the relationship between child and parent food hedonics and parent and child food group intake in...

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RESEARCH

Research and Professional Briefs

The Relationship between Child and Parent FoodHedonics and Parent and Child Food GroupIntake in Children with Overweight/ObesityHOLLIE A. RAYNOR, PhD, RD, LDN; EMILY L. VAN WALLEGHEN, PhD; KATHRIN M. OSTERHOLT, MS; CHANTELLE N. HART, PhD;
ELISSA JELALIAN, PhD; RENA R. WING, PhD; GARY S. GOLDFIELD, PhD
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ABSTRACTMany factors influence children’s dietary intake, includ-ing children’s and parents’ food hedonics (liking), andparent intake. This secondary data analysis studied therelationship between child and parent liking, and parentintake and child intake of fruits, vegetables, low-fatdairy, snack foods, and sweetened beverages in 4- to9-year-old overweight/obese (body mass index �85th per-centile) children presenting for obesity treatment (Sep-tember 2005 to September 2007) in Providence, RI. Onehundred thirty-five parent-child pairs, with completebaseline dietary (3-day food record) and food group hedo-nic data were included. Hedonic ratings were mean rat-ings using a 5-point Likert scale (lower scores repre-sented greater liking of a food group). Children were aged7.2�1.6 years, 63.0% girls, 12.6% African American, and17.8% Hispanic, with a mean body mass index z score of.3�0.6. Total servings consumed by children over 3 daysere: fruits 2.7�3.2, vegetables 3.4�2.5, low-fat dairy.4�2.1, snack foods 5.9�4.2, and sweetened beverages.7�3.1. After demographic and anthropometric vari-bles were controlled, parent intake was positively re-ated (P�0.05) to child intake of all food groups exceptweetened beverages. Child liking was only significantly

H. A. Raynor is an associate professor and E. L. VanWalleghen is a postdoctoral fellow, Department of Nutri-tion, University of Tennessee, Knoxville. K. M. Osterholtis a project coordinator, C. N. Hart is an assistant pro-fessor (research), E. Jelalian is an associate professor(research), and R. R. Wing is a professor, Department ofPsychiatry and Human Behavior, The Weight Controland Diabetes Research Center, The Miriam Hospital/Brown Medical School, Providence, RI. G. S. Goldfieldis an assistant professor of pediatrics, human kinetics,and psychology, University of Ottawa, Ottawa, ON,Canada, and a scientist, Healthy Active Living andObesity Research Group, Ottawa, ON, Canada.

Address correspondence to: Hollie A. Raynor, PhD,RD, LDN, Department of Nutrition, University of Ten-nessee, 1215 W Cumberland Ave, JHB 341, Knoxville,TN 37996-1920. E-mail: [email protected]

Manuscript accepted: September 8, 2010.Copyright © 2011 by the American Dietetic

Association.0002-8223/$36.00

sdoi: 10.1016/j.jada.2010.12.013

© 2011 by the American Dietetic Association

P�0.05) related to child intake of vegetables. In younghildren with obesity/overweight, parent intake wasonsistently related to child intake. Changing parentntake may be important in helping to change the di-tary intake of young children with overweight/obesity.Am Diet Assoc. 2011;111:425-430.

The prevalence of childhood obesity has tripled duringthe past 20 years in Westernized countries (1). AsAmericans’ genetic makeup has not greatly changed,

he rising prevalence of childhood obesity is believed to beconsequence of environmental factors promoting exces-

ive energy intake and decreased energy expenditure2,3). National diet surveys indicate that children anddults, especially those with overweight/obesity, do noteet dietary recommendations and generally consume

oo much fat and not enough fruits and vegetables, whichay contribute to energy imbalance (4,5). To develop

ffective childhood obesity prevention/treatment pro-rams, identifying modifiable determinants of child in-ake is important.

