Mothers’ Perceptions as Predictors of Toddler Fruit and Vegetable Consumption

Presented at the Council for the Advancement of Nursing Science 2012 National State of the Science Congress in Nursing Research

Washington, DC, September 15, 2012

Mildred A. Horodynski, PhD, RN, FAAN1; Manfred Stommel, PhD1; Holly Brophy-Herb, PhD2; Lorraine Weatherspoon, PhD, RD3

1Michigan State University (MSU) College of Nursing; 2 MSU Department of Human Development and Family Studies;

3 MSU Department of Food Science and Human Nutrition

Funded By: the Office of Planning, Research and Evaluation of the Administration of Children and Families (OPRE/ACF). Grant Number: 90-YF0046

• Since the 1970s, the prevalence of childhood obesity has more than doubled for children, 2 to 5 years of age.

• Approximately ten million American children over the age of six are already “obese”.1

1Ogden et al, 2010.

Background

• Recent estimates state:– 37% African American (AA) children are at risk of being

overweight.2

– 35% Non-Hispanic White children are at risk of being overweight.2

2Odgen, 2006.

Background

• Many children living in the US consume diets that do not meet national dietary recommendations.

• Data from the most recent NHANES show that diets of children as young as 2 years old include too much saturated fat, sodium, and calories from nutrient-poor and calorie dense foods and lack adequate vegetables and fruits.

• Toddlerhood is recognized as a critical period for the acquisition of

appropriate healthy eating behaviors.3

3Duke et al, 2004.

Background

• Fruit and vegetable consumption for children is important for healthy growth and development.

• Diets low in fruits and vegetables can increase the risk of cardiovascular disease4, diabetes5 and other chronic diseases later in life6.

4Joshipura, et al., 2001; 5Ford & Mordad, 2000; 6Cooke, et al., 2003.

Background

Background

• Several socio-demographic characteristics are associated with the consumption of fruits and vegetables in families:

• Lower SES and educational level6 • Race7

• Gender8 6Cooke, et al, 2003; 7Irala-Estever, et at, 2000; 8Gibson, et al, 1998.

Background

• Other factors influence toddlers’ fruit and vegetable intake: • Mother’s diet quality9

• Maternal self-efficacy10 • Perception of child as “picky eater”11

9Hoerr, et al, 2006; 10Carruth, Ziegler, Gordon, & Hendricks, 2004; 11Carruth, Ziegler, Gordon, & Barr, 2004.

• Home environments that support healthy eating for toddlers are important in establishing healthy future food choices and diet-related health outcomes in children.

• Parents play an important role in determining food choices and feeding behaviors of toddlers, based on the theory that the parent determines what food the toddler is offered.12

• Parental practices/styles and pressure to eat are interrelated with picky eating.

12Satter, 1990.

Background

• A child can communicate his/her food likes and dislikes at a very young age, first through body language (moving away from food offered) and later through verbalizing his/her food likes and dislikes.

• Preliminary evidence suggests that parents’ perceptions of their child’s “pickiness” increase as they get older from: • 25% at 7-8 months• 35% at 12-14 months• 50% at 19-24 months11

11Carruth, Ziegler, Gordon, & Barr, 2004.

Picky Eater

• Picky Eaters are defined as children who consume an inadequate variety of foods because they reject other foods.13

• Picky Eaters require many more exposures in order to accept a new/novel food.15

• Studies exploring ‘Picky Eaters’ are relatively recent and few in number.14

13Galloway et al, 2005; 14Dovey et al, 2008

Picky Eater

Picky Eater

After 15 ExposuresExposure

Ref

usal

of F

ood

First taste of the novel food

Figure: Likelihood for acceptance of fruits and vegetables in Picky/Fussy eating children.14

14Dovey et al, 2008, p. 188

Purpose

• To examine whether and how toddlers’ vegetable and fruit (V&F) consumption is associated with maternal V&F consumption, maternal efficacy, mothers’ perceptions of toddlers are “picky eaters”, and sociodemographic characteristics of the mothers.

Methods - Study Design

• Cross-sectional survey design with 199 low-income African American (AA) & 200 non-Hispanic White mother-toddler dyads.

