite well. If he wants that biscuit afterwards he has to eat all... (Joanne, 3:93)

...she knows she won’t get dessert unless you eat the dinner... you would have got a treat if you ate your dinner an hour ago... Next time maybe eat your dinner... it’s you know, the rules, like. (Jasmyn, 8:2,13)

I sometimes do say “okay if you eat all of your vegetables then you can have a Tim Tam.” I don’t always do that but yes, I do do it. (Joanne J, 2:26)

...he’s got to eat his dinner before he can have yoghurt... he’ll often say to me “How many more mouthfuls do I have to eat?”... “If you can do it in five mouthfuls, you can have some”. (Natalie, 8:6,8)

[dessert after dinner] ...they sit there and go “No, don’t want this, this is disgusting” then they wouldn’t get the treat... then obviously you’re not hungry enough and you can leave the table”. So it’s more that they miss out. (Carolyn, 8:6)

The rule is he has to eat his lunch, that’s the main thing otherwise he gets no sweets in his lunch box... (Veronika, 3:130)

...gets to a point where, do you say to him “If you eat some more, you have some ice cream”? (Penny, 7:15)

Addendum 4.1 21

Box 36 – Dessert or “treat” dependent on eating a healthy meal (continued)

a. Dependent on eating a healthy meal (continued)

...we usually reserve things for after dinner and if they’ve eaten a good dinner. They don’t have to finish everything on their plate but if they’ve had a good attempt at dinner then they’re allowed something... maybe two lollies out of the lolly bag... (Erin, 3:19)

We will offer dessert as a bit of a bribe for eating dinner, but I’m happy if they’ve made an effort, I don’t want to force to eat more then what they actually want to eat or anything like that, but as long as they’ve had a good go of eating the healthy food, I might say no dessert tonight if you don’t have a good go at your dinner... I probably work out the nights where they’re less likely to want the dinner that were having and offer dessert on those nights as incentive. (Kate, 8:2,4)

b. Too full for dessert

So I’m thinking, and if they’re too full, they just won’t have yoghurt, or you know, their glass of milk afterwards. So yeah, no I’m one of those bad parents who goes “Eat everything on your plate, or else there’s nothing else”. (Heidi, 7:10).

...they only get dessert if they’ve finished their meal and they’ve got space for it in their tummy. (Pip, 8:2)

he does have to eat all of his dinner before he gets birthday cake, because he can’t say “I’m full, I can’t eat any more dinner, but I can eat that cake”... he’s got to eat his dinner before he can have yoghurt. (Natalie, 8:4,6)

...if he doesn’t finish his tea then he doesn’t get anything else... that’s not a punishment that’s just because he’s not, obviously he’s not hungry (Tegan, 8:12)

Because quite often she’d say, “Mummy, can I have sweets?” and she’d still have stuff on her plate, and I’d just say, “You can’t have sweets obviously if you’re full, you can’t fit your sweets in either”. (Karren, 2:18)

Because as far as I’m concerned if you can’t fit your dinner in you can’t fit dessert in. (Veronika, 7:14)

c. To achieve a “balanced” diet

[school lunch] ...fifty cents every day that he’s eaten everything... he will probably go and get himself an ice block... Or a you know a handful of lollies... But I figured he gets whatever he wants is fine, he’s done well he’s ate his lunch. (Veronika, 3:130,136).

...Because you eat your fruit and veggies it’s okay that you have it. Which I guess could be interpreted as a reward, but it’s never that direct... I haven’t wanted him to perceive that there’s a direct reward, if I eat this, well then I’m going to get that, but for it to be more of a broad understanding that these things are in moderation (Narina, 8:1,4)

...you’ve eaten your fruit and you’ve had this and that, and yes you can have something out of the box”. (Carolyn, 3:22)

Box 37 – Not overtly mention dessert associated with dinner or as a reward

...we try not to say “You’ve got to eat everything on your plate”. But “If you want to eat, if you want to have your yoghurt or whatever after the meal, you have to”. (Heidi, 7:10)

I’ve never used that reward of eat up all your dinner on your plate and then you can have a piece of chocolate cake or a bowl of ice cream. I might make a comment... that because you usually eat so well, you can have things like this... (Narina, 8:8)

You’re putting something in the child’s mind if you mention it beforehand... I’d make the decision as to how we go with dinner. (Joanne J, 3:49,51)

Box 38 – Food reward for good behaviour

“Ok, you’ve been really good”, and grab a kinder surprise (Heidi, 3:78)