What a child consumes is influenced by a complex set ofariables at the macroenvironment level as well as theamily and individual levels (6). At the individual level,hild dietary intake has been shown to be related to ahild’s hedonic appraisal (liking) of specific foods (7,8). Athe family level, parental hedonics of specific foods, whichay be associated through a genetic link in food prefer-

nces, is correlated with child’s dietary intake (9). Inddition parent dietary intake, which may influence childntake through food accessibility and availability and/orarental modeling, has also been shown to be related tohild’s dietary intake (6,10-13).Whereas previous research has examined family level

eterminants of child intake of fruits and vegetables8,11-13), little research has examined the relationshipetween parent and child liking and parent dietary in-ake with child intake across a broad range of foodroups, and no studies have examined these relationshipsn children with overweight or obesity. Most importantly,xamining family- and child-level determinants of foodroup intake that are related to child weight status, suchs fruits and vegetables (14,15) and low-fat dairy (16,17),s well as energy-dense snack foods (18) and sugar-sweet-ned beverages (19), may assist in identifying modifiableeterminants of child intake that can be targeted in child-ood obesity prevention/treatment programs. Thus, this
tudy examined the relationship between child liking,
Journal of the AMERICAN DIETETIC ASSOCIATION 425

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parent liking, parent intake, and child intake of fruits,vegetables, low-fat dairy, snack foods, and sweetenedbeverages in children with overweight/obesity. It was hy-pothesized that both child and parent hedonics and par-ent intake would be associated with child intake for allfood groups.

METHODSParticipantsParticipants were recruited from September 2005 toSeptember 2007 in Providence, RI, through newspaperadvertisements, posters, flyers, direct mailings, televi-sion advertisements, and personal and family physi-cian referrals for two 6-month, family-based childhoodweight control trials (trial no. NCT00259324 and no.NCT00200265). The trials delivered a family-based inter-vention to participating parents via eight 1-hour sessionsacross 6 months. One trial focused on increasing physicalactivity and decreasing sweetened drink intake vs. de-creasing television watching and increasing low-fat milkintake (Trial 1). The other trial focused on increasingfruits, vegetables, and low-fat dairy vs. decreasing sweet/salty snack foods and sweetened drinks (Trial 2). Eligi-bility criteria for the trials included children aged 4 to 9years, body mass index (BMI) �85th percentile (over-weight/obese), not meeting at least one recommendeddietary (eg, fruits and vegetables, low-fat dairy, sweet-ened beverages, and energy-dense snack foods) or leisure-time activity (eg, physical activity and screen time) guide-line, a parent willing to attend eight treatment meetingsover 6 months, parent and child having ability to speakEnglish, not participating in another childhood weightcontrol program, no major psychiatric disease, and nodietary or physical activity restrictions.

The sample consisted of 135 children with overweightor obesity along with a parent who participated in thetrials with complete baseline data. This cross-sectional,secondary data analysis only investigated the relation-ship between child and parent food group hedonics andparent food group consumption on child food group con-sumption at entry into the trial (baseline). This study wasapproved by the Institutional Review Board of The Mir-iam Hospital in Providence, RI.

ProceduresFollowing a telephone screen, families attended an orien-tation, in which informed consent (and child assent forchildren aged �8 years) was obtained. Families werecheduled for a baseline assessment before randomiza-ion, in which anthropometric measures were collected,uestionnaires were completed, and food records wereeviewed. Measures were obtained from the child andarent.

easuresarticipant Characteristics. Child and parent sociodemo-raphic variables were assessed by self-reported ques-ionnaire and included ethnicity, race, sex, age, and par-nt education and marital status. Ethnicity, race, sex,nd parent education and marital status were all nomi-
al measures. o
426 March 2011 Volume 111 Number 3

nthropometric Measures. Height was measured, withouthoes, to the nearest 0.125 in using a wall-mounted sta-iometer (SECA, ITIN Scale Company, Brooklyn, NY).ody weight, wearing light clothing without shoes, waseasured to the nearest 0.1 lb using an electronic scale

