Research report

Parental perception of child weight in the first two years-of-life: apotential link between infant feeding and preschoolers’ diet ☆

Salma M.A. Musaad a,*, Sharon M. Donovan b, Barbara H. Fiese a, the STRONG KidsResearch Team 1

a Family Resiliency Center, Department of Human and Community Development, University of Illinois at Urbana-Champaign, 904 W. Nevada, MC-081,Urbana, IL 61801, USAb Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA

A R T I C L E I N F O

Article history:Received 26 August 2014Received in revised form 25 March 2015Accepted 27 March 2015Available online 2 April 2015

Keywords:Parental perceptionObesityPediatric nutritionBreastfeeding

A B S T R A C T

Approximately 23% of preschoolers are overweight or obese. Establishing a healthy dietary lifestyle atan early age can improve later child diet and body weight. This study examined the determinants of pastinfant feeding practices that do not follow standard feeding recommendations (breastfeeding for less than6 months duration, cow’s milk prior to the first year of age and solid foods at or before 4 months of age).It also examined the role of parental perception of child weight in the first 2 years-of-life on past infantfeeding practices as well as current child diet and body weight. Families of 497 preschoolers aged 22–63 months (39.0 ± 8.2) were recruited from 30 child care centers in East-Central Illinois. Main findingsindicate that past infant feeding practices were common and varied by socio-demographic factors in-cluding race/ethnicity, parental education and child gender. Children perceived as overweight in the first2 years-of-life tended to breastfeed for lesser duration. Additionally, the majority (79.8%) of preschool-ers who were classified as overweight using BMI percentile were perceived as non-overweight by theparent in the first 2 years-of-life. Mean daily total fatty/sugary food intake was higher among those per-ceived to be non-overweight in the first 2 years-of-life. These findings have identified parental perceptionof child weight in the first 2 years-of-life as a modifiable risk factor for unhealthy child diet and obesityamong preschoolers.

© 2015 Elsevier Ltd. All rights reserved.

Introduction

In the U.S., the prevalence of overweight or obesity in pre-school children (aged 2–5 years) has decreased from 26.7% in 2009–2010 (Ogden, Carroll, Kit, & Flegal, 2012) to 22.8% in 2011–2012(Ogden, Carroll, Kit, & Flegal, 2014), yet it still remains a public healthconcern. Additionally, the prevalence of severe obesity remains high(Skinner & Skelton, 2014). In an attempt to promote healthy infantfeeding and prevent childhood obesity, the American Academy ofPediatrics recommends a number of desired infant feeding

practices. These feeding practices include exclusive breastfeedingfor at least 6 months, the introduction of solid foods around 6 monthsof age and exposing the baby to a wide variety of healthy foods, con-suming human milk or formula for the first year-of-life and avoidingthe introduction of sugar-sweetened beverages (American Academyof Pediatrics, 2012; Clayton, Li, Perrine, & Scanlon, 2013).

Prior research has explained the adverse effects of not adher-ing to these infant feeding practices. For example, lack ofbreastfeeding is associated with high maternal control of feeding(Brown & Lee, 2013a) and mothers who breastfeed for more than3 months demonstrate higher responsiveness to child fullness cues(DiSantis, Hodges, & Fisher, 2013). However, a limitation of the ex-isting literature is information on the prevalence and characteristicsof infants that deviate from one or more of these feeding stan-dards (Clayton et al., 2013; Fox, Reidy, Novak, & Ziegler, 2006).Moreover, studies often relate these specific infant feeding prac-tices to child diet during the first 24 months-of-life (Brown & Lee,2012, 2013b; Fisher, Birch, Smiciklas-Wright, & Picciano, 2000; Foxet al., 2006; Grummer-Strawn, Scanlon, & Fein, 2008; Hodges et al.,2013; Woo et al., 2013). However, limited information relating infantfeeding to child diet in later preschool years is available (Saavedra,Deming, Dattilo, & Reidy, 2013; Vilela et al., 2014). It is importantto better understand these relationships because early childhood

☆ Acknowledgements: The authors would like to thank the participating familiesas well as the following funding sources: U.S. Department of Agriculture (Hatch 793-328) to Barbara Fiese (PI), Illinois Council on Food and Agricultural Research SentinelGrant to Kris Harrison, University of Illinois Health and Wellness grant to SharonDonovan and Barbara Fiese, the Dairy Research Institute to Barbara Fiese and SharonDonovan (PI’s) and the Christopher Family Foundation Food and Family Program.

* Corresponding author.E-mail address: smusaad@illinois.edu (S.M.A. Musaad).

1 The STRONG Kids Research Team includes Kristen Harrison, University of Illi-nois at Urbana Champaign, Kelly Bost, Brent McBride, Sharon Donovan, Diana Grigsby-Toussaint, Juhee Kim, Janet Liechty, Angela Wiley, Margarita Teran-Garcia, BarbaraFiese.

http://dx.doi.org/10.1016/j.appet.2015.03.0290195-6663/© 2015 Elsevier Ltd. All rights reserved.

Appetite 91 (2015) 90–100

Contents lists available at ScienceDirect

Appetite

journal homepage: www.elsevier.com/ locate /appet

is a critical period for establishing healthy eating habits that impactlong-term food choices (Anzman, Rollins, & Birch, 2010; McGuire,2012; Mikkilä, Räsänen, Raitakari, Pietinen, & Viikari, 2004; Skinner,Carruth, Bounds, Ziegler, & Reidy, 2002). Further, dietary intake duringthis period of development predicts risk for subsequent obesity(Skinner, Bounds, Carruth, Morris, & Ziegler, 2004).