[Eating Out] “You get to have dessert if you behave yourself”. Which I know isn’t good. Laughs. But sometimes it’s just easy. (Heidi, 3:72)

So say for five days in a row he did his homework without whinging or complaining, then we go, “Right, Saturday you can have a treat”. (Heidi, 3:94)

So if he has a job to do for five days, that he does it, then he might get taken out for that milkshake on the Saturday. It’s got to be good behaviour for a certain amount of time. (Heidi, 3:96)

When she was younger, and we were toilet training, we used food as a reward. As in, like, little M’n’Ms or yoghurt covered sultanas, or even sultanas as dried fruit were a real treat for her when she was younger... (Margot, 8:2)

Addendum 4.1 22

Box 38 – Food reward for good behaviour (continued)

...once a fortnight he has a lunch order. And that’s provided he’s been well behaved during the week. (Melissa, 3:47)

...with the tuck shop at school, he only got it once a term, but that was dependent on his behaviour in school... and his teacher knows that, that I use that as a reward. (Natalie, 8:2)

...But we do, do I guess well you know okay you’ve done all your homework and you’ve been a really good girl today then okay then you can have another piece of cake tonight. (Victoria, 3:10,14)

when you do let them then have it you explain to them okay you’re only getting this now because you’ve been really good and it’s a special treat... really well in your report card... some really good behaviour or you’ve achieved really great (Victoria, 5:4)

...she won a talent show at her school... fete and so she got to have popcorn and she got a lolly bag... so that was kind of the reward... pretty exciting (Victoria, 8:9,11).

...normally we say umm you can get to choose dinner and he tends to choose McDonalds. (Joanne, 8:8 & 10:9)

...needles [vaccinations] or something like that and I’ll say look as a good treat if you’ve been very, very good I’ll I don't know we’ll have McDonalds... (Veronika, 8:4)

...sometimes where I say to him you know mate you’ve been really good so here’s a Freddo frog... (Tegan, 8:2)

...we do fairy rings occasionally... the fairies don’t come unless your bedroom is clean, and then obviously I’ll just chuck in a couple of chocolates. (Karren, 3:5)

Tuckshop for one break on Friday, if you eat well Monday to Thursday... I’ve only relented on that with school because I just couldn’t come up with another option. (Narina, 3:86 & 7:4)

...if we’ve had a good week then... we might go for an ice cream after school on a Friday. (Joanne J, 8:2)

...when she was potty training... “Ok, if you have done really well during the week, you know, like you’ve gone every day, and you haven’t messed or anything” or whatever it is, at the end of the week if she had all like good marks, then she could choose what she wanted [sweets]. (Melanie, 8:22)

...sometimes you need to give them that, so you can get stuff done, and use it as bribery. Yeah, if you’re going to give them a biscuit, don’t just give it to them, just say “Right, now. If you get your pyjamas on, then you can have one” and they run off, it’s like “Yes”... (Penny, 5:2)

the very rare occasions we might use it as a treat, hey you have been really good today how about a Kinder surprise, oh wow and they go ballistic, but it hardly ever happens. Just to show them that they were exceptionally good, get value out of it because it doesn’t happen all the time they understand that that behavior was that special that ‘OMG we got chocolate I must have been amazing today’, so it just reinforces that, we don’t use it a lot it is very very rare, like when we had to buy a house and drag them around, not just any old time. When they could not be kids and have had to be grown ups, I know it was hard for them to do. We try and give them a little bit of a heads up to let them know that we appreciate it so that next time we have to do it hopefully we get a bit of cooperation. (Kylie, 3:17)

...they don't know it’s coming. But if I feel that they’ve done really well for the situation that they were in I will then feel you know I would like to reward them for having done something nice without them expecting that reward... never really take them anywhere and say if you’re really good I’m going to get you this. I kind of don't like doing that... (Veronika, 8:8)

Box 39 – Withholding food rewards

...there’s been times he’s tried and then failed, and we go “Well mate, you didn’t make the week, because you carried on yesterday. So no, nothing special”. (Heidi, 3:102)

...sometimes he hasn’t had it because he hasn’t been well behaved. (Melissa, 3:47)

He doesn’t get tuck shop unless his behaviour in school’s been good... I don’t know if that’s a good or a bad thing. But it seems to work... (Natalie, 8:2,4)

...if I had said “When we get home you can have an apple juice” but then on the trip home he’s been absolutely horrible, and the behaviour’s been terrible, then I’ll say “Well, you know. Sorry, but your behaviour was so bad that you’re not going to get it now”. (Natalie, 8:20)

...the thing that I’ve found that works the best for her is to take something away unfortunately.(Victoria, 3:48)

...they’ve been fighting or they’ve been badly behaved or whatever then we might just say... We’re not having the ice cream. (Tegan, 8:12)

“If you behave, you can get a treat”, and if they haven’t behaved, and they’ll say “Well I want my treat”, and I’ll say “Well you didn’t behave yourself”. (Jasmyn, 8:13)

Well, I won’t give her a treat or surprise if she’s being naughty. (Karren, 8:4)

If they you know if the boys were fighting over something or at the moment like in the Wii computer games, I don't know if I’d base it on food. I guess I’d say well no biscuit yeah. (Joanne, 8:14)

Addendum 4.1 23

Box 39 – Withholding food rewards (continued)

...if we’ve said there’s going to... You can have dessert and she hasn’t done a good job of her dinner or she’s spent the whole time complaining or not eating much then we say well you just don’t have it. (Erin, 7:14)

Oh definitely. If we plan to go and get ice cream or we plan to be out at the shops and when we’re out at the shops they get a babyccino or a milkshake or something, and he misbehaves I’ll say to him, sorry you haven’t been well enough behaved to have any treats today and we won’t do that. (Kate, 8:8)

Box 40 – Mothers descriptions of foods and drinks restricted “in moderation”

his big treat for big school. That’s lucky. (Heidi, 1:14)

sugary cereals... that’s his big pay off when we’re camping. (Heidi, 2:12)

...kids know which is the good sweet stuff. (Heidi, 3:78)

we’ll go to the servo, and you can buy a milkshake, you lucky devils”. (Heidi, 3:90)

He doesn’t know that soft drink’s this fabulous drink, so why give it to him (Heidi, 4:2)

Rather than suddenly going, “Wow! I can actually have all these amazing foods” (Pip, 1:14)

...bike riding days then it’s fine to have a bit of a treat... it’s a nice family time. (Pip, 3:72)

...before we introduced anything that I knew that they would love... would be potentially unhealthy for them... (Pip, 4:14)

...it might seem like it’s really yummy and stuff, but it doesn’t actually add anything to our diet.

(Carolyn, 3:2)

...six pack of doughnuts, and that’s a very big treat. They love that. (Carolyn, 3:32)

[Marshmallows] they’re you know a treat and they’re sometimes food (Melissa, 3:12)

...obviously some of them do taste good (Helen, 2:2)

really high sugary foods, whilst they’re really yummy... harder for them to control themselves I guess. Because it’s so exciting. (Victoria, 3:6,66,68)

...isn’t a special treat and it isn’t amazing if they get cupcakes all the time. (Victoria, 3:124)

I keep them as a treat... (Tegan, 2:2)

...tell them that you know, they do taste good... (Claire, 3:24)

...as he became aware that the yummy stuff [chips, lollies, chocolate] was not so good. (Narina, 5:10)

[Easter eggs] ...they’re yummy... they’re great but we don’t have a lot of it. (Narina, 5:16)

They’re things we just have sometimes because they taste nice. (Tara, 3:25)

Box 41 – Parents own preferences for foods and drinks restricted “in moderation” a. Parent preferences

[treats are] definitely cakes, bickies, because I love cakes and bickies. (Heidi, p12)

The stuff that I want, don’t want the kids to have, by any chance if I buy potato chips for me, then they’re up higher. They’re up high in the pantry... I’m a shocking chip person. I get into trouble with chips. (Lisa, 3:13,75)

My husband loves a Tim Tam and the girls do like Tim Tams so I’m outnumbered. (Joanne J, 3:20)

...sometimes we do go out say like a mother and daughter type of... like coffee and cake kind of thing. So it’s probably for me, a reward for me (Margot, 8:4)

I try not to have them too much in the house... things like you know, chocolate or junky type, well potato chips we never have in the house, but you know chocolate, because I’m a bit of a chocoholic, I have it. (Helen, 3:2,4).

...my son has a lot of allergies... and I’m still feeding him so my diet has changed as well... The Oreos are mine, because I can eat Oreos... like the chocolate now, she can actually eat it, and I can’t, which is just upsetting... I miss my chocolate. (Helen, 3: 40,48)

I know, potato crisps can get into the house sometimes. My husband really loves them... (Tara, 3:82).

