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Pediatric Weight Management

PWM: Family Influences (2006)


Baughcum AE, Powers SW, Johnson SB, Chamberlin LA, Deeks CM, Jain A, Whitaker RC. Maternal feeding practices and beliefs and their relationships to overweight in early childhood. J Dev Behav Pediatr 2001; 22: 391-408.

PubMed ID: 11773804
Study Design:
Cross-sectional (epidemiological study)
D - Click here for explanation of classification scheme.
Quality Rating:
Positive POSITIVE: See Quality Criteria Checklist below.
Research Purpose:

To analyze two new instruments that assess maternal feeding practices and beliefs and their relation to childhood overweight: 

  • Study #1: Infant Feeding Questionnaire
  • Study #2: Preschooler Feeding Questionnaire.
Inclusion Criteria:
  • English-speaking
  • At least 18 years old
  • Biological parent of a child who was 11 to 24 months at the time of the survey (Study #1)
  • Biological parent of a child who was 23 to 60 months at the time of the survey (Study #2).
Exclusion Criteria:

Children who had chronic medical conditions that affects appetite or growth.

Description of Study Protocol:

Study #1: Infant Feeding Questionnaire

  • 453 English-speaking mothers, at least 18 years of age, who at the time of the survey had a child 11 to 24 months of age and did not have a chronic medical condition affecting appetite or growth
  • 57% were recruited from nine WIC clinics in Kentucky and 43% from pediatric practices in Cincinnati
  • 105 children, 72% non-Hispanic Black, 67% Hispanic White, 2% Asian or Pacific Islander, 3% Hispanic Black and 17% other.

Study #2: Preschool Feeding Questionnaire

  • 634 mothers of children 23 to 60 months old
  • 56% recruited from the nine Kentucky WIC clinics and 44% from the Cincinnati Pediatric Research Group
  • 122 children, 68% non-Hispanic Black, 9% Hispanic White, 4% Asian or Pacific Islander, 3% Hispanic Black and 16% other.

Statistical Analyses

  • Exploratory factor analysis
  • Chi-square analysis to determine the association between maternal obesity (BMI at least 30kg per m2) and child overweight status (weight-for-height percentile at least 90%)
  •  T-tests to compare mean factor scores. Mean factor scores from the Preschool Feeding Questionnaire (PFQ) were compared between:
    • Mothers who were obese (BMI at least 30kg per m2) and those who were non-obese
    • Those who did and those who did not have an obese child
    • Those who had a low income and those who had a high income
  • Linear regression to control for confounding variables and to detect interaction among variables.
Data Collection Summary:

Independent Variables

Feeding behaviors.

Dependent Variables

  • Overweight in young children
  • Anthropometrics
    • Children’s height and weight were measured
    • Mothers’ height and weight were self-reported
    • Overweight defined as weight-for-height at or above the sex–specific 90th percentile used in the WIC program
  • Feeding practices and beliefs
    • Infant Feeding Questionnaire was designed as a self-administered questionnaire for mothers of children 11 to 24 months. The questionnaire was pilot tested with 45 mothers. Some items were deleted and the response scales were expanded from three to five responses on a Likert scale. No psychometrics was reported.
  • Preschooler Feeding Questionnaire (PFQ) was designed as a self-administered questionnaire for the mothers. PFQ was pilot tested with 44 low-income mothers prior to study; no items were eliminated but item scale changed from three-point to a five-point Likert scale. The PFQ validity and reliability were not addressed.
  • All questionnaire items were designed to explore one of eight a priori constructs: 
    • Concern about the infant’s weight (either over- or underweight)
    • Concern about the infant being hungry
    • Concern about how much the infant ate (both under- and overeating)
    • Control over how much the infant ate
    • Using food to calm the infant
    • Attention or nurturance by the mother during feedings
    • Establishing a feeding schedule
    • Awareness of the infant’s hunger and satiety cues and the infant’s ability to self-regulate energy intake
  • Demographics
    • Obtained from mother (e.g., family income, maternal education, household size, smoking history)
  • WIC income criteria was used as the income cut-point. Family income:
    • Low: Less than 185% of the poverty level at time of survey
    • High: Greater than185% of the poverty level.

Confounding Variables

  • Family income,
  • Maternal obesity
  • Child overweight.

Confounders not stated if adjusted for: gender, age, ethnicity, site.

Description of Actual Data Sample:
  • Infant feeding: 453 English-speaking mothers
  • Preschool feeding: 634 mothers of children 23 to 60 months old
  • Location: Kentucky, Cincinnati.
Summary of Results:

Infant Study

Mothers of overweight children were more concerned about their infants overeating or becoming overweight (P<0.05).

Children’s Study

  • Factor analysis showed there were significant differences in feeding styles between mothers in the low-income group compared to mothers in high-income groups. The mothers in the low-income group reported less difficulty in feeding but also a greater tendency to push their children to eat more than high-income mothers (P=0.004 and P<0.001, respectively).
  • Mothers in the low income group also reported a significantly higher degree of age-inappropriate feeding and a significantly lower degree of structure during feeding interactions. This included items about television watching, maternal interaction during meals and the child having a set mealtime routine (both P<0.001).
  • In addition, mothers in the low-income group reported higher levels of concern about their children’s overeating and becoming overweight than mothers in the high-income group (P=0.003)
  • Obese mothers reported greater concern about their child overeating and being overweight than non-obese mothers, independent of family income and whether the child was overweight (P=0.001) 
  • The scores for concern about underweight were twice as high as scores for concern about the child overeating or being overweight
  • 15% of the children were over the 90th weight-for-height percentile (WHP) and 5% were under the 10% percentile WHP
  • There was no significant difference between male and female in the prevalence of overweight (14% vs. 17%; P=0.31)
  • The prevalence of maternal obesity was higher in low-income mothers (32% vs. 8%, P<0.001) and their children were more often overweight (19% vs. 10%; P=0.001).
  • In the low-income families, obese mothers were not significantly more likely than non-obese mothers to have overweight children (25% vs. 17%, P=0.08).
Author Conclusion:
  • Although the study did not find specific feeding practices associated with childhood overweight, associations were found between child overweight and maternal concern about the child’s weight status (over- and under-weight)
  • Findings of study suggest that mothers of study preschoolers were more concerned about their children being underweight than being overweight. May represent a belief about the importance of having a larger child, a larger child may reflect a healthier child and a reflection of maternal nurturance in the first few years of life.
  • Perceptions of a child’s body weight may differ between Whites and non-Whites. There may be a greater acceptance of a larger child body size among Black women.
  • In this study, low-income mothers were three times more often obese and children in the low-income group were more often overweight; however obese mothers more not more likely to have overweight children than non-obese mothers (P=0.08). There were differences found in feeding behaviors between high and low income mothers.
  • The authors indicated that a specific ‘’feeding style” may or may not be the cause of childhood obesity.
Funding Source:
University/Hospital: Children's Hospital Medical Center, Unviersity of Cincinnati College of Medicine
Foundation associated with industry:
Reviewer Comments:


  • Reliability and validity of the Infant Feeding Questionnaire and the Preschooler Feeding Questionnaire was not addressed. Further testing of the instrument may be warranted.
  • Self-reported heights and weights of mothers. Maternal weight was self-reported. Child’s weight was obtained by WIC staff. 
  • The protocol used was not evaluated for reliability in this study
  • Failure to adjust for potential confounders.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) N/A
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) N/A
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) N/A
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? N/A
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) N/A
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) Yes
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? N/A
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) N/A
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? No
  7.5. Was the measurement of effect at an appropriate level of precision? N/A
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes