Transcript low

A “bottom up” typology of parent
feeding practices relates to Head
Start child BMI and diet
Frank Franklin, Michelle Feese Mary Lou
Lackey, Sheryl Hughes, Richard Shewchuk,
John Bentley, Edmond Kabagambe
UAB and Baylor College of Medicine
Background: Effect of Parent Feeding Style
and Practices on BMI and Diet
• Overall objective: Evaluate family-level
determinants and typology of diet and
BMI of normal low-income, ethnically
diverse dyads of preschool children and
their primary caregivers (CG)
• Prior research: Impact of parenting
styles in predominantly white middle
class children
Methods: Caregiver-Child Dyads
• Target population: 3-to-5 year old HS children
and primary caregiver (CG) (Hispanics,
African American, non-Hispanic Whites) in
Houston TX and Birmingham AL
• CG: Person responsible for > 50 % of child’s
diet outside HS; 95% females with 88%
mothers
• Total population: 770 CG-child dyads
consented
– 47% of eligible families consented
– 91% consented completed all assessments
(n= 704)
Methods: Assessments
Caregiver (CG) child feeding practices
Elicitation CG Strategies
Card Sort and Rating Scale
Child Feeding Strategy Clusters
24-Hour Dietary Recalls
3/CG, 3/child (2 weekdays &1 weekend day)
Collected using Nutrition Data System for
Research (NDS-R)
CG report of child diet when CG was present,
outside HS center
Defined food groups and diet score
Measured CG and child height, weight and BMI
Methods: Elicitation of Parenting
Strategies in Food and Feeding Domain
“What are the ways parents can help their
preschool child eat healthy foods?”
8 structured nominative groups for each
question with feeding experts and
separate groups of CG from each
race/ethnicity
Distillation and cognitive interviews of
nominated strategies
Results: 33 distinct strategies as
statements for card sorts and ratings
Methods: Card Sort Procedure
Keep junk
food out of
house
Mix FV
with other
foods your
child likes
Ask child to
help with
food
preparation
Keep child
from sweets if
they don’t eat
their FV
Show child
you enjoy
eating FV
Methods: CG Parenting in Food
and Feeding Domain
– Card sorts mapped multidimensional
scaling and hierarchical cluster analysis
– Derived Clusters
• Child Feeding Strategies : Five
• Each parent rated for their child via interview
– Strategies: effectiveness of each on a 3point scale (not very effective, a little bit
effective, and very effective)
Five CG-Derived Child Feeding
Strategy Clusters
1. Teachable Moments
2. Practical Methods
3. Supervise Child Diet with
Contingencies
4. Restrict Junk Foods/Sweets
5. Enhance Healthy Foods Available
Child Feeding Strategy Clusters
1. Teachable Moments
– tell child
• eating FV will make them strong
and healthy as a way to get them
to eat more FV
• they have to try at least a couple
of bites but don't have to eat it
• what will happen to them if they
eat too many bad foods
– using mealtimes to teach about
healthy eating
– ask to help you with food
preparation
Child Feeding Strategy Clusters
2. Practical Methods (examples)
–
–
–
–
–
–
add something to make F or V taste better
praise when you saw them eat F or V
reward with sweets if they eat their FV
mix F or V with other foods your child likes
give the specific F or V they like so at
least they eat some
parents deciding what F or V will be
served, and then let child decide which of
those they eat
Child Feeding Strategy Clusters
3. Supervision with Contingencies over Child
Diet
– make child feel guilty when they didn't
eat vegetables
– insist child sit at the table until they eat
their F or V
– keep child from
• going to play if they didn't eat their F
or V
• having sweets if they didn't eat their F
or V
Child Feeding Strategy Clusters
4. Restrict Junk Foods/Sweets
– limit snacking between meals
– set limits on the amount of sweet
