Appetite 74 (2014) 125–132

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Child temperament and maternal predictors of preschool children’s eating and body mass index. A prospective study Heidi Bergmeier, Helen Skouteris ⇑, Sharon Horwood, Merrilyn Hooley, Ben Richardson School of Psychology, Deakin University, Melbourne, Australia

a r t i c l e

i n f o

Article history: Received 17 June 2013 Received in revised form 26 November 2013 Accepted 1 December 2013 Available online 15 December 2013 Keywords: Child eating behaviour Temperament BMI Preschool Maternal practices Prospective study

a b s t r a c t Research has previously identified relationships between child temperament and BMI during childhood. However, few studies have addressed the broader implications of child temperament on the development of obesogenic risk factors, such as maternal feeding, child eating and body mass index (BMI) of preschoolers. Hence, the current study evaluated cross-sectional and prospective associations between child temperament, maternal feeding, maternal parenting styles, mother–child interaction, preschoolers’ eating behaviours and BMI. Child irritability, cooperation-manageability and easy–difficult temperaments, mother–child dysfunctional interaction, maternal pressure to eat and restriction were significantly cross-sectionally associated with child eating behaviours. Child enjoyment of food was significantly associated with child BMI. Child easy–difficult temperament and mother–child dysfunctional interaction predicted child eating behaviours longitudinally and baseline child BMI measures predicted child BMI longitudinally. Average maternal ratings of child temperament were relatively neutral, potentially explaining why most associations were not robust longitudinally. Future research should include a sample of greater socio-economic and BMI diversity as well as objective measures of child temperament, diet composition, maternal feeding practices, and mother–child interaction. Ó 2013 Elsevier Ltd. All rights reserved.

Introduction The implications associated with rising global prevalence rates of childhood overweight and obesity are concerning (Australian Bureau of Statistics, 2009). Worldwide childhood obesity trends estimate 43 million children to be overweight or obese (de Onis, Blossner & Borghi, 2010). It is predicted that this upward trend will continue, with 60 million children (9.1%) being classified as overweight and obese in 2020 (de Onis et al., 2010). Indeed, obesity rates are increasing in children under five years of age in developed and developing countries (Smith, Craig, Raja, McNeill, & Turner, 2013; Yu et al., 2012). Moreover, the prevalence of so-called ‘‘lifestyle diseases’’, once predominantly identified in adulthood only, such as insulin resistance, hypertension and hypercholesterolemia, have become increasingly more evident in children in accordance with the acceleration of pediatric obesity rates (Labree, van de Mheen, Rutten, & Foets, 2010; Wu, Dixon, Dalton, Tudiver, & Liu, 2011). Research shows that child weight status is determined by multiple characteristics involving complex interactions of factors within the child ecology, such as genetic predisposition to body

⇑ Corresponding author. E-mail address: [email protected] (H. Skouteris). 0195-6663/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.appet.2013.12.006

structure, physical activity levels, sleep patterns and temperament as well as between child, family (e.g., parental food practices; family socioeconomic status) and community/societal factors, such as access to recreational facilities and peer BMI (Davidson & Birch, 2001; Harrison et al., 2011). Whilst much research has been published on the obesogenic risk factors of child eating and physical/ sedentary activity, only a few studies have examined child temperament as an obesogenic risk factor. This is surprising given the associations between temperament and other aspects of child cognitive and social–emotional development (Calkins, 2005; Rueda & Rothbart, 2009; Sanson, Hemphill, & Smart, 2004) and that child self-regulation and soothability have been implicated in obesity development (Johnson & Birch, 1994; Schore, 2001). Temperament refers to constitutionally based differences in behavioural style that are evident from the earliest years (Sanson et al., 2004). These individual differences specifically refer to emotional, motor and attentional reactions and patterns of behavioural and attentional self-regulation. Temperament traits include negative affectivity/emotionality (easily distressed, inhibited, cry often and low soothability), self-regulation/effortful control (self soothing) and positive affect/approach (high soothability, uninhibited and approach novel situations). Child temperament differs from child eating, physical and sedentary activities in that it is an intra-individual characteristic that the child brings to the