Parental obesity status is known to affect the relationship betweenchild eating behavior and childhood obesity (Fuemmeler, Lovelady,Zucker, & Østbye, 2013). However, other parental influences (e.g.,nutrition knowledge, feeding practices) are well recognized and playan important role in the prevention and treatment of pediatric over-weight (Anzman et al., 2010; Skouteris et al., 2011). One potentialfactor influencing parent feeding choices is their perception of theirchild’s weight. Parental perception of child weight is related to,among many factors, parental recognition of the child’s functionalabilities, parental beliefs about their child’s weight destiny (fatal-ism), parental weight status, parental mental health status and socialand cultural determinants (Mareno, 2013). However, previous re-search has shown that 30%–80% of parents do not accuratelycategorize their child’s weight status, particularly parents ofpreschool-aged children (Azimah et al., 2008; Baughcum, Chamberlin,Deeks, Powers, & Whitaker, 2000; Fisher, Fraser, & Alexander, 2006;Lundahl, Kidwell, & Nelson, 2014; Parry, Netuveli, Parry, & Saxena,2008; Rietmeijer-Mentink, Paulis, van Middelkoop, Bindels, & vander Wouden, 2013; Vanhala, Keinänen-Kiukaanniemi, Kaikkonen,Laitinen, & Korpelainen, 2011). Parents who do not perceive theirchild as overweight are less likely to offer a healthy dietary life-style, which influences how the parent regulates their child’s foodintake as well as their receptiveness to messages regarding pre-vention of excessive weight gain (Birch et al., 2001; Lindsay et al.,2009). Recognizing a child’s overweight status is a first step in theprevention and treatment of overweight and the willingness to makebehavior changes (Elder, Ayala, & Harris, 1999; Mareno, 2013). Pa-rental perception is often used to assess parental feeding attitudesand styles about child feeding including parental control in feedingand was found to correlate with child weight (Birch et al., 2001).

That parental perception of an infant’s weight status may reflectthe way parents view their child’s hunger and, subsequently, playa role in child diet seems intuitive. Parents play a central role in de-ciding how to feed their young children and often make decisionsbased on whether they think their child is hungry or in need of morefood (Birch & Anzman, 2010; Hodges et al., 2013). Parental respon-siveness to the child feeding cues affects the child’s self-regulationof food intake and consequently feeding frequency or amount(DiSantis, Hodges, Johnson, & Fisher, 2011; Hodges et al., 2013). Pa-rental decisions such as the initiation or termination of child feeding(Hodges, Hughes, Hopkinson, & Fisher, 2008) or dictating the typeand variety of food the child eats (Skinner et al., 1997) predict dietquality and child eating behavior (Daniels et al., 2014). Studies typ-ically examine the association of parental perception of child weightwith determinants of child diet during the same time period. Forexample, mothers of 6–12 month old children who perceive theirinfants as large at 6 months of age or who follow baby-led weaningapproaches (spoon feeding and purees 10% of the time or less) vs.traditional weaning approaches (spoon feeding and purees more than10% of the time) report lower levels of control (e.g., pressure to eat)(Brown & Lee, 2011). Further, mothers of 5 year old girls who per-ceive their child as overweight tend to restrict food intake (Birch& Fisher, 2000) and mothers of 7–9 year old children who per-ceive their child as underweight may use more pressuring techniques(Webber, Hill, Cooke, Carnell, & Wardle, 2010). This is a problembecause heightened parental control may promote an unhealthfulchild diet due to reduced responsiveness to hunger and satiety cuesand less regulation of dietary intake (Birch, 1998; Carper, Orlet Fisher,& Birch, 2000; Morrison, Power, Nicklas, & Hughes, 2013) withharmful implications for child weight (Frankel et al., 2014; Mallan,

Nambiar, Magarey, & Daniels, 2014; Rodgers et al., 2013; Webber,Hill, Saxton, Van Jaarsveld, & Wardle, 2009). However, studies thatexamine the association of parental perception of child weight duringthe first 2 years-of-life with child diet in the preschool years aresparse.

Few studies have addressed the direct relationship between pa-rental perception of child weight and the recommended feedingpractices mentioned earlier. Some studies suggest that parentalmisperception of child weight is tied to the tendency to breastfeedless and exhibit greater control of the infant’s feeding in the first2 years (Blissett & Farrow, 2007; Webber et al., 2010). Mothers whoperceive their infants not to be satisfied tend to introduce formulaand solids before the recommended age (Adamo & Brett, 2014;Redsell et al., 2010; Wright, Parkinson, & Drewett, 2004). It is pos-sible that such mothers believe their child is growing at a slow rateor that their child’s weight is inadequate (Redsell et al., 2010).

This study uses data from the Synergistic Theory and Researchon Obesity and Nutrition Group (STRONG) Kids project, an inter-disciplinary 3-wave project conducted over 5 years in preschool (2–5year-old) children to explore childhood obesity within a develop-mental ecological framework (Harrison et al., 2011). In order todescribe the early feeding patterns and determine early factors thatcontribute to unhealthy weight gain, a secondary data analysis ofthe STRONG Kids project was undertaken with the following ob-jectives: (1) to describe the prevalence and characteristics of childrenby past infant feeding group (breastfeeding for less than 6 monthsduration, cow’s milk prior to the first year of age and solid foodsat or before 4 months of age); (2) to evaluate whether parental per-ception of child weight in the first 2 years-of-life affects the likelihoodof belonging to a past infant feeding group after controlling for otherpast infant feeding groups, demographic factors (race/ethnicity, levelof parental education, income, employment, Women, Infants, andChildren (WIC) participation, child gender) and child allergy or sen-sitivity to cow’s milk; (3) to determine the association of parentalperception of child weight in the first 2 years-of-life with currentdiet in the preschool years after accounting for demographic factors,parental perception of child weight as a preschooler (currently), childBMI percentile, other current dietary intake and past infant feeding.Since data from the first wave were used, this study has a cross sec-tional design. Nevertheless, this cohort provides valuable insight andfuture research directions related to the characteristics of specificinfant feeding groups and the association of early parental percep-tion of child weight with child diet in the preschool years. Wehypothesize that a large proportion (>50%) of the parents do notfollow at least one of the infant feeding recommendations whichwould be associated with an unhealthy child diet in the preschoolyears. We also hypothesize that parental perception of child weightwould influence early feeding and food intake in the preschool years.

Materials and methods

Data were drawn from the STRONG Kids cohort that followedpreschool age children and primary caregivers (n = 497 pairs) over3 waves (Harrison et al., 2011). Wave 1 recruitment used an unequalprobability sampling frame to identify licensed day care centers(n = 33) across five counties in East-Central Illinois that (1) were reg-istered with the state Bureau of Child Care and Development, acondition for receiving federal food assistance; (2) were locatedwithin 65 miles of the study center in one of four small urban areastargeted to maximize racial/ethnic diversity; and (3) enrolled aminimum of 24 children in the targeted age range to recruit. Be-ginning in January 2009, 91% (n = 30) of the centers permittedrecruitment of children and their parents. Written informed consentwas obtained from the parents of the children involved in this study.Assent was obtained from the children to measure height and weight.Response rates of the parent/child pairs varied by center and ranged

91S.M.A. Musaad et al./Appetite 91 (2015) 90–100

from 60% to 95% across centers. This research was approved by theInstitutional Review Board at the University of Illinois at Urbana-Champaign (IRB number 09143) and meets all requirements forethical conduct for research with human subjects.