drinks your child can have
– ask others to support you in getting
your child to eat F or V and to not go
against you by giving your child
candy or sweets
– keep junk food out of the house
– cut back on how often your child
eats fast food
Child Feeding Strategy Clusters
5. Enhance Healthy Food Availability
(examples)
•
•
•
•
•
•
show your child that you enjoy eating FV
offer F or V without forcing your child to eat
them
include some form of F or V or juice in most
meals so that your child gets used to eating
them
sit at the table and eating together as a family
put F or V where your child can easily reach
them buy F or V instead of junk food
make sure that F or V are available around
your house
Authoritarian Child Feeding Practices
(examples)
• Physically struggle to get him/her to
eat
• Promise something other than food if
he/she eats
• Say something to show your
disapproval for not eating dinner
• Warn that you will take away
something other than food if he/she
doesn’t eat
Authoritative Child Feeding Practices
(examples)
• Encourage to eat by arranging the food
to make it more interesting
• Reason to get him/her to eat
• Allow to choose the foods he/she
wants to eat for dinner from foods
already prepared
• Compliment for eating food
• Say something positive about child’s
food during dinner
Permissive Child Feeding Practices
(examples)
• Allow to eat as much as he/she wants
• Permit to decide whether he/she gets a
second or third helping
• Let decide how much he or she should
eat off of the plate
• Allow to eat what and when he/she
wants to eat
Methods: Defined Food Groups
Purpose: reduce number of variables
in regression models while defining
meaningful food subgroups
17 subgroups of NDS foods
subdivided larger food groups
by fat or sugar content and
energy density or how
normally selected or served
Defined Food Groups: CG and Child
Alcohol, Added Fats, Cakes/desserts,
Fried Vegetables, Non-fried
Vegetables, Fruit, Fruit Juice, High fat
dairy, Low fat dairy, Low-energy
beverages, Sugar-sweetened
beverages, Fatty meats, Lean meats,
Whole grains, Refined grains
Methods: Energy Adjustment of Defined Food
Group Servings
Goal: Examine effect of food composition on BMI
Problem: Defined food group servings correlated with
energy intake
Approach:
1. Transform each food group to attain normality
2. Regress each food group on total energy intake
using Willett’s method
3. Add mean intake of entire population to each
residual from regression analysis to obtain energyadjusted food groups
4. Regress energy-adjusted food groups as
independent variables on BMI as the dependent
variable.
BMI:CG and HS Children 3-5 years
of age (2004-2005)
Race/
Ethnicity-Gender
Obese*
(%)
Caregivers
AA-M
AA-F
57
*Adult BMI: Obese ≥30
18
29
44
W-M
W-F
Children
18
H-M
H-F
Obese**
(%)
20
40
39
34
**Child BMI :Obese: ≥95th percentile
Methods: Diet Score
Sugar sweetened beverages (+), lean meats
(-) and refined grains (-) associated
significantly with child BMI z-scores
Purpose: combine associations between
these food groups and create quartiles
Sugar sweetened beverages ranked in
descending order
Lean meats and refined grains ranked in
ascending order
Dietary score: Sum of quartile ranks
Higher diet score indicates better diet
Regression of Child Diet and Feeding
Strategy Clusters on BMI Z-score
Multiple regression with diet score
and 5 child feeding strategy
clusters to predict child BMI z-score
Diet score
ß-coefficient = – 0.1025 (p < 0.001)
Supervision with contingency
ß-coefficient = -0.2426 (p < 0.05)
Other strategy clusters not significant
Derivation of Child Feeding Factors
Principal components analysis and
Varimax rotation
5 CG derived feeding strategy clusters
3 Sets of parenting practices from
Hughes Child Feeding Questionnaire
(authoritarian, authoritative and
permissive)
Child Feeding Factor Solution