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relationship with his/her parent. Subsequently, researchers have recently argued for the need to extend the uni-directional, topdown models of childhood obesity to incorporate the bi-directional interactions of factors encompassed by ecological models (Skouteris et al., 2011). This view is supported by studies showing highquality parent–child relationships contribute to the cognitive, social, and emotional factors involved in obesity prevention through their influence on child emotion regulation and stress response (Anderson, Gooze, Lemeshow, & Whitaker, 2012; Dallman, 2010; Schore, 2001). Furthermore, it is possible that child temperament is associated with maternal feeding practices given that maternal practices are associated with other child characteristics, such as age and gender (Anzman & Birch, 2009). To date, only five longitudinal (Faith & Hittner, 2010; Francis & Susman, 2009; Graziano, Calkins, & Keane, 2010; Wu et al., 2011) and three cross-sectional studies (Haycraft, Farrow, Meyer, Powell, & Blissett, 2011; Hughes, Shewchuck, Baskin, Nicklas, & Qu, 2008; Tan & Holub, 2011) have examined whether child temperament is associated with or predicts child weight status in pre-schooler children and only two of these studies included measures of maternal feeding behaviours and cognitions implicated in child overweight and obesity (Bergmeier, Skouteris, Horwood, & Richardson, 2013). All but one of the studies (Haycraft et al., 2011) identified a link between child temperament and weight status. Thus, researchers have proposed that the temperament traits potentially implicated in the development of child overweight and obesity are: (a) poor self regulation (Francis & Susman, 2009; Graziano et al., 2010; Tan & Holub, 2011); (b) high emotionality (e.g., anger, frustration) (Haycraft et al., 2011); (c) low negative affectivity (Hughes et al., 2008); and (d) high and low soothability (Francis & Susman, 2009; Wells et al., 1997). Wells et al. (1997) proposed that children rated as ‘‘difficult’’ resulted in certain parental strategies of care, such as, fussy children being offered more calorie-dense foods. In contrast, Faith and Hittner (2010) found highly soothable girls in their study demonstrated greater weight gain. Upon further analysis however, they found that standardised weight increases were noted in both low- and high-soothability girls until the age of 4 years, before diverging between 4 and 6 years of age. Studies by Francis and Susman (2009), Graziano et al. (2010) and Tan and Holub (2011) found that children’s failure to self-regulate in laboratory-based tasks was associated with greater gains in BMI. Graziano et al.’s study also revealed that poorer emotion regulation skills were found to be a stronger predictor than BMI at 2 years of age in determining which children would be classified as overweight at 5.5 years of age. In terms of maternal factors, the review revealed a negative relationship between parental beliefs concerning their child’s ability to self-regulate and their implementation of restrictive feeding practices (Tan & Holub, 2011). Alternatively, it also identified a positive relationship between indulgent feeding and parents who rated themselves and their child as experiencing less negative affectivity (Hughes et al., 2008). Furthermore, the indulgent feeding style was related to higher BMI in preschool-aged children. Much of the existing childhood obesity literature has already provided evidence of the association between maternal child feeding practices, child eating and child BMI, and a recent review of the literature evaluated maternal correlates of maternal feeding practices, including child eating behaviours, child BMI, mother–child interaction and maternal parenting styles (McPhie, Skouteris, Daniels, & Jansen, 2012). Moreover, McPhie et al. (2011) extended research to date by examining the cross-sectional associations between maternal parenting styles, maternal-child interactions, maternal feeding practices, preschool child eating behaviours and preschool child BMI. Their results showed that maternal pressure

to eat was associated positively with child food fussiness, but associated negatively with child enjoyment of food. In contrast, maternal warmth and monitoring of her child’s food intake were associated negatively with child BMI, whereas mother–child dysfunctional interaction was associated positively with child BMI. McPhie et al. (2012) extended their study by prospectively evaluating these associations 12-months apart. Results showed maternal pressure to eat positively predicted change in child enjoyment of food, maternal warmth negatively predicted child unhealthy food habits and maternal pressure to eat positively predicted child BMIz after 12-months. Given the recent literature highlighting the importance of child temperament’s role in childhood obesity (Bergmeier et al., 2013), the aim of the current study was to extend McPhie et al. (2012) research by evaluating child temperament as a correlate and predictor, of child eating behaviour and child BMI. It was hypothesized that higher ratings in temperaments perceived as being more difficult (e.g., irritability), dysfunctional mother–child interaction, maternal restriction of food, child enjoyment of food and lower ratings of food fussiness would be associated with BMIz at T1 and T2. It was also hypothesized that higher ratings of BMIz at T1 would be associated with lower ratings of food fussiness and higher ratings of child enjoyment of food and BMIz at T2. Method Participants The current study recruited mother–child dyads to participate in an Australian Research Council Discovery grant study: How do parenting and parent–child interactions impact on preschool children’s eating, physical activity habits, and subsequent patterns of weight gain? The child temperament component of the study comprised 201 mothers of 116 (57.7%) female and 85 (42.3%) male preschoolers. Study design This prospective study evaluated maternal and child factors collected at two time points (T1; T2) set approximately 12-months apart. Participants were recruited between 2009 and 2011. Measures Demographic information Mothers were asked to report socio-demographic information including their child’s age and gender at the commencement of the study (Time 1; T1). Maternal weight status Mothers were asked to report their height and weight, and BMI was subsequently calculated (weight/height2, kg/m2) at (T1). Child weight status Mothers were asked to report their child’s height and weight measurements at commencement of the study (T1) and approximately 12-months later (T2), which were used to calculate child BMI z-scores. In order to classify children as normal weight, overweight or obese, the study used BMI cut-off points developed by the Centers for Disease Control and Prevention (2000). This approach uses updated growth curves to provide age and sex specific cut-off points based on how children should grow in view of current health promotion norms. Child overweight was classified as BMI-for-age between the 85th and 95th percentile and child