A questionnaire was designed to collect data on the followingitems from the parents: demographic characteristics, WIC partic-ipation (for female parents/caregivers only), food allergy or sensitivityto cow’s milk, child’s diet in the first 2 years-of-life and as a pre-schooler (currently) and items from the Child Feeding Questionnaire(CFQ) (Birch et al., 2001). Parents completed surveys online or inpaper format if they did not have Internet access.

The CFQ is a commonly used self-report of parental beliefs, at-titudes and practices regarding child feeding (e.g., concern aboutchild weight, perceived child weight, restriction and monitoring)that includes 28 items presented on a 5-point Likert-scale (Birchet al., 2001). The CFQ assessed the parental perception of child’sweight by obtaining their weight status at different time periods(0–11 months, as a toddler (12–23 months) and as a preschooler(currently)). For this study, parental perception of child weight inthe first 2 years-of-life was calculated from the 2 CFQ items thataddress the parental perception of the child’s weight when the childwas 0–11 months and 12–23 months (Birch et al., 2001). The itemsare measured on a scale ranging from 1 to 5 using the anchors: mark-edly underweight, underweight, average, overweight or markedlyoverweight. Perceived child weight currently was based on the CFQitem that addresses parental perception of the child’s weight as apreschooler and is measured on a similar scale. The overallCronbach’s alpha for the three parental perception items is 0.79.

Child dietary history (reported diet in the first 2 years-of-life)was assessed by asking parents to indicate what foods they fed thechild during the following 8 time periods: 1 month or less, 2–3months, 4–5 months, 6–9 months, 10–12 months, 13–18 months,19–24 months and more than 24 months. Diet items includedbreastfeeding, cow’s milk, infant cereal from a bottle or spoon, babyfood (pureed, commercially available or home prepared) and tablefood (chopped, or mashed or regular). Parental responses to thesequestions were used to determine the number of children who be-longed to the following past infant feeding groups: being breastfedfor less than 6 months duration, fed cow’s milk prior to the first yearand fed solid foods (cereal from a bottle or spoon, baby food, or tablefood) at or before 4 months. Breastfeeding history was also cat-egorized into never breast fed, breast fed under 6 months durationand breast fed for 6 months or more.

Height (cm) and weight (kg) of the children were measured attheir day care sites by trained research assistants. To ensure accu-racy, each measurement was taken 3 times and the average wasrecorded across the three measurements. Height was measured usinga stadiometer (Seca, Model 242, Hanover, MD, USA) and weight wasmeasured using a scale (HealthOmeter, Model 349KLX, Jarden Con-sumer Solutions, Boca Raton, FL, USA). Child BMI was calculated asweight (kg)/height2 (m2) and was converted into age and gender spe-cific BMI percentiles (CDC, 2000).

Statistical analysis

All analyses were conducted using the Statistical Analysis Soft-ware (SAS) version 9.3 (SAS Institute, Cary, NC, USA). The BMIpercentiles were initially categorized into 4 categories of under-weight (<5th percentile), healthy weight (5th to <85th percentile),overweight (85th to <95th percentile) or obese (≥95th percentile).Due to the limited sample size of underweight (n = 10) and obese(n = 31) children participants were classified into 2 groups of eithernon-overweight by combining the first 2 categories, or over-weight by combining the 3rd and 4th categories (Crawford, Timperio,Telford, & Salmon, 2007; Shloim, Hetherington, Rudolf, & Feltbower,2013). The mean of the 2 CFQ items assessing parental perception

of the child’s weight during 0–11 months and 12–23 months wascalculated. Since the responses to both items were in relative agree-ment (Kappa statistic = 0.6 (95% confidence interval (95%CI) = 0.4,0.7), the mean (2.9 ± standard deviation (SD) = 0.5) provided a generalestimate for the combined duration and was considered to repre-sent parental perception of child weight in the first 2 years-of-life.The mean was also dichotomized by grouping children with a scoreof 3 or under who were considered to be markedly underweight(n = 11 during 0–11 months, n = 8 during 12–23 months), under-weight (n = 70 during 0–11 months, n = 59 during 12–23 months)and average (n = 363 during 0–11 months, n = 392 during 12–23months) by the parent into one group of children perceived as non-overweight. Children with a score greater than 3 who wereconsidered overweight (n = 35 during 0–11 months, n = 22 during12–23 months) or markedly overweight (n = 4 during 0–11 months,n = 1 during 12–23 months) by the parent were combined intoanother group of children perceived as overweight (Crawford et al.,2007). Similarly, for the CFQ item parental perception of child weightas a preschooler (currently), children with a score of 3 or under whowere reported as markedly underweight (n = 3), underweight (n = 34)and average (n = 430) were combined into one group. Those witha score greater than 3 who were reported as overweight (n = 13)or markedly overweight (n = 2) by the parent were combined intoanother group (Crawford et al., 2007). The study findings did notchange after excluding children who were underweight accordingto BMI percentile and children who were perceived to be marked-ly underweight or underweight by the parent in the first 2 years-of-life or currently (not shown). Therefore, results using the combinedweight status categories are reported in this manuscript.

To explore the age at introduction of cow’s milk and solid foods,survival analysis was utilized to generate Kaplan–Meier curves (PROCLIFETEST in SAS) and presented for the first year-of-life. This methodtakes into account that for some children the age of introductionwas not reported at the time of survey completion for one or moreitems. It estimates the cumulative probability (chance) of taking aspecific food or drink up to a particular age. Children who were notreported to start on any particular food or drink item by 12 monthswere considered censored observations. The survival curves werealso stratified by parental perception of child weight in the first 2years-of-life to see if it modified early feeding in that time period.

Differences in the characteristics of children according to whetherthey did or did not belong to a past infant feeding group were ex-amined using Chi square or Fisher’s exact tests (full table providedas supplementary material). Logistic regression was used to inves-tigate the association of parental perception of child weight in thefirst 2 years-of-life as the predictor with each past infant feedinggroup separately as the outcome after adjusting for other past infantfeeding groups, demographic factors (race/ethnicity, level of pa-rental education, income, employment, WIC participation, childgender) and child allergy or sensitivity to cow’s milk. No adjust-ment was done for child current diet and BMI percentile becausethese variables were assessed when the child was a preschooler (cur-rently) while past infant feeding was based on parental report ofinfant feeding during the first 24 months-of-life.