Factor 1 Factor 2
Authoritarian Low
High
Factor 3
Medium
Authoritative Medium High
Low
Permissive
Medium High
Low
Cluster 1
High
Low
Medium
Cluster 2
High
Medium
Medium
Cluster 3
Medium Low
High
Cluster 4
High
Low
Medium
Cluster 5
High
Low
Low
Description of Child Feeding Factors
Factor 1 Low demands, supervision
monitoring, contingency with many
other strategies
Factor 2 All practices with few
strategies
Factor 3 High demands, supervision
monitoring, contingency with low
permissive, low facilitation
Regressions of Child Feeding Factors
+/- Diet Score on Child BMI Z-score
Predictors
ß coefficient
ß coefficient
Factor 1
- 0.013
0.015
Factor 2
- 0.17*
- 0.17*
Factor 3
- 0.15*
- 0.12*
Diet Score
Not entered
- 0.15*
* p < 0.01
Correlation of Child Feeding Factors
with Parenting Constructs
Factors Demandingness Responsiveness
1
- 0.04
0.30*
2
0.93 *
- 0.20 *
3
0.20 *
- 0.35 *
* p < 0.001
Typology From Child Feeding Factors
Factor 1 Factor 2 Factor 3
Type 1
Low
High
%
Medium
18
Low
26
Medium
28
Medium Medium
22
Type 2
Medium Medium
Type 3
Medium
Type 4
High
Low
Types: Characteristics and Differences
Type 4: all three factors; thus used all
practices and strategies
Type 2: low on demands, supervision
involvement, monitoring contingency,
many other strategies and practices
Types 1 and 3: do not use the full array of
practices
Major difference of Type 4 vs.2 is high
demands and supervision with
contingencies
Major difference of Type 4 vs.2, 3 is use of all
practices and strategies
CG and Child BMI and Child Diet in Four Types
Typology
CG BMI
Child BMI Child Diet
Z-score
Score
0.83
4.25
1
31.0
2
30.9
0.97
4.02
3
32.1
0.82
4.83
4
31.4
0.72
4.77
% of Expert Derived Typology (Hughes)
within CG Derived Typology
Caregiver
1
2
3
4
Authoritative
16
21
1
31
Authoritarian
74
18
4
43
Indulgent
4
46
52
20
Uninvolved
6
16
43
6
Expert
Top Down Parenting Typology
Demandingness
Responsiveness
High
Low
High
Low
Authoritative
Indulgent
Authoritarian
Uninvolved
CG Typology Derived From Child Feeding
Factors
Factor 1 Factor 2 Factor 3
Type 1
Low
High
%
Medium
18
Low
26
Medium
28
Medium Medium
22
Type 2
Medium Medium
Type 3
Medium
Type 4
High
Low
Conclusions (1)
• Type 4 vs. 2 better child diet and BMI
• Factors 1 and 3 > in Type 4 vs. 2
• High factors 2 and 3 ~ low child BMI and
high child diet; factor 1 no effect
• Thus factor 3 is major BMI-relevant
difference in Type 4 vs. 2
• Factor 3 is high in authoritarian (“telling”)
practices, supervision with contingency
Conclusions (2)
• Type 4 vs. 2: ~ 2 X higher %
authoritarian and authoritative styles
• Both authoritarian and authoritative
styles: high demandingness.
• Top down and bottom up typologies:
demandingness is consistent better BMI
and diet relevant parenting construct
• Potential of typology to target families
for intervention
Future: Intervene in HS and Homes with
Focus on Meal and Play Interactions
That’s All Folks!
Questions
Correlations: Strategy Clusters, Problem
Clusters and Diet to Child BMI Z-Score
• Strategy cluster 3 (r= -0.088,
p=0.018)
• Other strategy clusters and
problem clusters not correlated
• Sugar sweetened beverages (r=
0.09, p=0.01)
• Lean meats (r= - 0.08, p=0.03)
• Refined grains (r= - 0.08, p=0.04)
• Diet score (r= - 0.146, p<0.0001)
Strategy Cluster 3 and Caregiver and Child Diet Score and BMI
Caregiver BMI
Caregiver Diet
Score
.38*
.19*
.15*
Strategy
Cluster 3
Child Diet
Score
-.1
1
*
-.10*
Child BMI
Z-score
* p< 0.05
Parenting Practices, Home Availability,
Caregiver and Child Diets and BMI: Head Start
** Diet Score: Average of
Vegetables Low Fat
NDS and Block fruit, lean
Fruit
.61*
Dairy
.10*
meat, refined grains and
.85*
.12*
sugar beverage groups
Healthy
7
Food Home
.56*
.0
Caregiver Diet .04
Availability
Caregiver
.05
Score**
BMI
.3
4*
Supervision
.48*
with Contingency
.27*
.19*
*
0
5
.
