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
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EXPLORING THE RESTRICTIVE EEDING · Aim of the study and research methods . ... (QUAL → quant) was selected for research. This commenced with an exploratory qualitative component
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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
2.2 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
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
4.5 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
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
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
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
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
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
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 2.5 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
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
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).
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,
& 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.
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.
• 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.
− 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).
• 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*.
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
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).
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
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
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
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
^ 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
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
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,
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.
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
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).
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 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).
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
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
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
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.
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
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
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
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
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.
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).
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
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
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.
References 223
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• 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**
• 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
(+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
• 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.
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
• 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.
• 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
• 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)
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.
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
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.
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 &
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
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
- 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
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
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 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).
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.
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’.
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
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
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
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
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
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
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
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
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
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
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
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
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)
...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).
...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)
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)