Child current dietary intake (food or drinks the preschooler con-sumed during the past 7 days) was estimated using parental reportsof children’s consumption of the following foods: milk (includescow’s, soy, or other types of milk consumed from a cup, glass, cartonor with cereal), fruits, vegetables/soy-based or vegetarian prod-ucts, sugared beverages (non-diet soda pop, fruit drinks, 100% fruitjuices), French fries, fast food, candy/sweets and salty snacks usingitems from the United States Department of Education’s Early Child-hood Longitudinal Study, Birth Cohort (ECLS-B) interview protocolfor 2-year-olds (U.S. Department of Education, 2008). Responseoptions included 0 = “my child did not eat/drink any _____ duringthe past 7 days,” 1 = “once a day,” 2 = “twice a day,” 3 = “three times

92 S.M.A. Musaad et al./Appetite 91 (2015) 90–100

a day,” 4 = “four or more times a day,” 5 = “1 to 3 times during thepast 7 days,” 6 = “4 to 6 times during the past 7 days” and 7 = “don’tknow.” For the purpose of creating a continuous score of food intakeon a common scale responses 5 and 6 were recoded as fractions rep-resenting average times per day (i.e., 1–3 times a week averages to.2857 times per day; 4–6 times per week averages to .7143 timesper day). Responses of 7 (don’t know) were treated as missing data.Scores for sugared beverages, French fries, fast food, candy/sweetsand salty snacks were combined (summed) to create a measure oftotal fatty/sugary foods per day. Scores for fruits and vegetables/soy-based or vegetarian products were combined to create a measureof total fruit/vegetables per day. Scores were also categorized by the75th percentile of the data which consisted of 3-times per day formilk, 4-times per day for total fruit/vegetables and 4-times per dayfor total fatty/sugary foods.

Mean scores for child current dietary intake were examined acrosscategories of breastfeeding (never breast fed, breast fed under 6months duration, breast fed for 6 months or more) using the Kruskal–Wallis test and across categories of parental perception of childweight in the first 2 years-of-life (non-overweight and over-weight) using the Wilcoxon 2-sample test. The association of parentalperception of child weight in the first 2 years-of-life with childcurrent dietary intake as the outcome was further confirmed usinglogistic regression after controlling for demographics, parental per-ception of child weight as a preschooler (currently), child BMIpercentile, other current dietary intake and past infant feeding. Thiswas accomplished using a staged modeling approach whereby 5 lo-gistic regression models were separately tested using each childdietary variable (milk, total fruits/vegetables and total fatty/sugary foods) as the binary outcome. Each model used one of thefollowing sets of independent variables: demographic factors (race/ethnicity, level of parental education, income, employment, WICparticipation, child gender), child weight variables (parental per-ception of child weight in the first 2 years-of-life and currently, childBMI percentiles), the other child current diet variables (used con-tinuously), past infant feeding group (breastfeeding for less than 6months duration, cow’s milk prior to the first year of age and solidfoods at or before 4 months of age) and reported diet in the first 2years-of-life. Diet in the first 2 years-of-life variables were con-verted into the ever fed vs. not fed format due to sample sizeconstraints. The final model included all demographic variables aswell as the variables found to be significant at the 0.1 level in theother 4 models. Suitability of each model was determined using theAkaike Information criterion and the P value for the Likelihood RatioChi square. The extent of agreement between parental perceptionof child weight in the first 2 years-of-life and child BMI percentilecategories was investigated using the Chi square test or Fisher’s exacttest. A 2-tailed P value <0.05 was considered statistically signifi-cant. Missing values were excluded for significance testing. Noadjustment for multiple testing was performed. Data are ex-pressed as number (%) or mean ± SD.

Results

Description of the population

General characteristics of the study sample are presented inTable 1. Over half of the parents (56%) were Non-Hispanic White,with college or post graduate education (54%) and employed (64%).Approximately 35% reported an annual household income of $70,000or more which is higher than the U.S. median household incomefor 2013 ($52,250) (http://www.census.gov/content/dam/Census/library/publications/2014/acs/acsbr13-02.pdf), whereas 28%reported an income of $25,000–$69,999 or $24,000 or less. Thechildren had a mean age of 39 months ± 8.2, just under half werefemales (49%) and they had a low prevalence of allergy or sensi-

tivity to cow’s milk (3%). Most children were perceived to be non-overweight in the first 2 years-of-life (89%) and as preschoolers(currently) (94%). A lower proportion of the children were non-overweight according to child BMI percentiles (63%). Around 28%were never breastfed while just over half (53%) were exclusivelybreastfed at 1 month of age. Out of the total sample of 497 chil-dren, 179 children (36%) were breastfed for less than 6 monthsduration, 112 (23%) were fed cow’s milk prior to the first year and287 (58%) were fed solid foods (cereal from a bottle or spoon, babyfood, or table food) at or before 4 months.

The age at introduction of cow’s milk, cereal, baby food and tablefood is presented in the form of survival curves (Fig. 1). By 1 year ofage, the probability of being introduced to cow’s milk was 26%. The prob-ability of being introduced to cereal from a bottle or spoon was 95%,to commercial or home prepared baby food was 92% and to table foodwas 67%. No differences were seen when stratified by parental per-ception of child weight in the first 2 years-of-life (not shown).

Table 1Characteristics of study sample (n = 497).