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obesity for a BMI-for-age at or above the 95th percentile (Ogden & Flegal, 2010). Validation of maternal-report BMI All families taking part in the broader study were invited to participate in home visits to validate maternal reports of BMI. Mothers (n = 64) were asked to report their own and child’s (n = 65) measures prior to being evaluated by researchers using calibrated scales and stadiometer. The correlations between the objective and maternal-reported BMI data collected on the same day were .67 and .97, for children and mothers, respectively (McPhie et al. 2011). Maternal parenting styles The Warmth and Control subscales of the parenting style questionnaire from the Longitudinal Study of Australian Children (LSAC; Wake, Nicholson, Hardy & Smith, 2007) were included in the questionnaire at T1 to evaluate how parents behave and respond emotionally to their child. The Warmth and Control subscales were developed for classifying styles of parenting based on Baumarind’s (1973) typologies: Authoritative parenting (high levels of warmth combined with high control) is considered the optimal combination for promoting healthy child development outcomes; Authoritarian parenting (high control and low warmth) is associated with lower self-esteem, aggressiveness and social competence; Permissive (high warmth and low control) is associated with impulsivity and substance use; Neglectful (low warmth and low control) is associated with emotional problems and delinquency. Mothers were asked to record responses on a five-point Likert scale (1 = Never; 5 = All the time) to questions such as ‘‘How often do you hug or hold this child for no particular reason?’’: The Cronbach’s alpha for the Warmth subscale was .84, and .70 for the Control subscale (after the deletion of one item; ‘‘When you discipline this child, how often does he/she ignore the punishment?’’ to improve the internal consistency to an acceptable level; (McPhie et al., 2011).

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Child eating behaviours The Food Fussiness and enjoyment of food subscales of the Child Eating Behaviour Questionnaire (CEBQ; Wardle, Guthrie, Sanderson, & Rapoport, 2001) were completed at T1 and T2 to assess child eating behaviours. The Food Fussiness subscale was developed to measure eating behaviours characterised as being highly selective (e.g., picky) about groups of foods that are accepted, whereas child enjoyment of food was developed to measure eating behaviours characterised by enjoyment of eating and interest in food. Mothers rated the extent statements relating to levels of enjoyment of food and openness to trying new foods depicted their child, such as ‘‘My child enjoys tasting new foods’’, using a fivepoint Likert scale (0 = Never; 4 = Always); Cronbach’s alphas were .91 and .94, for the two subscales, respectively. Higher scores represented higher levels of each child eating behaviour. Child temperament The Short Temperament Scale (STS; Sanson, Prior, Oberklaid, Garino, & Sewell, 1987) was used to measure child temperament traits at T1 by means of parental responses recorded on a six-point Likert scale (1 = Almost never; 6 = Almost always) to questions such as: ‘‘My child cries when left alone to play’’. The STST was based on the model of temperament developed by Thomas and Chess (1977). Dimensions of temperament measured include: Approach (shy versus outgoing); Rhythmicity (regularity of biological functions such as sleeping); Cooperation/Manageability (ease of adaptation to everyday events); Activity/Reactivity (active reaching for objects, and intensity of reactions); and Irritability (crying and fussing). The composite easy–difficult temperament scale was developed using the three temperament dimensions, Cooperation, Irritability, and Approach. Children scoring at the difficult end of this scale tend to show more problems such as crying and sleep difficulties. The Cronbach’s alphas for the approach, activity–reactivity, easy–difficult, irritability and cooperation-manageability subscales ranged from 0.82 to 0.85. Procedure

Maternal child feeding behaviours The restriction and pressure to eat subscales of the Child Feeding Questionnaire (CFQ, Birch et al., 2001) were administered at T1 to measure maternal feeding attitudes and behaviours. The CFQ is one of most widely used tools for measuring parental controlling feeding practices. The Restriction subscale was developed to measure parental practices designed to limit their child’s food intake or prevent their child from eating, whereas the pressure to eat subscale was developed to measure parental practices intended to encourage their child to eat. Parents were asked to record their responses on a five-point Likert scale (1 = Never; 5 = All the time) to questions such as ‘‘How concerned are you about your child becoming overweight?’’ and ‘‘I intentionally keep some foods out of my child’s reach’’; Cronbach’s alphas were .78, .95 and .73 for the three subscales, respectively. Mother–child interactions The Parent–Child Dysfunctional Interaction (PD) subscale of the Short Form of the Parenting Stress Index (PSI-SF; Abidin, 1995) was used to examine stressful aspects of parent–child interactions at T1. The PSI-SF was designed to identify parents at risk of child abuse or neglect and the PD subscale measures the levels of mother–child dysfunction as reported by the mother. For example, mothers were asked to indicate the extent to which they agreed with statements such as, ‘‘My child is not able to do as much as I expected’’ and ‘‘Since having a child I feel that I am almost never able to do things that I like to do’’. Higher scores indicate higher levels of parent–child dysfunctional interaction. Cronbach’s alpha for this subscale was .63.