We’ve got into the habit of coming back from church and just getting a bag of chips... she likes that. It’s sort of like our treat for the week... she likes chips. So yeah, that’s I guess our junk hit. (Karren, 2:34)

I have a craving for chocolate and then I hide it for myself... I mean sometimes we might buy a bar of chocolate and they’ll have a tiny bit. But not that often, and we just explain to them it’s something you have every now and then, not all the time... if I buy it, I would tend to hide it... (Rebekah, 3:18,22,24)

Addendum 4.1 24

Box 41 – Parents own preferences for foods and drinks restricted “in moderation” (continued)

a. Parent preferences (continued)

It’s like my energizer for me... so like a chocolate bar like a Kit Kat or something is for me for my break... when they’re asleep or when they don’t see me eating it... My husband doesn’t have a sweet tooth, so it’s only me that has cravings for it... Like my treats, like my simple joy. (Racy, 3:2-16)

...he’s [husband] a sucker for picking up a six pack of doughnuts, and that’s a very big treat. They love that. (Carolyn, 3:32)

...if we were eating it, it was something that they could have, within reason. I know some parents will avoid giving their children hot chips until they know what hot chips are but you know, if that was something that we were eating then that was something that they were allowed to have from sort of two and up. (Kate, 5:4)

Well actually to be honest I eat too much, I eat far too much sweet things myself. So, I, yeah I don’t want her to be the same so we don’t really have too much of it in the house for the kids. (Mhari, 2:8)

We make an exception on bike rides because we figure we’re doing exercise so we deserve something like an ice cream, or a milkshake, or hot chips... but it works on me as well, is that I will cycle further if I know there’s an ice cream at the end of it, and so we’ll do that with the kids. (Pip, 1:8 & 8:2)

I’ll make fish and chips and I’ll get, there’s a particular brand of chips... really low fat... So that is a treat meal for us, it’s a treat meal for me, it’s something I really enjoy. (Pip, 3:38)

b. Mother’s need to restrict themselves

Because, well you see I would eat it all, and my husband wouldn’t eat it at all. I would just, if it was there, I would be like “Nom nom nom”, snacking all the time. Yeah, so it’s easier not to have it. (Heidi, 3:82)

I’ll buy them for if we’re having a birthday party at our house, I will. But generally I try not to, and that’s more so that I don’t eat them, rather than her. Otherwise I’ll just sit there and eat them all. (Margot, 3:46)

I’m just trying to teach them, and me... I’m trying also for my own sake not to have lots of sugary, fatty foods at every possible opportunity. (Pip, 3:28)

I don’t like to have crisps in the house. That’s partly because I will eat them. (Pip, 3:52)

We don’t mind liquorice every now and then... ( 3:4) [Qantas lounge] So they know that they can have one of each treat. But they can’t just go... to town... which helps [Dad], he’s a liquorice nut. So it helps him to also not eat a jar of liquorice and then fly all the way to Perth going “I’ve been greedy. I feel sick”. (Pip, 3:60)

I have very little chocolate or sweet things. Because the thing is if I buy them I’ll eat them and then I don't want to eat them either. (Victoria, 3:18)

...if I bought a packet of chocolate chip cookies for example and I gave them one each then I would probably have one as well. So chocolate chip cookies are the evil thing that I can’t resist. (Victoria, 3:24)

...it’s when I’m at home at night after the kids have gone to bed that’s when I have no self-control at all. So yeah if I don't have it in the house then it’s not a problem. (Victoria, 3:30)

...they get enough lollies and chocolate and stuff from other places... and then if it’s in the house I’ll eat it so I would rather see it out of the house. (Tegan, 3:16,18)

Well actually to be honest I eat too much, I eat far too much sweet things myself. So, I, yeah I don’t want her to be the same so we don’t really have too much of it in the house for the kids... I don’t have enough self control of myself to say no you don’t need that. But I expect the kids not to have it. (Mhari, 2:4,8)

Mainly not having it in the house. It’s mainly for me and my husband’s health as well, we don’t have things in the house that might be tempting as well. (Erin, 3:2)

I wouldn’t have chocolate in the house, but they wouldn’t last very long with me. (Penny, 3:57) Dissenting quote

And chocolate mostly it’s for me and my husband and Sean wouldn’t really have any, we just keep it in the fridge. My younger son might have a bit of that but Sean wouldn’t really have any of that chocolate. ...He just, he’s not umm yeah he’s not really interested yeah and chocolate side of it. (Joanne, 3:48)

Review - In another part of the transcript this mother referred to taking biscuits on trips out when the study child was younger. She said she never gave packets of lollies and chocolate was introduced the child started going to parties. No reference was made by the mother of her preference for chocolate. The quote above was the only reference to eating chocolate.