Characteristic Number (%)or mean ± SD

Race/ethnicityHispanic 34 (6.8)Non-Hispanic Black 131 (26.4)Non-Hispanic White 278 (55.9)Other 54 (10.9)

Parent’s genderFemale 444 (89.3)

EducationGrade school/high school 68 (13.7)College/technical school 159 (31.9)College graduate/post-graduate work 268 (53.9)Unknown/missing 2 (0.4)

Annual household income≤$24,000 141 (28.4)$25,000–$69,999 141 (28.4)≥$70,000 176 (35.4)Prefer not to answer/unknown 39 (7.9)

Employment statusEmployed 318 (63.9)Unemployed 27 (5.4)Retired/disabled/stay at home 51 (10.3)Student 96 (19.3)Unknown/missing 5 (1.0)

Child’s genderFemale 243 (48.9)

Child’s current age (months) 39.0 ± 8.2Child has allergy/sensitivity to cow’s milk 15 (3.0)Parental perception of child weight in first 2 years-of-life

Non-overweight 440 (88.5)Overweight 44 (8.9)

Parental perception of child weight currentlyNon-overweight 467 (93.9)Overweight 15 (3.0)

Child BMI percentileNon-overweight 313 (62.9)Overweight 94 (18.9)

Dietary historyNever breastfed 137 (27.6)Breastfed <6 months duration 179 (36.0)Breastfed ≥6 months duration 181 (36.4)Exclusive breastfeeding history

At 1 month 264 (53.1)At 2–3 months 190 (38.2)At 4–5 months 91 (18.3)At 6–9 months 8 (1.6)At 10–12 months 2 (0.4)

Cow’s milk <1 year 112 (22.5)Solid foods ≤4 months 287 (57.8)

SD: standard deviation.

93S.M.A. Musaad et al./Appetite 91 (2015) 90–100

Past infant feeding

The demographic, child weight and dietary variables by past infantfeeding group (breastfeeding for less than 6 months duration, cow’s milkprior to the first year of age and solid foods at or before 4 months ofage) are shown in Table 2. For simplicity, data are presented only forchildren who belonged to each past feeding group and differences inthe proportion of the significant variables across children who did ordid not belong to each past feeding group are described in the text.However, the table indicating the proportion of all variables across chil-dren who did or did not belong to each feeding group is provided assupplementary material. To confirm the findings, logistic regressionmodeling was used to determine the association of the variables witheach past feeding group as the outcome. All the variables listed in Table 2were tested in the models except for the child current diet and BMI per-centile since the reporting time differed from that of the past feeding.Both unadjusted (univariate) and adjusted models were examined. Theadjustment was done for the other past infant feeding groups, demo-graphic factors (race/ethnicity, level of parental education, income,employment, WIC participation, child gender) and child allergy or sen-sitivity to cow’s milk. Main model findings are reported in the text.

Breastfeeding for less than 6 months durationHaving been breastfed for less than 6 months was significantly

associated with parental employment, parental perception of childweight in the first 2 years-of-life, current child intake of fruit/vegetables, being fed cow’s milk prior to the first year of age andsolid foods at or before 4 months of age (Table 2). To elaborate onthese findings, compared to breastfeeding for more than 6 monthsduration, breastfeeding for less than 6 months duration was

associated with a decrease in the proportion of retired/disabled/stay-at-home parents (13.2%–5.0%) as well as an increase in theproportion of children who were perceived as overweight by theparent in the first 2 years-of-life (6.3%–13.4%), consumed lesser fruit/vegetables (0–4 times a day) (72.9%–86.0%), were fed cow’s milkprior to the first year of age (17.9%–30.7%) and were fed solid foodsat or before 4 months of age (51.9%–68.2%) (supplementary material).

Model results supported these findings. Notably, in the unad-justed model using breastfeeding for less than 6 months duration asthe outcome, compared to children perceived as non-overweight by theparent in the first 2 years-of-life, those perceived as overweight wereapproximately 2-times more likely to have been breastfed for less than6 months duration (Odds Ratio (OR) 2.2, 95%CI 1.2–4.1, P = 0.013). Thisassociation was attenuated, albeit with the same trend, in the ad-justed model (OR 1.6, 95%CI 0.7–3.8). Furthermore, children who werefed cow’s milk prior to the first year of age (OR 1.9, 95%CI 1.3–3.1,P = 0.003) and solid foods at or before 4 months of age (OR 1.9, 95%CI1.4–2.9, P = 0.001) were approximately 2-times more likely to have beenbreastfed for less than 6 months duration in the unadjusted models.These associations remained in the adjusted models.

Cow’s milk prior to the first year of ageHaving cow’s milk prior to the first year of age was signifi-

cantly associated with the level of parental education, WICparticipation and being fed solid foods at or before 4 months of age(Table 2). Compared to having cow’s milk after the first year of age,having cow’s milk prior to the first year of age was associated witha decrease in the proportion of more educated parents who arecollege graduates or conducted post-graduate work (62.7%–49.1%),as well as an increase in the proportion of WIC participants

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Fig. 1. Probability of being introduced to cow’s milk and solid foods (cereal, baby food and table food) during the first year presented as survival curves. The horizontalreference line represents the median (0.5).

94 S.M.A. Musaad et al./Appetite 91 (2015) 90–100

Table 2Description of past infant feeding groups according to parental and child characteristics (n = 497).a

Characteristics Breastfed <6 monthsduration (n = 179)n (%)

Cow’s milk <1 year(n = 112)n (%)

Solid foods ≤4 months(n = 287)n (%)

Race/ethnicityHispanic 10 (5.6) 4 (3.6) 20 (6.9)Non-Hispanic Black 49 (27.4) 27 (24.1) 81 (28.2)Non-Hispanic White 103 (57.5) 66 (58.9) 161 (56.1)Other 17 (9.5) 15 (13.4) 25 (8.7)

EducationGrade school/high school 27 (15.1) 15 (13.4)b 32 (11.2)b

College/technical school 60 (33.5) 42 (37.5) 109 (37.9)College graduate/post-graduate work 92 (51.4) 55 (49.1) 145 (50.5)Unknown/missing 1 (0.4)

Annual household income≤$24,000 55 (30.7) 28 (25.0) 82 (28.6)$25,000–$69,999 51 (28.5) 36 (32.1) 88 (30.7)≥$70,000 61 (34.1) 38 (33.9) 97 (33.8)Prefer not to answer/unknown 12 (6.7) 10 (8.9) 20 (6.9)

Employment statusEmployed 122 (68.2)b 76 (67.9) 192 (66.9)Unemployed 14 (7.8) 6 (5.4) 13 (4.5)Retired/disabled/stay-at-home 9 (5.0) 6 (5.4) 22 (7.7)Student 31 (17.3) 21 (18.8) 56 (19.5)Unknown/missing 3 (1.7) 3 (2.7) 4 (1.4)

WIC participantNo 98 (54.7) 58 (51.8)b 160 (55.8)Yes 72 (40.2) 52 (46.4) 118 (41.1)Unknown/missing 9 (5.0) 2 (1.8) 9 (3.1)

Child’s current age<3 years 66 (36.9) 48 (42.9) 106 (36.9)≥3 years 113 (63.1) 64 (57.1) 181 (63.1)

Child’s genderFemale 86 (48.0) 52 (46.4) 126 (43.9)b

Male 93 (51.9) 60 (53.6) 161 (56.1)Child has allergy/sensitivity to cow’s milk?