Healthometer Professional, Sunbeam Products Inc, Bocaaton, FL). BMI was calculated by dividing weight inilograms by height in meters squared. For children,hose with a BMI �85th percentile for age and sex origher based on US population norms were consideredverweight/obese and eligible to participate. BMI z valuesz-BMI) standardized for child age and sex were calcu-ated based on comparison to population norms (20).edonic (Liking) Ratings of Foods. Parents completed hedonicatings of foods alone, whereas children completed hedo-ic ratings with the help of a research assistant. Eachood was listed, along with a picture of the food, andarents and children rated hedonics for each food indi-idually. Hedonic ratings were obtained using a 5-pointikert scale, anchored by 1�“I like it a lot” and 5�“I doot like it a lot”; thus, lower scores reflect greater liking ofoods. Each point on the scale was also represented by aace demonstrating appropriate degrees of like and dis-ike. To aid children, research assistants read each foodtem to the child and asked the child about his/her hedo-ic rating by reading each of the 5-point ratings whileointing to the face that represented each hedonic rating,nd asking the child to point to the face that described hisr her liking/disliking of the food. This method of obtain-ng hedonic ratings has been used with young childrenreviously (21-23). Ratings for each food group were cal-ulated as the mean rating of the food items within eachood group (nine fruit items [eg, apples, bananas, andranges, and did not include 100% juice], 11 vegetabletems [eg, carrots, celery, and green beans, and did notnclude fried potatoes], four low-fat dairy items [eg, milk,ogurt, and string cheese], 10 snack-food items [eg, cook-es, ice cream, and potato chips], and three sweetened-everage items [eg, soda, fruit punch, and ice tea, and didot include 100% juice]). Foods in each food group werehose that are most frequently reported eaten by theontinuing Survey of Food Intakes by Individuals (24),nd in this sample all but two of the food items had beenaten by at least 85% of the children and parents. A list ofhe food items can be obtained from the authors. Thereas an option to indicate whether a food had never been

aten; these foods were not included in the mean ratingsor each food group. Thus, the mean hedonic rating forach food group was the sum of the ratings for each foodhat received a hedonic rating divided by the total num-er of food items in the food group that had received aedonic rating (23). Foods never consumed were not in-luded in the sum or denominator.ietary Intake. Information on parent and child dietary in-ake was assessed using 3-day food records collected ataseline. During the orientation, parents were given in-tructions on how to complete the food records for them-elves and for their child. Younger than age 8 years, chil-ren do not have the cognitive capabilities to self-report foodntake (25); thus, all parents were asked to complete theood records for their children. During the 3-day period, ifhe child was under the supervision/care of another adult
ther than the parent, the parent was instructed to obtain

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information from this other adult about what the childconsumed. Food records were completed on 2 weekdays and1 weekend day. Food records were reviewed for complete-ness and portion sizes of recorded foods were reviewedfor accuracy with the use of measuring cups and spoonsand a ruler by a trained research assistant. Each foodrecord was entered into the Nutrition Data System forResearch (version 2006, 2006, Nutrition CoordinatingCenter, University of Minnesota, Minneapolis, MN)software. Using the Nutrition Data System for Re-search software food grouping system, total number ofservings consumed during the 3-day period was calcu-lated for fruits (did not include 100% fruit juice), veg-etables (did not included fried potatoes), low-fat dairy,snack foods (eg, cookies, cakes, chips, and candy), andsweetened beverages (did not include 100% fruit juice).Serving sizes for each food group were based on theDietary Guidelines for Americans 2005 (26).

Analytic PlanMeans and standard deviations and percentages were

Table 1. Child and parent demographics, food group hedonic ratingsto study the relationship between child and parent liking, and parenand sweetened beverages in children presenting for obesity treatme

Variable

Age (y)Body mass indexStandardized body mass index

FemaleWhiteAfrican AmericanHispanic/LatinoOtherMarriedSome college educationHedonic ratingsb

FruitsVegetablesLow-fat dairySnack foodsSweetened beverages

FruitsVegetablesLow-fat dairySnack foodsSweetened beveragesServings consumedFruitsVegetablesLow-fat dairySnack foodsSweetened beverages

aNA�not applicable.bHedonics were rated on a 5-point Likert scale, with lower scores reflecting greater lik

calculated to determine sociodemographics and anthro- a

ometrics of the sample. Mean and median hedonic rat-ngs of each food group and mean servings consumeduring the 3 days for each food group were quantified.pearman’s rho correlations assessed the relationshipetween child liking, parent liking, and child intake andearson correlations assessed the relationship betweenarent intake and child intake for each food group. Hier-rchical regressions for each food group analyzed theelationship between child liking and parent liking (re-oded as 0 or 1, with 0 coded as hedonic ratings indicatingo degree of liking and 1 coded as hedonic ratings indi-ating some degree of liking) and parent intake on childntake, above and beyond the independent contribution ofhild and parent demographics and anthropometrics.hus, on Block I, child z-BMI, ethnicity, race, sex, and ageere force entered, and on Block II, parent sex, educa-

