Child and adolescent overweight is becoming more prevalent in recent decades. In the United States, more than one of every three children was overweight or obese in 2012 [1]. In European countries, the corresponding rate ranged from 18.0% to 57.0% in 2010 [2]. In 2015-2016, the prevalence of obesity among US children and adolescents reached 18.4% and 20.6%, respectively [3]. The overweight and obesity rates among Chinese children and adolescents were 9.6% and 6.2% in 2012, respectively, which increased by 113.3% and 195.2% as compared to the rates reported in 2002. According to data released by the World Health Organization (WHO), in 2018 the overweight and obesity rates for Chinese children and adolescents aged 5-19 reached 28.5% and 11.7%, respectively. Although the overweight and obesity rates among Chinese children and adolescents were lower than those of some developed countries, the increasing speed of overweight and obesity are striking, and China now has the largest number of obese and overweight children and adolescents in the world [4].
Children and adolescents’ obesity is related to impaired health and some adult-associated diseases, including type II diabetes, dyslipidemia, hypertension, cardiovascular disease, and orthopedic complications [5]. Overweight children and adolescents have been shown facing challenges of social and psychological problems such as stigmatization and poor self-esteem [6]. Thus, is imperative to investigate the determinants of children and adolescents’ weight outcomes. Parental feeding behaviors has been found to influence children’s nutritional intakes [7]; parental feeding practices also contributed to the intergenerational transmission of obesity[8]. Thus, parental feeding knowledge and feeding practices have been considered as potentially modifiable risk factors of eating behaviors for children and adolescents. Exploring the prospective relation between parental feeding knowledge and practices and children and adolescents’ weight status has become a main focus of recent studies [9-11]. “Feeding practices” has been defined by some scholars as context-specific practices and “goal-directed behavior or strategies parents employ to control what, when, and how much their children eat” [12]. Others stated parental feeding practices as specific behaviors or strategies that parents used to maintain or modify children's dietary intakes [13]. This research considered parental feeding practices as parental eating styles and how parents monitored and restricted children and adolescents’ food intakes and physical activities. The next section moved to a review of related literature that guided this research.
Parental Feeding Knowledge and Children and Adolescents’ Obesity
Mothers’ knowledge about making healthy food choices for their children was found to be negatively linked to the percent of energy intakes from fat that children consumed [14]. Researchers indicated that mothers with the highest BMIs and poor nutritional knowledge were least likely to use health as a criterion for children’s food selection [15]. Grier and colleagues pointed out that appropriate parental knowledge on nutrition and food intakes could lower the likelihood of children and adolescents being overweight [16]. It was also found that parents who acknowledged that eating vegetables and fruits was beneficial to health were more likely to purchase such food, which led to lower odds of their children being overweight [17]. Chen [18] added that if parents had healthy feeding knowledge, then their children were more likely to intake eggs, nuts and milk, and were less likely to consume fast food and soft drinks. In short, previous studies provided evidence that healthy parental feeding knowledge influenced children and adolescents’ weight status.
Parental Food Intake Styles and Children and Adolescents’ Weight Status
A large body of literature suggested that strong similarities existed between children and their parents in terms of food preferences, food intake patterns and their willingness to try new foods [19, 20]. Children naturally prefer sweet and salty foods and avoid bitter and sour flavors. They learn about eating by watching the eating habits and food preferences of their primary role models, most times their parents. Children were also found to be more likely to try unfamiliar foods after they had seen their mothers ate this same food [21, 22]. Acharya and colleagues found that parents’ and children’s dietary intakes were highly correlated, especially for fruits, vegetables, sweetened beverages and meats [23]. Obese children tended to have ready access to energy dense food at home, which was especially true if their parents preferred this type of food [24]. In this sense, parental attitudes and styles towards food selection as well as eating behaviors significantly impacted children and adolescents’ attitudes towards food choices [25]. Parents who reported a lack of time or money constraints tended to rely upon energy dense fast food, which often led to children and adolescents’ overweight [26].