No 172 (96.1) 108 (96.4) 277 (96.5)Yes 7 (3.9) 4 (3.6) 10 (3.5)

Parental perception of child weight in first 2 years-of-lifeNon-overweight 155 (86.6)b 100 (89.3) 257 (89.6)Overweight 24 (13.4) 12 (10.7) 26 (9.1)Unknown/missing 4 (1.4)

Parental perception of child weight currentlyNon-overweight 172 (96.1) 109 (97.3) 270 (94.1)Overweight 7 (3.9) 3 (2.7) 11 (3.8)Unknown/missing 6 (2.1)

Child BMI percentileNon-overweight 106 (59.2) 72 (64.3) 175 (60.9)Overweight 37 (20.7) 23 (20.5) 59 (20.6)Unknown/missing 36 (20.1) 17 (15.2) 53 (18.5)

Milk0–3 times a day 145 (81.0) 96 (85.7) 238 (82.9)>3 times a day 32 (17.9) 15 (13.4) 46 (16.0)Unknown/missing 2 (1.1) 1 (0.9) 3 (1.1)

Total fruit/vegetables0–4 times a day 154 (86.0)b 92 (82.1) 235 (81.9)>4 times a day 25 (13.9) 18 (16.1) 51 (17.8)Unknown/missing 2 (1.8) 1 (0.4)

Total fatty/sugary foods0–4 times a day 127 (70.9) 78 (69.6) 198 (68.9)>4 times a day 52 (29.1) 33 (29.5) 89 (31.0)Unknown/missing 1 (0.9)

Breastfed <6 monthsNo – – –Yes

Cow’s milk <1 yearNo 88 (49.2)b – –Yes 55 (30.7)Unknown/missing 36 (20.1)

Solid foods ≤4 monthsNo 57 (31.8)b 34 (30.4)b –Yes 122 (68.2) 78 (69.6)

a Percentages are calculated within each past feeding group. Percentages may not add up to 100 due to rounding. A child may belong to more than one feeding group,thus the sum of feeding groups does not add up to the total.

b P <0.05 within the specific feeding group using Chi square or Fisher’s exact test.

95S.M.A. Musaad et al./Appetite 91 (2015) 90–100

(32.5%–46.4%) and the proportion of children who were fed solidfoods at or before 4 months of age (57.8%–69.6%) (supplementarymaterial).

In general, the model results supported these findings. In the ad-justed model, breastfeeding under 6 months duration wassignificantly associated with having cow’s milk prior to the first yearof age (OR 2.0, 95%CI 1.2–3.4, P = 0.006). Additionally, race/ethnicityemerged as a significant factor. Compared to Non-Hispanic Whites,Hispanics were less likely to have cow’s milk prior to the first yearof age (OR 0.2, 95%CI 0.0–0.9, P = 0.042).

Solid foods at or before 4 months of ageHaving solid foods at or before 4 months of age was signifi-

cantly related to the level of parental education and child gender(Table 2). Compared to having solid foods after 4 months of age,having solid foods at or before 4 months of age was associated withan increase in the proportion of a parent with college/technical schooleducation (23.8%–37.9%) and the proportion of male children (44.3%–56.1%) (supplementary material). These results were supported bythe model findings. Notably, females were 40% less likely than malesto have solids at or before 4 months (OR 0.6, 95%CI 0.4–0.9, P = 0.009).The finding remained unchanged after adjusting the model. In theadjusted model, breastfeeding under 6 months duration was sig-nificantly associated with having solid foods at or before 4 monthsof age (OR 1.9, 95%CI 1.1–3.1, P = 0.016).

Breastfeeding is associated with a healthier child diet in thepreschool years

Breastfeeding history was significantly associated with childcurrent diet. As shown in Table 3, current intake of total fruit/vegetables increased, whereas intake of fatty/sugary foods decreased,with increasing duration of breastfeeding.

Parental perception of child weight in the first 2 years-of-life isdiscordant with current child BMI percentile

Since parental perception of child weight in the first 2 years-of-life was associated with breastfeeding history and given the

reported relationship between breastfeeding and childhood obesity,we sought to examine the extent of agreement between the obesitymeasures (BMI percentile, parental perception of child weight inthe first 2 years-of-life and perception of child weight currently).There was significant disagreement (discordance) between currentchild BMI percentile and parental perception of child weight, bothin the first 2 years-of-life and currently, mostly within overweightchildren (Table 4). In the overall sample, among children who arecurrently classified as non-overweight according to BMI percen-tile, the majority (91.7%) were perceived as non-overweight by theparent in the first 2 years-of-life, while a small proportion (6.1%)were perceived to be overweight. However, among children whoare currently classified as overweight according to child BMI per-centile, the majority (79.8%) were perceived as non-overweight bythe parent in the first 2 years-of-life. Similarly, among children clas-sified as non-overweight according to child BMI percentile, 95.8%were perceived to be non-overweight by the parent currently, while1.6% were perceived to be overweight. However, among children clas-sified as overweight according to child BMI percentile, 91.5% wereperceived to be non-overweight by the parent currently (Table 4).In order to determine if these relationships differed by breastfeedingstatus the analysis was broken down by breastfeeding history. Similartrends were observed and were thus not presented. For example,among children classified as overweight according to child BMI per-centile, the majority were perceived as non-overweight by the parentin the first 2 years-of-life within children who were never breastfed(80.0%) (P = 0.011), within children who were breastfed for less than6 months duration (70.3%) (P = 0.001) and within children who werebreastfed for more than 6 months duration (90.6%) (P = 0.713).