.00
Unhealthy
Child Diet
-.09* Child BMI
-.34*
Food Home
Score**
Z-score
Availability
.38*
French
Fries
.77*
Sweetened
Beverages
.09*
-.11*
* p< 0.05
Four CG-Derived Problem
Clusters
1. Vegetables Unappealing/
Sweets Appealing to Child
2. Child Attributions: Favors Sweet
Drinks, Snacks, Fast Food
3. External Influences on Child Diet
4. Competing Demands on CG
3 Factor Solution: Standardized
Factor 1 Factor 2
Authoritarian Low
Factor 3
High
High
Authoritative Medium High
Low
Permissive
Medium High
Very Low
Cluster 1
High
Low
Low
Cluster 2
High
Medium
Low
Cluster 3
Low
Low
High
Cluster 4
High
Low
Medium
Cluster 5
High
Low
Very low
Correlations of Factors with the
Hughes Styles
Factors Authoritarian Authoritative
Indulgent
Uninvolved
1
0.10**
- 0.14**
0.16**
- 0.13**
2
0.37**
0.55**
- 0.49**
- 0.42**
3
- 0.10**
0.24**
- 0.22**
0.08*
* P < 0.05, ** p < 0.01
Eligibility for Head Start
Household income < the federal poverty
level ($20,000 for a family of 4)
or
If the family is eligible or in the absence of
child care would potentially be eligible for
public assistance
Head Start: National Enrollment
(Fiscal YR 2005)
National Enrollment 906,993
5 years old and older 4%
4 years old 52%
(Early Head Start) 3 years old and under 44%
Eligibility: Household income < the federal poverty level
($20,000 for a family of 4)
Race/Ethnic Composition
Black/African-American 31 %
White 35 %
Hispanic/Latino 33 %
American Indian/Alaskan Native 5.2%
Asian 1.9%
Hawaiian/Pacific Islander 0.8%
Bi-Racial/Multi-Racial 7.4%
Unspecified/Other 18.6%
Defined Food Groups: Grains
Refined grains: bread and roll , grains, flour,
dry mixes , pasta , other breads , ready to eat
cereals (presweetened), ready to eat cereal
(not presweetened
Whole grain: whole grain breads, whole grain
ready to eat cereals, presweetened/not
presweetened , whole grain grains, flour/dry
mixes, some whole grain/whole grain loaftype bread , some whole grain ready to eat
cereals, presweetened/not presweetened
Defined Food Groups:
Sugar-sweetened beverages: sweetened
fruit drinks, soft drinks , sweet tea, nondairy frozen dessert
Low-energy beverages: unsweetened water,
artificially sweetened fruit drinks/soft
drinks, unsweetened tea
Low fat dairy: low fat/fat free milk, low fat/fat
free yogurt ready to drink flavored low
fat/fat free milk
High fat dairy: whole/reduced fat milk,
cheese –full/reduced fat , frozen dairy
dessert , ready to drink flavored whole and
reduced fat milk
Defined Food Groups: Fruits and
Vegetables
Fruit juice: citrus juice, non-citrus juice.
Fruit: non-citrus fruits, citrus fruits
Non-fried Vegetables: vegetables including
those in salads, stews, stir fried/other
mixed dishes, tomatoes, white potatoes,
other starchy vegetables, deepyellow/dark green vegetables, avocado &
similar
Fried vegetables: fried potatoes, fried
vegetables
Defined Food Groups
Cakes/desserts: refined grain/some whole
grain cakes, cookies, pies, chocolate candy
Chips : vegetable savory snacks , whole
grain/refined grain snack chips , popcorn
Sweets sauces and Candies: reduced fat
sauces & condiments/diet sweet sauces,
sugar, syrup, honey, jam, sweet flavored
milk beverage powder without non-fat dry
milk, non-chocolate candy
Added Fats: oil, regular butter & other animal
fat, regular margarine shortening, reduced
fat margarine
Alcohol: beer, wine, liquor
Defined Food Groups
Lean meat: lean poultry/eggs, lean pork, fish/
shellfish, beef, legumes , lean cold cuts &
sausage
Fatty meats: beef , cold cuts/sausage , fried
chicken/ poultry , nut & seed butters , pork ,
fried fish , nuts & seeds