Participants were recruited for the larger study through advertisements placed in parenting magazines, childcare centres, preschools and kindergartens across metropolitan and rural Victoria. Following approval from The Deakin University Human Research Ethics Committee. Self-report questionnaires and reply paid envelopes were sent to participants over 2 different time points (T1; T2), set approximately 12-months apart. The first questionnaire pack containing demographic questionnaires, the LSAC parenting styles measure, PSI-SF, CFQ, CEBQ, STSC and a reply paid envelope were sent to participants at the commencement of the study (T1). Approximately 12 months later (T2), participants were mailed invitations to complete another CEBQ and child weight and height were again self-reported by mothers at this follow up time point two. Statistical analyses Correlations were conducted to examine the associations amongst the T1 covariates (maternal educational achievement, family income, and maternal BMI), T1 predictors (Child BMIz, child temperament, maternal child feeding practices, maternal Warmth and Control, and mother–child dysfunctional interaction) and T1 outcome variables (child eating behaviours and child BMIz). Hierarchical regressions were conducted to examine crosssectional predictors of T1 child eating and BMIz. In addition, hierarchical regressions were conducted to examine prospective predictors of child eating and BMIz at T2. In the regression models, maternal covariates were entered at Step 1, child BMIz T1 was entered

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at Step 2, child temperament at Step 3, maternal warmth, control and mother–child dysfunctional interaction were entered at Step 4, maternal child feeding practices were entered at Step 5 and child eating fussiness T1 and child enjoyment of food T1 was entered at Step 6. Results Preliminary data analysis Prior to conducting analyses, all the data were examined using SPSS 20.0 for missing values, normality, homogeneity, linearity, outliers, multicollinearity and singularity. Missing values were addressed by Expectation Maximization method using SPSS 20.0, which iteratively fits a distribution to the data and inserts missing values based on the distribution using potential score ranges. The child temperament category ‘Approach’ was excluded from regressions due to multicollinearity. Intercorrelations between variables, means and standard deviations are shown in Table 1. Results yielding a p value equal to or less than .05 (p 6 .05) were considered statistically significant. Participant characteristics At the commencement of the study (T1), children were aged between 2 and 5 years (M = 2.92, SD = 0.75). Based on maternal self-reported child weight and height and age appropriate BMI classifications (CDC, 2000), 33 (16%) were underweight, 142 (71%) children were classified as being a healthy weight, 20 (10%) considered overweight and 6 (3%) obese at T1. The mothers ranged in age from 25 to 52 years (M = 36.11, SD = 4.09) and the majority were born in Australia (81.9%), followed by Europe (8.9%) and New Zealand (3.4%). More than half of the mothers (67.7%) had achieved at least a bachelor degree level of education, and at the time of the study 17.6% of the participants reported an annual family income in excess of A$145,001, 44.5% reported an income between A$85,001-A$145,000, 31.5% reported an income between A$45,001-A$85,000 and 6.4% reported a family income below A$45,000. Mother’s BMI ranged from 16.62 to 42.24, with an average BMI of 25.03 (SD = 4.54) at T1. Based on adult cut-off points which classify a BMI of 25 kg/m2 as overweight and 30 kg/m2 as obese (Cole, Bellizzi, Flegal & Dietz, 2000), the sample consisted of 1.9% underweight, 52.9% normal weight, 35.2% overweight and 10% obese mothers. Baseline cross-sectional associations between child temperament and child and maternal predictors of child eating and BMIz As shown in Table 2, the cross-sectional hierarchical regression analysis shows the inclusion of Step 2 child temperament accounts for 15% of the variance in child enjoyment of food, in which child irritability and cooperation-manageability temperaments were significant negative correlates, b = .20, p < .01, b = .26, p < .05 and child easy–difficult was a significant positive correlate, b = .29, p < .01. Step 3 accounted for 4% of the variance in child enjoyment of food, with mother–child dysfunctional interaction emerging as a significant negative correlate, b = .23, p < .01. Step 4 contributes 19% of the variance in child enjoyment of food; maternal restriction of food was a significantly positive correlate, b = .20, p < .01, whilst maternal pressure to eat was a significant negative correlate, b = .39, p < .01. Step 2 child temperament also accounted for 10% of the variance in child food fussiness; child irritability was a significant positive correlate, b = .24, p < .05, and child easy–difficult temperament was a negative correlate, b = .35, p < .01. Step 3