Addendum 4.1 25

Box 42 – Parents lack of preference for totally or inadvertently restricted foods and drinks

I’m vegetarian... I guess that may have also steered us towards I guess healthier options... my aversion to McDonalds and all those things anyway (Natalie, 3:174,176)

Sodas and things she doesn’t drink at all... I’m not a big soda drinker (Helen, 1:2 & 2:13).

They’re not really big on chips. I don't really like chips so I tend not to buy those at all... and my husband doesn’t really eat chips either... so the kids have never really been exposed to it that much. (Victoria, 3:8,14)

Lily has eaten at Hungry Jacks once in her life and she’s never been to a McDonalds or a KFC... because I don't eat that food. (Victoria, 3:104,106)

...chips would be pretty rarely... Like more when we’re socialising but we don't I don't like them I would only buy them if my husband had people come over to watch the footy or something (Tegan,1:2; 3:22)

I started with the soft drink early so now he just doesn’t even if someone offers it to him, he doesn’t like it. So that’s because I don’t drink it, he doesn’t see me drinking it either. So, and I don’t give it to him, so he’s kind of figured out that it’s not a good thing to have. (Penny, 2:4)

[McDonalds]...we don’t eat it ourselves either so. So we think it’s good for her to avoid it (Mhari,2:6)

...like chips and things like that we limit... But crisps, bags of crisps we don’t really eat them ourselves that often. So the only time she eats them is friend’s place perhaps or parties again. (Mhari, 1:4; 3:18)

We don’t really go to fast food restaurants, mainly because we don’t want to eat it, so we don’t go with them. I think they’ve tried Macdonald’s once. They didn’t like the burgers, so I was like ‘oh good’ that helps... it wouldn’t be our choice so they don’t know that much about it. (Erin, 3:47,49)

...my husband’s German, he likes his cake. So that goes in the cupboard and the kids know that’s his. They’re not particularly interested because they’re not allowed to have it, so they don’t question it... I don’t particularly like them (Karren, 3:18,22). [Mother’s lack of preference for cake overrides father preference].

Dissenting quote

Yeah, we don’t have orange juice in our house either. Laughs. Because Brad and I, don’t, or my husband and I don’t drink it... he’s only allowed basically one juice a day at school... Every day, five days, yeah, and that’s his big treat for big school. That’s lucky. (Heidi, 1:12,14)

Review - The study child is given a fruit juice popper as a treat every day but the parents appear to be disinterested in fruit juice drinks. However, mother likes and drinks soft drinks – referred to soft drink as a ‘fabulous drink’

Box 43 – Mothers’ beliefs about the desirability of restricted foods

...we’re reasonable about letting him have treats... then, he doesn’t feel like he’s starved of them... (Pip, 3:88)

...we do allow him little treats so he’s not completely deprived... (Natalie, 3:7)

...She certainly hasn’t missed out on having lollies, or having potato chips or anything. But they are so minimal... (Lisa, 1:6)

I’ll make things for her that, you know, so she’s not missing out. (Rebekah, 3:56)

...you can have two blocks of chocolate today, but that’s all your having today. And of course he’ll ask for more, because he likes it, and I’ll just say no, you’ve had your treat for today and that’s it. I suppose that’s a bit mean but anyway. (Kate, 3:6)

sultanas, just a little handful ... as a little sweet treat. Pretty boring probably. Deprive my children. (Karren, 3:56)

...Because you don’t want to let them miss out on the joys of life, I guess. Some food can be an

element of that joy, that joyful experience from childhood that you do remember, and reminisce about... The joys of different flavours and that doesn’t necessarily mean it has to be all the time, but the occasional, my philosophy is, I don’t want to miss out, but enjoy the different flavours that’s available there. Because it’s there to experience it, and food can be a wonderful experience... (Karren, 4:2,6)

I grew up with my grandparents you know always, I always felt like I had some little treat that they’ve given me and it would be that just one lolly right? Or something and I thought that was quite lovely and I certainly don't want to take that away from them. (Veronika, 3:158)