Data Collection Procedure

• Trained Data Collectors• Made home visits

• Maternal and child height and weight measurements

• Mealtime feeding observation with toddler

• Questionnaire packet

Self-Report Measures

• Toddler/Parent Mealtime Behavior Questionnaire: Picky Eater Subscale (r=.73)

• Food Frequency Questionnaire (child and adult)

• Feeding Self-Efficacy Questionnaire (r=.83)

• Demographic Survey

Food Frequency Questionnaire

Assessed usual weekly food intake of fruits and vegetables on a 3-point scale:

• Rarely/never• 3 or fewer times a week• 4 or more times a week

‘Picky Eater’ Subscale of TPMBQ

• 5 items• 5-point Likert response scale• 1 = “never” and 5 = “always”• Sample item: My child is a

picky eater

Feeding Self-Efficacy Questionnaire

• 8 items• 5-point Likert response scale• 1 = “not confident at all” to 5

= “always”• Sample item: I can get my

child to try veggies.

Data Analysis

• Frequency distributions, measures of central tendency and variability

• Linear regression models with picky eater scale scores as outcome

• Logistic regression models for dichotomous outcomes measuring toddlers’ vegetable and fruit consumption

  African American (N= 199)

Non-Hispanic White (N=200)

Maternal Age 

= 27 (±8.3) (yrs) = 28 (±7.5) yrs

Range = 15 – 62 Range = 17 – 66

Education: High School 143 (72%) 165 (74%)

Employment Status: Unemployed* 114 (58%) 123 (62%)

Adult BMI >25 151 (77%) 145 (74%)

Marital Status: Single 168 (84%) 115 (58%)

Additional Child(ren) 146 (73%) 146 (73%)

Toddler’s Age 

= 25 (±8.7) (mths) = 25 (±7.9) (mths)

Range = 12 – 48 Range = 12 – 48

Toddler CDC Percentile ≥85 94 (47%) 82 (41%)

Characteristics of Study Participants (* p<0.05)

Fruit and Vegetable Consumption

African American(N=199)

Non-Hispanic White(N=200)

Mother’s Vegetable Consumption N % N %

≤3 times/week 86 43 57 29

4+ times/week 113 57 143 71

Mother’s Fruit Consumption

≤3 times/week 96 48 106 53

4+ times/week 103 52 94 47

Toddler’s Vegetable Consumption

≤3 times/week 95 48 55 28

4+ times/week 104 52 145 72

Toddler’s Fruit Consumption

≤3 times/week 81 41 71 36

4+ times/week 118 59 129 64

Predictors of Maternal Perceptions of their Toddlers as ‘Picky Eaters’

PredictorsRegression coefficient

Standard Error p-value

Race (1=African American, 0=White)

.166 .066 .012

Adult age (in years) .003 .004 .541

Education (reference category: less than high school)

High school -.255 .089 .012

Greater than high school -.161 .090 .074

Employment Status (reference category: not employed)

Full-time worker -.077 .085 .368

Part-time worker .111 .084 .187

Maternal self-efficacy -.502 .046 .000

Toddler age .008 .004 .035

Toddler gender .034 .064 .599

Summary statistics R2 = .367 F = 22.39 <.0001

• Race, education, self-efficacy, and toddler age predicted “picky eater” perception (37% of the variance).

• African American.• Mothers with less education.• Lower maternal self-efficacy• Older toddlers

Results: Sociodemographics and Maternal Characteristics Predict “Picky Eater” Perception

Results of Logistic Regression Analysis for Associations of Toddler Vegetable Consumption

PredictorsOdds Ratio 95% CI p-value

Race (1=African American, 0=White)

2.217 1.279, 3.846 .005

Education (reference category: less than high school)

High school 1.291 0.627, 2.659 .756

Greater than high school 1.388 0.697, 2.763 .473

Child viewed as picky eater 0.397 0.271, 0.582 .000

Maternal vegetable intake* 10.143 5.702, 18.043 .000

Maternal fruit intake* 1.793 1.003, 3.205 .049

Toddler age 1.006 0.975, 1.038 .695

*Four times or more a week versus ≤3 times a week.