contributed 8% of variance to child food fussiness, in which mother–child dysfunctional interaction was a significant positive correlate, b = 33, p < .01. Finally, Step 5 child eating behaviour was the only step to contribute significant variance (5%) in child BMI, with child enjoyment of food emerging as a significant positive correlate b = .29, p < .01. Prospective associations between child and maternal T1 variables and child eating and BMIz at T2 The hierarchical regression analysis (Table 2) shows the inclusion of maternal covariates at Step 1 significantly accounted for 5% of the variance in child food fussiness. Annual family income emerged as a positive correlate of enjoyment, b = .16, p < .05, whilst maternal education was a significant negative correlate, b = .17, p < .05. Furthermore, the addition of Step 3 child temperament significantly accounted for 1% of the variance in child food fussiness, in which child easy–difficult temperament was a significant negative correlate, b = .35, p < .01. Step 4 also significantly accounted for 8% of the variance in child food fussiness with mother–child dysfunctional interaction emerging as a significant positive correlate, b = .31, p < .01. Only the addition of Step 2 significantly accounted for 8% of the variance in child BMIz at T2, in which child BMIz at T1 was a significant positive correlate, b = .29, p < .01. None of the steps significantly accounted for the variance in child enjoyment of food at T2 (see Table 3). Discussion The expected associations between child temperament and child BMI were not found within this sample. Based on associations identified in previous research (Faith & Hittner, 2010; Francis & Susman, 2009; Graziano et al., 2010; Tan & Holub, 2011; Wu et al., 2011), it was expected that child temperament would have significantly contributed to child BMI outcomes here also. Child temperament traits irritability, cooperation-manageability and easy–difficult, however, did predict child enjoyment of food and child temperament traits irritability and easy–difficult predicted child Food Fussiness cross-sectionally. Interestingly, easy–difficult was the only child temperament trait that also predicted child eating (child Food Fussiness) longitudinally. Other childhood obesity research (e.g., Tan & Holub, 2011; Wu et al., 2011) focusing on child temperament in pre-schoolers has evaluated associations with child BMI status, rather than child eating behaviours. However, it is known that parents’ reports of ‘‘difficult temperaments’’ are associated with children consuming significantly higher amounts of carbohydrates (Wells et al., 1997); moreover, as children who exhibit lower food fussiness have been shown to eat more (Spence, Carson, Casey, & Boule, 2010) it would follow that they would also consume a greater amount of calories. It is possible that child temperament was not a significant correlate of child eating behaviours and child BMI (with the exception of easy–difficult temperament) because the average maternal rating of child temperament was relatively neutral and most of the children participating in the study were classed within the healthy BMI range; as such, the sample under-represented overweight/obese BMI and temperament classification groups of Australian children. It is also possible that associations between child temperament and child eating may have a greater influence on child weight status once children’s growth rates enter slower phases. The expected associations between child temperament, maternal feeding, maternal parenting styles, mother–child interaction and child eating behaviours and child BMI were not found within this sample. Mother–child dysfunctional interaction showed a

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H. Bergmeier et al. / Appetite 74 (2014) 125–132 Table 1 Intercorrelations, means and standard deviations of child and maternal T1 variables. Bold indicates significant result at p < .05 or p > .01.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 M SD

1 App

2 Rhy

3 Coo

4 Act

5 Irr

6 Eas

7 MBI

8 Inc

9 Edu

10 CB1

11 War

12 Con

13 Int

14 Fus

15 Enj

16 Res

17 Pre

18 Mon

1

.29** 1

.34** .44** 1

.14 .01 .03 1

.40** .31** .43** .19** 1

.79** .33** .65** .01 .04 1

.02 .06 .03 .02 .06 .07 1

.10 .18* .10 .02 .10 .09 .09 1

.09 .01 .01 .04 .06 .03 .09 .35** 1

.02 .05 .08 .05 .03 .05 .05 .04 .01 1

.05 .00 .05 .03 .06 .04 .01 .08 .17 .07 1

.02 .02 .03 .01 .10 .06 .11 .11 .12 .02 .17 1

.36** .20** .33** .16* .53** .20** .00 .03 .03 .01 .07 .02 1

.29** .11 .14* .05 .15* .24** .14* .04 .07 .09 .01 .05 .39** 1

.30** .16* .11 .11 .30** .15* .01 .02 .00 .22** .04 .03 .35** .54** 1

.08 .04 .07 .13 .11 .01 .08 .01 .06 .02 .04 .04 .16* .03 .15* 1

.24** .18 .07 .10 .17* .14* .06 .13 .11 .12 .04 .01 .19** .21** .48** .06 1

31.62 5.71

27.54 4.62

27.33 4.42

21.24 4.63

12.11 3.88

71.06 7.19

25.06 4.42

5.18 1.86

6.41 1.64

-.03 1.31

26.90 2.68

19.53 2.44

26.15 8.36

9.92 4.95

11.79 2.93

28.78 5.67

9.07 4.09

.12 .15* .12 .12 .11 .11 .09 .12 .03 .04 .14 .05 .02 .05 .00 .16* .02 1 13.44 2.21

Abbreviations and numerical codes: App & 1 = Approach; Rhy & 2 = Rhythmicity; Coo & 3 = Cooperation-manageability; Act & 4 = Activity–reactivity; Irr & 5 = Irritability; Eas & 6 = Easy–difficult; MBI & 7 = Maternal BMI; Inc & 8 = Annual family income; Edu & 9 = Mother’s highest level of education; CB1 & 10 – Child BMIz T1; War & 11 = Warmth; Con & 12 = Control; Int & 13 = Dysfunctional interaction; Fus & 14 = Food fussiness; Enj & 15 = Enjoyment of food; Res & 16 = Restrictive feeding; Pre & 17 = Pressure to eat; Mon & 18 = Food monitoring. * Correlation is significant at the 0.05 level (2-tailed). ** Correlation is significant at the 0.01 level (2-tailed).