Scholars also highlighted the importance of parents sharing meals with their children. Through meal sharing, children learned eating habits and styles from their parents. Parents who created a positive mealtime environment by using constructive mealtime practices (including encouraging food tasting) rather than negative parenting practices (such as hurrying and forcing children to eat) led to more positive child eating behavior and lower body weights [27]. Powell and colleagues found that children whose mothers ate at the same time as they did and ate the same foods as their children were easier to feed and refused less food than children of mothers who did not. Children also displayed less fussy eating behaviors if mealtimes were free of distractions, such as television and toys [28]. In contrast, children and adolescents who had a low frequency of eating meals with their parents often reported frequent sweet beverage consumption, snacking, and eating “on-the-go.” Eating “on-the-go” in mothers, emotional eating and eating by the television/late at night in fathers often resulted in a higher risk of children and adolescents being obese [29]. These findings emphasized that parental eating habits and styles are determinants of children and adolescents’ weight status.
Parental Monitoring and Restricting Behaviors and Children and Adolescents’ Weight Status
There has been an increasing body of research on the role of parenting styles and the risk of obesity in children and adolescents. Authoritative parenting often includes a lot of monitoring and dietary restriction, which was generally found to be linked to a lower risk of children and adolescents’ obesity [30]. Some studies found that adolescents with lower BMIs also reported eating healthier meals in families that had rules around media and food, such as restricting television watching during dinner or consumption expectations [31]. Indulgent parenting was positively associated with child BMI [32]. Other scholars further classified parental feeding styles into four types: emotional feeding (EF), controlling over eating (COE), instrumental feeding (IF) and prompting/encouragement to eat (PEE) [33]. Studies showed that emotional feeding, prompting/encouragement and control over eating affected the occurrence of obesity in childhood [10]. Food restriction for promoting health was associated with increased consumption of junk food, sweets, and snacks. In contrast, encouraging balance and food variety by parents were associated with increased vegetable consumption and smaller waist circumference. Weight was negatively associated with parental pressure and food restriction for weight control [34]. These findings suggested that parental monitoring and restricting children and adolescents’ eating and activity behaviors have significant impacts on children and adolescents’ weight status.
The existing analyses, however, had some limitations. First, most studies of parental effects on children and adolescents’ weight status have not considered the rural-urban differences in China. China is a country with significant rural-urban gaps in living standards, lifestyles and cultural values [35]. Such differences have caused dissimilar communication patterns between parents and children in these two spheres. Prior research indicated that rural and urban parents showed disparate ways educating children. Rural adolescents were closer to their mothers than their urban counterparts; urban adolescents reported more conflicts with their parents than their rural ones [36]. Considering the rural and urban differences, this research proposed the following two hypotheses:
H1:Urban and rural parents had different feeding knowledge and practices in China;
H2:Urban and rural parents’ feeding knowledge and practices impacted Chinese children and adolescents’ weight status in different manners.
The second gap in the literature is a lack of differentiation between mothers’ and fathers’ influence on Chinese children and adolescents’ obesity. Although some research on Western societies has done some pioneer work, the results were not consistent. Some observed significant differences in maternal and paternal feeding practices [37]; but others did not find so [38, 39]. As to the link between parental feeding practices and child and adolescent obesity, Zhang and associate found no significantly different impacts of parental feeding practices on child weight status [40]. But others indicated that mothers had a stronger influence over their children’s weight and were more concerned about their children’s eating behaviors; fathers only played a role in imposing child feeding practices [41]. In addition, mothers’ parenting styles, feeding practices, modeling and encouraging of healthful behaviors were found to have stronger impacts on adolescents’ BMI z-scores, dietary patterns, physical activity habits and unhealthy weight control behaviors as compared to fathers [42, 43]. The eating behaviors of mothers were shown to be more important predictors of children’s body size than eating behaviors of fathers [29]. Other research, nevertheless, showed fathers’ parenting style being more significantly linked to more fruit and vegetable intakes along with lower BMI among daughters [44]. Given the differentials documented above, this research proposed two hypotheses for testing among Chinese children and adolescents:
H3:Chinese mothers and fathers had different feeding knowledge and practices;
H4:Mothers’ and fathers’ feeding knowledge and practices impacted Chinese children and adolescents’ weight status in different manners.