Results of Logistic Regression Analysis for Associations of Toddler Fruit Consumption

PredictorsOdds Ratio 95% CI p-value

Education (reference category: less than high school)

High school 0.930 0.481, 1.799 .549

Greater than high school 1.195 0.633, 2.256 .406

Child viewed as picky eater 0.641 0.452, 0.908 .012

Maternal vegetable intake* 1.683 0.986, 2.870 .056

Maternal fruit intake* 9.864 5.670, 17.160 .000

*Four times or more a week versus ≤3 times a week.

• Toddlers were more likely to consume vegetables 4 or more times/week when mothers:– Did NOT view their toddler as “picky eater” (OR 2.5;

95% CI: 1.7-3.7)– Consumed more vegetables themselves (OR: 10.1; 95%

CI: 5.7-18.0)– Non-Hispanic White (OR:2.2; 95% CI: 1.3-3.8)

Results: Maternal perception of “picky eater”, mothers’ fruit and vegetable intake & sociodemographics predict toddler vegetable intake

Toddlers were more likely to consume fruit if mothers:

• Did NOT view toddler as “picky eater” (OR: 1.6; 95% CI: 1.1-2.2)

• Consumed more fruit themselves (OR: 9.9; 95% CI: 5.7-17.2)

Results: Toddler Fruit Consumption

Final Model

Maternal Education (-)

Maternal Self-Efficacy (-)

Toddler Age (+)

“Picky Eater” Perception

Toddler Fruit Intake

Maternal Fruit Intake

Maternal Vegetable Intake

Maternal Race (AA)

+

+

+

-Toddler Vegetable Intake

-

-

• Mothers’ intake of fruits and vegetables has a strong influence on toddler fruit and vegetable intake.

• Mothers’ own dislike of certain fruits and vegetables may limit introduction of certain fruits and vegetables to toddlers.

• Mothers are their toddlers’ greatest role models.

Conclusions

• Self-efficacy has been identified as a key factor in determining F&V intake.15

• AA mothers who are ambivalent about being a positive role model relative to eating F&V, made less of an effort in ensuring that their children are eating enough F&V.16

• In our study, mothers’ feelings of low feeding self-efficacy were associated with viewing their toddlers as “picky eaters”.

• Increasing feeding self-efficacy among mothers could lead to increased F&V consumption among toddlers.

15Granner, 2004; 16Reimer, 2007.

Conclusions

• “Picky eating” is one aspect of child development.• Perceptions of a toddler as a picky eater may be related to

parenting style or culture.• In our study, mothers who viewed their toddlers as a picky

eater may be more “Laissez-faire”, where toddlers choose, which, if any, fruits and vegetables to eat.

Conclusions

Limitations

• Self-Report measures• Measurement issues

Implications for Research

• Measurement of “Picky Eater” construct:• Studies have attempted to characterize “picky eating” using

various measures, such as the Child Feeding Questionnaire17, asking the caregiver if they considered their child a “picky eater”18, or by designing a questionnaire for their own specific study.19

• Differences in measuring the “picky eater” construct requires an applicable, validated measure.

• Understanding the concept of “picky eating” is needed to deliver a multi-faceted approach to get children to independently choose and eat fruits and vegetables in their diets.

17Birch et al, 2001; 18Carruth et al, 2004; 19Smith et al, 2005

Implications for Practice

• Increase mothers’ own fruit and vegetable intake• Increase maternal self-efficacy• Receive additional education about their own

and their toddler’s healthy food intake.

Implications for Education

Mothers need knowledge to:• Provide a healthy diet, especially including adequate

vegetables and fruits, and life style for their toddler’s growth and to maintain an appropriate weight and ultimate health.

• Gain an increased awareness regarding the quality of their own food intake and the influence on the quality of their toddlers’ food intake.

The findings from this study:

• Provide useful insight on how nurses and other health professionals can maximize F & V intake for vulnerable children.

• Identify the need for healthy eating strategies, for addressing for prevention of childhood obesity and other health-related conditions, that are individualized and effective for vulnerable children and their families.

• Identify the need for further research in understanding the problem and measuringthe concept of “picky eating”.

Thank You

Questions?

1.Odgen, C.L., Carroll, M.D., Curtin, L.R., Lamb, M.M., Flegal, K.M. (2010). Prevalence of high body mass index in US children and adolescents, 2007-2008. Journal of the American Medical Association, 303(3), 242-9.