Table 2 Cross-sectional child and maternal predictors of child eating behaviour and BMI. Bold indicates significant result at p < .05 or p > .01. Predictors

Enjoyment T1

Fussiness T1

Child BMIz T1

Step 1 Maternal education Family income Maternal BMI Step 2 Rhythmicity Cooperation-manageability Activity–reactivity Irritability Easy–difficuly Step 3 Warmth Control Interaction (dysfunctional) Step 4 Restriction Pressure to eat Monitoring Step 5 Fussiness T1 Enjoyment T1

R2 change = 00 (n.s.) .00 (n.s.) .02 (n.s.) .11(n.s.) R2 change = 0.15 (p < .01) .08 (n.s.) .26 (p < .05) .03 (n.s.) .38 (p < .01) .29 (p < .01) R2 change = 0.04 (p < .05) .06 (n.s.) .07 (n.s.) .23 (p < .01) 2 R change = .19 (p < .01) .20 (p < .01) .39 (p < .01) .04 (n.s.)

R2 change = .03(n.s) .10 (n.s.) .06 (n.s.) .14 (n.s.) R2 change = .10 (p < .01) .03 (n.s.) .19 (n.s.) 00 (n.s.) .24 (p < .05) .35 (p < .01) R2 change = .08 (p < .01) .04 (n.s.) .07 (n.s.) .33 (p < .01) R2 change = .02 (n.s.) .02 (n.s.) .12 (n.s.) .05 (n.s.)

R2 change = 00 (n.s.) .00 (n.s.) .04 (n.s.) .05 (n.s.) R2 change =.01 (n.s.) .03 (n.s.) .06 (n.s.) .05 (n.s.) .00 (n.s.) .01 R2 change = .01 (n.s.) .08 (n.s.) .01 (n.s.) .02 (n.s.) R2 change = .01 (n.s.) .01 (n.s.) .14 (n.s.) .06 (n.s.) R2 change = .05 (p < .05) .02 (n.s.) .29 (p < .01)

cross-sectional association with lower enjoyment of food. Mother– child dysfunction interaction was cross-sectionally and longitudinally associated with higher food fussyness. These findings were inconsistent with McPhie et al.’s (2011) results, which showed higher dysfunctional interaction was associated, cross-sectionally, with higher child BMI but not between mother–child dysfunctional interaction and child eating behaviours. In contrast, the results of the current study support Hughes et al.’s (2008) results showing associations between mother–child lower negative affectivity ratings, indulgent maternal feeding styles and higher child BMI. Washington, Reifsnider, Bishop, Ethington, and Ruffin (2010) also found that children who had positive interactions with their mothers had higher BMIs. Whilst mother–child dysfunctional

interaction was not associated with child BMI in our study, it is possible that the impact of on child weight status may not have been evident after only one year. Indeed, Wu et al. (2011) found the relationship between children with more difficult temperaments and less sensitive mothers were at greater risk of becoming overweight or obese did not become apparent until the primary school years. Average maternal ratings of mother–child dysfunctional interaction in the current study were within the lower half of the score range and as discussed earlier, average maternal child temperament ratings were neutral. Therefore, the association between mother–child interaction and child BMI identified within this sample aligns with the theoretical perspectives proposed by Harrison et al.’s (2011) ecological development of obesity model

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Table 3 Temperament, child and maternal variables predicting Child Eating Behaviour and BMI after one year. Bold indicates significant result at p < .05 or p > .01. Predictors Step 1 Maternal education Family income Mother BMI Step 2 child BMIz T1 Step 3 Approach Rhythmicity cooperation-manageability Activity–reactivity Irritability Easy–difficult Step 4 Warmth Control Interaction (dysfunctional) Step 5 Restriction Pressure to eat Monitoring Step 6 Fussiness T1 Enjoyment T1

Enjoyment T2 2

R change = 0.07 0.02 (n.s.) 0.03 (n.s.) 0.06 (n.s.) R2 change = 0.08 R2 change = 0.20 0.00 (n.s.) 0.01 (n.s.) 0.21 0.02 (n.s.) 0.11 (n.s.) 0.02(n.s.) R2 change = 0.21 0.09 (n.s.) 0.02 (n.s.) 0.1 (n.s.) R2 change = 0.22 0.02 (n.s.) 0.04 (n.s.) 0.05 (n.s.)

Fussiness T2 (n.s.)