ion, BMI, age, marital status, ethnicity, and race wereorce entered. Then if child liking, parent liking, or parentntake were significantly correlated with child intake for

food group, these variables were entered stepwise intoeparate blocks, with child liking entered on the first

food group servings consumed during a 3-day period in an analysiske and child intake of fruits, vegetables, low-fat dairy, snack foods,Providence, RI

ild (n�135) Parent (n�135)

™™™™™™™™™™™™™™™ mean�standard deviation ™™™™™™™™™™™™™™3.2�1.6 38.0�5.8.5�4.0 33.8�8.6.3�0.6 NAa

™™™™™™™™™™™™™™™™™™™™™™™™% ™™™™™™™™™™™™™™™™™™™™™™™3.0 92.6.4 71.1.6 8.9.8 17.0.2 3.0

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™™™™™™™™™™™™™™™ mean�standard deviation ™™™™™™™™™™™™™™3.8�0.6 1.8�0.5.3�0.7 1.9�0.5.7�0.7 2.2�0.7.7�0.6 2.0�0.6.9�0.8 2.9�1.0™™™™™™™™™™™™™™ median (interquartile range) ™™™™™™™™™™™™™™3(0.8) 1.7 (0.8)(1.0) 1.9 (0.6)(1.3) 2.3 (1.1)(0.8) 2.0 (0.9)(1.3) 2.7 (1.0)™™™™™™™™™™™™™™™ mean�standard deviation ™™™™™™™™™™™™™™3.7�3.2 2.4�2.7.4�2.5 7.3�5.7.4�2.1 1.4�1.6.9�4.2 5.1�4.6.7�3.1 3.7�7.5

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March 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 427

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block, and parent intake on the third additional block. Ifchild liking or parent liking were not entered into theequation due to not having a statistically significant re-lationship in the simple correlations, those variables thatwere significant were entered into earlier blocks (ie, ifchild liking and parent liking were not significant, parentintake was entered into the first additional block). Two-tailed tests of significance were used for all analyses, withP�0.05 indicating significance. All analyses were con-ducted using SPSS software (version 17.0, 2007, SPSSInc, Chicago, IL).

RESULTS AND DISCUSSIONDemographic and anthropometric characteristics of thesample are reported in Table 1. Both children and par-ents, on average, were obese, primarily white, with par-ents moderately well educated and mainly married. The

Table 2. Hierarchical regression models ofchild food group consumption in a study ofand parent intake and child intake of fruisweetened beverages in children presenting

Block Variables

FruitsI Child age, sex, race, eth

body mass indexII Parent age, sex, race, e

marital status, body mIII Parent intake

R 2cum�0.169b, F (13, 1

VegetablesI Child age, sex, race, eth


marital status, body mIII Child hedonic ratingIV Parent intake

R 2cum�0.363, F (14, 12

Low-fat dairyI Child age, sex, race, eth



R 2cum�0.390, F (13, 12

Snack foodsI Child age, sex, race, eth



R 2cum�0.216, F (13, 12

Sweetenedbeverages

I Child age, sex, race, ethbody mass index

II Parent age, sex, race, emarital status, body m

III Parent intakeR 2

cum�0.143, F (13, 12

aR 2��Incremental variance accounted for by each bloc

bR 2cum�Variance accounted for by entire model.