Parental perception of child weight in the first 2 years-of-life isassociated with child diet in the preschool years

Given the discordance between parental perception of childweight in the first 2 years-of-life with the child’s current BMI per-centile and the observed associations with breastfeeding, weinvestigated the relationships between parental perception of theirchild’s weight and their child’s current diet. Total fatty/sugary foodswere significantly associated with parental perception of child weight

Table 3Association of breastfeeding history with preschoolers’ diet.a

Breastfeeding history P valueb

Never (n = 137) <6 months (n=179) ≥6 months (n = 181)

Milk 2.4 ± 1.0 2.5 ± 1.0 2.3 ± 1.0 0.249Total fruit/vegetables 3.1 ± 1.6 2.9 ± 1.5 3.4 ± 1.4 0.005Total fatty/sugary foods 4.2 ± 2.4 3.4 ± 1. 9 2.9 ± 1. 6 <.0001

a Child current dietary intake is presented in times per day as the mean ± SD within each breastfeeding group.b Mean child diet was compared across breastfeeding categories using the Kruskal–Wallis test.

Table 4Association of child BMI percentile with parental perception of their child’s weight in first 2 years-of-life and currently as a preschooler.a

Child BMI percentile P valueb

Non-overweight (n = 313) Overweight (n = 94)

Parental perception of child weight in first 2 years-of-life <0.001Non-overweight 287 (91.7) 75 (79.8)Overweight 19 (6.1) 18 (19.1)Unknown/missing 7 (2.2) 1 (1.1)

Parental perception of child weight currently 0.009Non-overweight 300 (95.8) 86 (91.5)Overweight 5 (1.6) 7 (7.4)Unknown/missing 8 (2.6) 1 (1.1)

a Data presented as number (percent) within each child BMI percentile category.b Chi square test or Fisher’s exact test.

96 S.M.A. Musaad et al./Appetite 91 (2015) 90–100

in the first 2 years-of-life. Mean daily total fatty/sugary food intakewas higher among those perceived to be non-overweight in the first2 years-of-life (3.5 ± 1.9) compared to those perceived to be over-weight in the first 2 years-of-life (2.9 ± 2.0, P = 0.013). Total fatty/sugary food was also significantly associated with parental perceptionof their child’s current weight, but in the reverse direction seen forparental perception in the first 2 years-of-life. Mean daily total fatty/sugary food intake was lower among those perceived to be non-overweight currently (3.4 ± 1.9) compared to those perceived to beoverweight (4.9 ± 2.6, P = 0.016). This inverse relationship may beexplained by the disagreement between parental perception of childweight currently with that in the first 2 years-of-life, whereby 75%of those perceived to be overweight in the first 2 years-of-life werecurrently perceived as non-overweight (P < 0.0001) (not shown).

The associations of the intake of total fatty/sugary foods withparental perception of child weight in the first 2 years-of-life andcurrently were confirmed using logistic regression modeling for totalfatty/sugary foods as the outcome (not shown). Breastfeeding didnot appear to play a role in this association when tested in the model.

Discussion

The past feeding history of a large proportion of children in theSTRONG Kids cohort did not adhere with established recommen-dations. Approximately 72% were ever breastfed, close to the U.S.national average of 76.5% (CDC, 2013), but less than the SurgeonGeneral’s 2020 recommendations of 82% (American Academy ofPediatrics, 2012). Approximately 23% were fed cow’s milk prior tothe first year of age and by 6 months of age more than half of theinfants had been introduced to cereal. Since the cumulative effectsof past feeding practices are even less desirable, we examined howthey interrelate (cluster) together. Our results reveal that the pastfeeding groups cluster together in the STRONG Kids cohort. Chil-dren who were fed cow’s milk prior to the first year of age and solidfoods at or before 4 months of age were approximately 2-times morelikely to have been breastfed for less than 6 months duration. Thisis consistent with the literature. For example, children who werebreastfed for 6 months or less received complementary foods earlierthan those who were breastfed for more than 6 months (DiSantiset al., 2013). These findings are concerning because the durationof breastfeeding and the early introduction of solid foods are linkedto adverse childhood outcomes including infections, allergy, asthmaand obesity (American Academy of Pediatrics, 2012; Dogaru,Nyffenegger, Pescatore, Spycher, & Kuehni, 2014; Huh, Rifas-Shiman,Taveras, Oken, & Gillman, 2011; Imai, Gunnarsdottir, Thorisdottir,Halldorsson, & Thorsdottir, 2014; Ip et al., 2007; Khan, Vesel, Bahl,& Martines, 2014; Moss & Yeaton, 2014; Seach, Dharmage, Lowe,& Dixon, 2010). We also observed variations by demographic factors,which warrant further investigation because socio-demographicvariations in feeding are related to childhood obesity (Pearce, Taylor,& Langley-Evans, 2013), providing an important avenue for obesityprevention efforts targeting families with high risk behaviors.

We observed that breastfeeding for 6 months or more was as-sociated with increased intake of fruit/vegetables in the preschoolyears. Other studies support this finding (Burnier, Dubois, & Girard,2011; De Lauzon-Guillain et al., 2013; Möller, de Hoog, van Eijsden,Gemke, & Vrijkotte, 2013). It would be interesting to determine thetype of association, e.g. if a threshold exists for the nature andamount of breastfeeding leading to increased intake. However, somestudies did not find a relationship between breastfeeding dura-tion and healthy eating in young children (Byrne, Magarey, & Daniels,2014; Valmórbida & Vitolo, 2014). This may be attributed to howthe benefits of breastfeeding manifest later in adolescence (Savage,Fisher, & Birch, 2007). Moreover, other known modifiers such as pa-rental diet and parental control in feeding (Wardle, Carnell, & Cooke,2005), food availability (Pearson, Biddle, & Gorely, 2009), food access

(Krølner et al., 2011), child care setting (Nicklas et al., 2001) andsocio-economic status (Gatica, Barros, Madruga, Matijasevich, &Santos, 2012; Rasmussen et al., 2006) may play a larger role. Ad-ditionally, limited literature exists for an association betweenbreastfeeding history and consumption of fatty/sugary foods. In thisstudy, we found that breastfeeding for 6 months or more was neg-atively associated with intake of fatty/sugary foods. Although thisfinding requires further investigation, it nevertheless adds to theevidence that breastfeeding equates with healthier eating habits andlower obesity risk (Baughcum et al., 2001; Burdette, Whitaker, Hall,& Daniels, 2006; De Kroon et al., 2011; Martin et al., 2013; Owenet al., 2005; Perrine, Galuska, Thompson, & Scanlon, 2014; Robinsonet al., 2013). Alternative explanations for the association ofbreastfeeding with healthier eating are that mothers who breastfeedfor longer durations follow a healthier lifestyle and offer more fruitsand vegetables to their child (Blissett, 2011; Blissett & Farrow, 2007)or that breastfeeding promotes acceptance of a wider range of foods(Mennella, Jagnow, & Beauchamp, 2001). The direction of this as-sociation is yet unclear. It could be that parental feeding stylesinfluence the choice to breastfeed or that breastfeeding has a de-sirable influence on parental feeding styles that ultimately translatesto fruit/vegetables consumption (Blissett & Farrow, 2007; Patrick,Nicklas, Hughes, & Morales, 2005; Wardle et al., 2005). However,longitudinal studies linking parental feeding styles and dietary out-comes are lacking (Blissett, 2011; Robinson & Fall, 2012). In anattempt to clarify these associations further we are currently in-vestigating the longitudinal link between feeding style, breastfeedingand subsequent dietary outcomes.