(n.s.) 0.04 (n.s.) (n.s.) (n.s.)

(n.s.)

(n.s.)

regarding the complex reciprocal interactions between child temperament, child eating behaviours, maternal parenting styles, maternal feeding practices and mother–child interaction. For instance, recent evidence suggests that maternal responsiveness to child negative affectivity varies according to parenting stress (Paulussen-Hoogeboom, Stams, Hermanns, & Peetsma, 2008). Furthermore, comparisons between maternal reports and laboratory measures of child temperament, show maternal personality influences the extent to which a mother correctly rates her child’s temperament (Hayden, Durbin, Klein, & Olino, 2010). Future research, with the sample size to ensure significant power for path analyses or structural equation modelling and incorporating a comprehensive range of maternal and child covariates (e.g., maternal BMI and child temperament), is needed to help understand the complex reciprocal interactions between these child obesogenic risk factors. The cross-sectional association between greater maternal feeding restriction and child enjoyment of food was inconsistent with other research. Previous findings show that higher maternal feeding restriction is associated with children showing greater enjoyment of food and exhibiting less eating restraint when provided with access to foods that are normally restricted (Jansen, Mulkens, Emond, & Jansen, 2008; Jansen, Mulkens, & Jansen, 2007). The negative cross-sectional association between maternal pressure to eat and child enjoyment of food was consistent with McPhie et al.’s (2011) findings that show maternal pressure to eat was associated with lower enjoyment of food. However, this association between maternal pressure to eat and child enjoyment of food did not persist over time and may not be robust. Previous research (Fisher, Mitchell, Smiciklas-Wright, & Birch, 2002; Galloway, Fiorito, Francis, & Birch, 2006; Galloway, Fiorito, Lee, & Birch, 2005) has revealed longitudinal associations between pressure to eat and lower child BMI, however, this association was not evident in our study. Average maternal ratings in this study for pressure to eat and restriction feeding practices were similar, therefore, this finding suggests the need to determine mediating factors that facilitate the relationship between pressure to eat and child BMI. In terms of demographics, maternal education was negatively associated, with child food fussiness and annual family income and child enjoyment of food were positively associated longitudinally. McPhie et al. (2011) also reported an association between family income and child enjoyment of food, albeit their study

2

R change = 0.05 (p < 0.05) 0.17 (p < 0.05) 0.16 (p < 0.05) 0.13 (n.s.) R2 change = 0.00 (n.s.) 0.01 (n.s.) R2 change = 0.10 (p < 0.01) 0.1 (n.s.) 0.02 (n.s.) 0.10 (n.s.) 0.03 (n.s.) 0.15 (n.s.) 0.35 (p < 0.01) R2 change = 0.07 (p < 0.01) 0.06 (n.s.) 0.12 (n.s.) 0.31 (p < 0.01) R2 change = 0.01 (n.s.) 0.03 (n.s.) 0.11 (n.s.) 0.05 (n.s.)

Child BMIz T2 R2 change = 0.03 (n.s.) 0.05 (n.s.) 0.00 (n.s.) 0.02 (n.s.) R2 change =.08 (p < 0.01) 0.29 (p < 0.01) R2 change = 0.01 (n.s.) 0.01 (n.s.) 0.10 (n.s.) 0.08 (n.s.) 0.07(n.s.) 0.02(n.s.) 0.00 (n.s.) R2 change = 0.01 (n.s.) 0.02 (n.s.) 0.03 (n.s.) 0.10 (n.s.) R2 change = 0.00 (n.s.) 0.01 (n.s.) 0.02 (n.s.) 0.01 (n.s.) R2 change = 0.00 (n.s.) .03 (n.s.) 0.01 (n.s.)

was cross-sectional. These findings suggest demographics, such as maternal education and family income, may mediate the relationship between child temperament and other maternal and child factors associated with child eating. Consistent with McPhie et al’s study, our results did not reveal associations between maternal BMI and child eating or BMI. Prior research, however, shows that mothers with a higher BMI may be more likely to ‘‘comfort eat’’ (Koenders & van Strien, 2011; Nguyen-Rodriguez, Chou, Unger, & Spruijt-Metz, 2008; Ozier et al., 2008), and Hughes et al. (2008) suggested that mothers teach children to eat comfort food, which in turn, may reduce food fussiness because children learn to associate eating with positive emotions. Further research is needed to understand the mechanisms driving the associations between maternal BMI and child obesogenic risk factors. Child enjoyment of food, as measured at the first time point, was associated with higher child BMI. After 12 months this relationship was no longer evident, and child BMI at T1 emerged as the strongest predictor of child BMI at T2. Longitudinal research is needed to understand how and when these associations change over time to better understand the most pertinent times for implementing interventions. Limitations and future directions As discussed earlier, a significant limitation of the study was the under-representation of child BMI and temperament classification groups. In addition, the majority of the mothers were born in Australia, more than half the mothers were tertiary educated and annual family incomes were in the middle to upper economic bracket. Therefore, these findings may not be generalizable to mother–child dyads from other demographics. Another potential limitation was that children’s temperament and mother–child interaction measures were obtained via parental self-report and no objective measures were assessed to confirm their accuracy. Indeed, recent evidence into the relationship between maternal self-reported feeding practices and objectively-rated observed maternal feeding practices shows there is no significant association between what mothers say they do and what they actually do (Farrow, Blissett, & Haycraft, 2011; Haycraft & Blissett, 2008). Moreover, research shows independently-rated observations of maternal feeding allow researchers to analyse factors mediating