vast majority of parents were mothers. (


Table 1 shows the mean and median hedonic ratingsnd mean number of servings consumed of the differentood groups during the 3-day period. The values indicatehat most foods were moderately well liked, with lowercores indicating greater liking. Interestingly, the childatings of fruits and low-fat dairy were similar to those ofnack foods, indicating that the hedonic values of theseood groups were similar in these children. Children andarents consumed fewer than the number of recom-ended servings for fruits and vegetables and low-fat

airy, and higher than the number of recommended serv-ngs for energy-dense snack foods and sweetened bever-ges. Of particular note is that these young children withverweight or obesity consumed close to three servings ofweetened beverages across 3 days.Parent intake was consistently positively correlatedith child intake across all food groups, including fruits

and parent hedonics and parent intake onlationship between child and parent liking,getables, low-fat dairy, snack foods, and

obesity treatment in Providence, RI

R 2�

a P value

standardized0.063 0.129

y, education,ndex 0.070 0.207

0.036 0.025.90, P�0.05



0.049 0.0120.151 0.001

31, P�0.001



0.169 0.00094, P�0.001



0.034 0.02456, P�0.01



0.065 0.00356, P�0.10

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dairy (r�0.447, P�0.01), snack foods (r�0.238, P�0.01),and sweetened beverages (r�0.222, P�0.01). Thus, par-ent intake was included in all regression models of childintake. In contrast, child liking (r��0.287, P�0.01) andparent liking (r��0.239, P�0.01) of vegetables were onlyrelated to child liking of vegetables. Thus, child likingand parent liking were only entered in the regressionmodel for child liking of vegetables. No other correlationsbetween child liking and parent liking and child intake ofany other food groups were significant.

Table 2 shows the results of the hierarchical regres-sions. All models accounted for a significant (P�0.05)amount of variance for child intake for each food group,except for sweetened beverages. For all significant mod-els, after child and parent demographics and anthropo-metrics were controlled, parent intake significantly(P�0.05) increased the proportion of the variance ex-plained for child intake for each food group. Child likingalso significantly (P�0.05) increased the proportion of thevariance explained for child intake for vegetables.

This study is the first to examine the relationship be-tween child and parent food group liking and parent foodgroup intake on food group intake of children with over-weight or obesity. Results indicated that parent intakewas associated with child intake across all food groups,except sweetened beverages, above and beyond the con-tribution of parent and child demographics and anthro-pometrics. In contrast, child liking was only related tochild intake of one food group: vegetables. The magnitudeof the relationships between parent–child dietary intakewas moderate and consistent with previous studies thatexamined intake in other food groupings in nonobeseparents and children (27-30). Because parent intake ap-pears to influence child intake for many food groups,understanding the mechanisms by which parent intakeinfluences child intake may provide useful targets forintervention in child obesity prevention/treatment pro-grams. Systematic and narrative reviews have shownevidence that parent intake may influence child intakethrough increasing the availability and accessibility offoods in the home and/or by parent modeling (6,11,31).The findings from this investigation suggest that chang-ing parent dietary intake may be an effective strategy tochange overall dietary intake in children with overweightand obesity.

Limitations of the study include the use of a select,fairly homogenous sample (ie, primarily white familieswith children with overweight or obesity presenting for afamily-based weight control study), so it is unknownwhether these results generalize to children with over-weight or obesity of other races or ethnicities and in othercommunity settings. In addition, the majority of parentswere mothers, and research has shown that the relation-ship between mother–child dietary intake is strongerthan that for father–child intake (32,33). In addition,although a validated measure of food liking was used inthis investigation, absolute dislike (ie, hate) of foods wasnot assessed, which may differentially influence intake.

CONCLUSIONSIn young children with overweight and obesity, parentintake of specific food groups, rather than child and par-
ent liking of these food groups, was most consistently
elated to child food group intake. This relationship maye due to food availability/accessibility in the home,nd/or parent modeling. Additional research is needed toetermine the mechanisms by which parent intake iselated to child intake. This study suggests that changingarent dietary intake may be important in helping tohange young children’s dietary intake. Research usingamily-based interventions, in which both children andarents are asked to make a change in behavior, alsondicates that changing parent dietary intake may be anmportant strategy in changing children’s dietary intake34). These results highlight the importance of targetingarents and their own behaviors in the prevention andreatment of childhood obesity.

STATEMENT OF POTENTIAL CONFLICT OF INTEREST:No potential conflict of interest was reported by the au-thors.

FUNDING/SUPPORT: This research was supported bygrant no. DK074919 from the National Institute of Dia-betes and Digestive and Kidney Diseases, and grant no.7-05-HFC-27 from the American Diabetes Association.

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