2. Ogden, C.L., Caroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & Flegal, K.M. (2006). Prevalence of overweight and obesity in the United States, 1999-2004. The Journal of the American Medical Association, 295(13), 1549-1555

3. Duke, R., Bryson, S., Hammer, L., & Agras, W. (2004). The relationship between parental factors at infancy and parent-reported control over children’s eating at age 7. Appetite, 43, 247-252.

4. Joshipura, K.J., Hu, F.B., Manson, J.E., Stampfer, M.J., Rimm, E.B., & Speizer, F.E. (2001). The effect of fruit and vegetable intake on risk for coronary heart disease. Annals of Internal Medicine, 134, 1106-1114.

5. Ford, E.S., & Mordad, A.H. (2001). Fruit and vegetable consumption and diabetes mellitus incidence among US adults. Preventive Medicine, 32, 33-39.

6. Cooke, L.J., Wardle, J., Gibson, E.L., Sapochnik, M., Sheiham, A., & Lawson, M. (2003). Demographic, familial and trait predictors of fruit and vegetable consumption by preschool children. Public Health Nutrition, 7, 295-302.

7. De-Irala-Estevez, J., Groth, M., Johansson, L., Oltersdorf, U., Prattala, R., & Martinez-Gonzalez, M.A. (2000). A systemic review of socio-economic differences in food habits in Europe: Consumption of fruits and vegetables. Evergreen Journal of Clinical Nutrition, 54, 706-714.

8. Gibson, E.L., Wardle, J., & Watt, C.J. (1998). Fruit and vegetable consumption, nutritional knowledge, and beliefs in mothers and children. Appetite, 31, 205-228.

9. Smith, A.M., Roux, S., Naidoo, N.T.R., & Venter, D.J.L. (2005). Food choices of tactile defensive children. Nutrition, 21, 14-19.

10.Hoerr, S., Horodynski, M. (2006). Predictors of nutritional adequacy in mother-toddler dyads from rural families. Journal of the American Dietetic Association, 106, 1766-1773.

References

References

11. Carruth, B.R., Ziegler, P.J., Gordon, A., & Hendricks, K. (2004). Developmental milestones and self-feeding behaviors in infants and toddlers. Journal of the American dietetic Association, 104(1), S51-S56.

12. Carruth, B.R., Ziegler, P.J., Gordon, A., & Barr, S.I. (2004). Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering new food. Journal of the American Dietetic Association, 104(1), S57-S64

13. Satter, E. (1990). The feeding relationship, problems and interventions. Journal of Pediatrics, 117(2 pt 2), 5181-9.14. Galloway, A.T., Fiorito, L.M., Lee, Y., & Birch, L.L. (2005). Parental pressure, dietary patterns and weight status

among girls who are ‘picky/fussy’ eaters. Journal of the American Dietetic Association, 105, 541-548.15. Dovey, T.M., Staples, P.A., Gibson, E.L., & Halford, J.C. (2008). Food neophobia and ‘picky/fussy’ eating in

children: A review. Appetite, 50, 181-193.16. Granner, M.L., Sargent, R.G., Caalderon, K.S., Hussey, J.R., Evans, A.E., & Watkins, K.W. (2004). Factors of fruit

and vegetable intake by race, gender, and age among young adolescents. Journal of Nutrition Education and Behavior, 36, 173-180

17. Reimer, K., Smith, C., Reicks, M., Henry, H., Thomas, R., & Atwell, J. (2007). Child-feeding strategies of African American women according to stage of change for fruit and vegetable consumption. Public Health Nutrition, 7, 505-512

18. Birch, L.L., Fisher, J.O., Grimm-Thomas, K., Markey, C.N., Sawyer, R., & Johnson, S.L. (2001). Confirmatory factor analysis of the Child Feeding Questionnaire: A measure of parental attitudes, beliefs, and practices about child feeding and obesity prevention. Appetite, 36, 201-210.

19. Horodynski, M.A., Stommel, M., Brophy-Herb, H., & Weatherspoon, L. (2010). Low-income African American and Non-Hispanic white mothers’ self-efficacy, “picky eater” perception, and toddler fruit and vegetable consumption. Public Health Nursing Journal, 27, 408-417.