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the relationship between maternal ratings of child enjoyment of food and temperament (Forestell & Mennella, 2012). It is recommended that future studies include objective measures for rating mother–child interaction and child temperament and that bi-directional mother–child interactions are researched so that models of childhood obesity move from uni-directional and top-down approaches to approaches that include attention to parent, child and dyadic-level factors (Skouteris et al., 2011). Conclusion In the current study, only child temperament difficult was the longitudinally associated with child eating behaviour. Longitudinal associations between child temperament and child BMI were not evident, potentially due to average maternal neutral ratings of child temperament. Not surprisingly, child BMI at baseline emerged as the strongest predictor of child BMIz one year later. The findings also revealed a longitudinal association between mother–child dysfunctional interaction and child food fussiness. These findings support the argument that childhood obesity research needs to incorporate the factors encompassed by ecological models. Longitudinal research comprising a sample of greater socio-economic, ethnic and BMI diversity as well as objective measures of child temperament, diet composition, maternal feeding practices, and mother–child interaction will help close the gap in our understanding of child obesity determinants. References Abidin, R. (1995). Parenting stress index. Professional manual (3rd ed.). Florida: Psychological Assessment Resources. Anderson, S. E., Gooze, R., Lemeshow, S., & Whitaker, R. C. (2012). Quality of early maternal–child relationship and risk of adolescent obesity. Pediatrics, 129(1), 132–140. Anzman, S. L., & Birch, L. L. (2009). Low inhibitory control and restrictive feeding practices predict weight outcomes. The Journal of Pediatrics, 155(5), 651–656. Australian Bureau of Statistics (2009). Children who are overweight or obese. http:// www.abs.gov.au/AUSSTATS/[email protected]/Lookup/ 4102.0Main+Features20Sep+2009 (Accessed on 02.05.12). Baumrind, D. (1973). The development of instrumental competence through socialization. In D. A. Pick (Ed.), Minnesota symposium on child psychology (pp. 3–46). Minneapolis, MN: University of Minnesota Press. Bergmeier, H., Skouteris, H., Horwood, S., & Richardson, B. (2013). The associations between child temperament, maternal feeding and child body mass index during the preschool years. A systematic review of the literature. Obesity Reviews. doi: 10.1111/obr.12066. Birch, L. L., Fisher, J. O., Grimm-Thomas, K., Markey, C. N., Sawyer, R., & Johnson, S. L. (2001). Confirmatory factor analysis of the Child Feeding Questionnaire: A measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite, 36, 201–210. Calkins, S. (2005). Temperament and its impact on child development. Comments on Rothbart, Kagan and Eisenberg from Centre of Excellence for Early Childhood Development child encyclopedia.com/documents/CalkinsANGxp.pdf. Centers for Disease Control and Prevention (2000). CDC growth charts. United States. . Retrieved 27.05.13. Cole, T. J., Bellizzi, M. C., Flegal, K. M., & Dietz, W. H. (2000). Establishing a standard definition for child overweight and obesity worldwide: International survey. British Medical Journal, 320, 1–6. Dallman, M. F. (2010). Stress-induced obesity and the emotional nervous system. Trends in Endocrinology & Metabolism, 21(3), 159–165. Davidson, K. K., & Birch, L. L. (2001). Childhood overweight. A contextual model and recommendations for future research. Obesity Reviews, 2(3), 159–171. de Onis, M., Blossner, M., & Borghi, E. (2010). Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr, 92(5), 1257–1264. Faith, M. S., & Hittner, J. B. (2010). Infant temperament and eating style predict change in standardized weight status and obesity risk at 6 years of age. International Journal of Obesity, 34(10), 1515–1523. http://dx.doi.org/10.1038/ ijo.2010.156. Farrow, C., Blissett, J., & Haycraft, E. (2011). Does child weight influence how mothers report their feeding practices? International Journal of Pediatric Obesity, 6, 306–313. Fisher, J. O., Mitchell, D. C., Smiciklas-Wright, H., & Birch, L. L. (2002). Parental influences on young girls’ fruit and vegetable, micronutrient, and fat intakes. Journal of the American Dietetic Association, 102(1), 58–64. Forestell, C. A., & Mennella, J. A. (2012). More than just a pretty face. The relationship between infant’s temperament, food acceptance, and mother’s perceptions of enjoyment of food. Appetite, 58, 1136–1142.

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