To the best of our knowledge, this is one of a few studies toprovide evidence for a potential role of parental perception of childweight in the first 2 years-of-life with past infant feeding as wellas child diet in the preschool years. Our results reveal that, com-pared to children perceived as non-overweight by the parent in thefirst 2 years-of-life, those perceived as overweight were 2-times morelikely to have been breastfed for less than 6 months duration. Al-though this association was attenuated after adjusting for other pastinfant feeding practices, demographic factors and child allergy orsensitivity to cow’s milk, the trend persisted. This relationship mayreflect parental attitudes and beliefs about feeding habits (Baughcum,Burklow, Deeks, Powers, & Whitaker, 1998; Johannsen, Johannsen,& Specker, 2006; Mareno, 2013) or correctly observed weight changesif these children were introduced early to formula (Dewey, 1998)or solid foods (Clayton et al., 2013). Since parental perception of childweight in the first 2 years-of-life and breastfeeding status were bothmeasured by parental recall, this finding is taken with caution. Theywere also assessed with reference to the same developmental timeperiod in the child’s life, hence we do not expect differential recallto bias this association.

We also observed that current fatty/sugary food intake was loweramong children perceived as overweight by the parent in the first2 years-of-life compared to non-overweight. This may be due to theparent successfully adjusting the diet of a child who was indeed over-weight in the first 2 years-of-life, using less pressure (Webber et al.,2010) or exhibiting concern and restricting food intake (Scaglioni,Salvioni, & Galimberti, 2008; Wehrly, Bonilla, Perez, & Liew, 2014).This relationship warrants further investigation because tracking ofparental perception from an early age is a modifiable risk factor withpotential implications for subsequent child diet and obesity risk(Thompson, 2013; Thompson, Adair, & Bentley, 2013; Wehrly et al.,2014).

One can speculate that breastfeeding may be involved in the re-lationship of parental perception of child weight in the first 2 years-of-life with later child diet. However, we observed that breastfeedingduration was negatively associated with later intake of fatty/sugary foods, which does not align with the observed associationbetween parental perception of child weight in the first 2

97S.M.A. Musaad et al./Appetite 91 (2015) 90–100

years-of-life and intake of fatty/sugary foods. Furthermore, the re-lationship between parental perception of child weight in the first2 years-of-life with intake of fatty/sugary foods was unchanged inthe presence or absence of breastfeeding in a model, hence wecannot assume a mediating role for breastfeeding. One can arguethat the result is driven by the children’s BMI percentile. However,BMI percentile was not associated with intake of fatty/sugary foods.Furthermore, among children perceived as overweight in the first2 years-of-life, about half are currently classified as overweight andhalf as non-overweight according to BMI percentile. When strati-fying this association by BMI percentile, the trend persisted. Thissuggests an association of parental perception of child weight in thefirst 2 years-of-life with dietary intake in the preschool years irre-spective of child weight at that latter time. This question is bestanswered by longitudinal studies assessing early parental percep-tion of child weight and future dietary patterns.

Mirroring the literature, we found that parental perception ofchild weight in preschoolers did not agree with child BMI percen-tile (Rietmeijer-Mentink et al., 2013; Towns & D’Auria, 2009).Additionally, we extended this finding by showing that the discor-dance existed using parental perception of child weight in the first2 years-of-life. There are two possible explanations for this finding.Either the children were non-overweight in the first 2 years-of-life and they were subjected to unhealthy diets and becameoverweight later in life, or they were already overweight in the first2 years-of-life yet were perceived to be non-overweight by theirparent. Thus, it is possible that current BMI is reflective of paren-tal misperception of body weight in the first 2 years-of-life, whichled to feeding patterns that promoted weight gain.

Strengths of this study include that both healthy and un-healthy child dietary behaviors were examined. Child BMI wasobjectively assessed. Furthermore, parental perception of childweight was assessed using a validated and known questionnaire thatwas designed for an age group that included our sample (Birch et al.,2001). Study limitations include the cross sectional nature of thestudy, thus we cannot determine causality. As in all observationalstudies of dietary intake, it is possible that the diet was reportedwith some degree of error resulting from recall bias. However, weexpect this bias to be lower for current diet because it was mea-sured over a relatively recent duration (past 7 days). Parental feedingattitudes and styles may have differed in the preschool years sincethe first 2 years of the child’s life. However, studies suggest that theseare fairly stable (Faith et al., 2004). We did not adjust for birth weightwhen testing for an association with breastfeeding (Brown & Lee,2013a; Robinson et al., 2013). Additionally, we do not know the childweight and height during the first 2 years-of-life to directly comparewith parental perception at that time point. Lastly, confounding byunmeasured factors is another potential limitation.

Conclusions

Parental perception of child weight in the first 2 years does notreflect preschoolers’ child BMI. Yet it appears to be associated withpreschoolers’ diet seemingly through mechanisms other thanbreastfeeding. Thus, in addition to breastfeeding, another poten-tial mechanism for promoting more healthy diets is by improvingparental recognition of the child’s weight. Parents who incor-rectly perceive their child’s weight status are less likely to offer ahealthy dietary lifestyle and may require more tailored messagesregarding recognition and management of unhealthy weight gain.This study also contributes to the body of evidence linking past infantfeeding with key socio-demographic characteristics and un-healthy dietary patterns, with direct consequences for childhoodobesity. Implications for practice include finding ways to enhanceprovider–parent communication in relation to understanding pa-rental attitudes about child weight, addressing parental concerns

and strategies to ameliorate the determinants of unhealthy infantfeeding practices.

Appendix: Supplementary material

Supplementary data to this article can be found online atdoi:10.1016/j.appet.2015.03.029.

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