Study Design:
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Quality Rating:
Research Purpose:

To explore the relationship of the child-feeding strategies and eating patterns and other household characteristics of weight status among Mexican-American preschool-aged children living in low-income households.

Inclusion Criteria:
  • Target child was born between January 1, 1993 and January 31, 1995.
  • At least one of the child’s parents was self-identified as Latino, Mexican-American, Mexican or Hispanic.
  • Child not developmentally delayed or handicapped.
  • Child living with both biological parents (i.e., not raised by grandparents or adopted).
  • If the family had more than one preschool-aged child, the youngest child with a qualifying birthdate was designated as the target child.
  • At risk of overweight: BMI=85th percentile.
  • Overweight: BMI=95th percentile.
Exclusion Criteria:
  • Twins and children living in homeless shelters were excluded from the study because these conditions might complicate the target child-parent feeding relationship.
  • Single parent households.
Description of Study Protocol:


  • Convenience sample recruited from Head Start, Healthy Start, WIC, county day care centers and migrant education programs.


  • Took height and weight of preschool-aged children and their mothers.
  • Anthropometric data from fathers were obtained by self-report, because most fathers were not at home during the interviews and had to be reached by telephone later.
  • A 57-item food frequency questionnaire based on foods mentioned during focus groups with Mexican-American parents in California was developed and administered.
  • Measure level of parent acculturation: Country of origin, where parent’s early life was spent, years of residence in the United States and language proficiency using a 12-item scale.
  • Assess level of food insecurity, most commonly used child-feeding strategies, household size, income, education, occupation, participation in food assistance and nutrition education program, early infant-feeding practices and health history of the child.

Child-Feeding Strategies Included

  1. Mother Control
    • Child cannot go out to play or watch television until he or she eats
    • Has rule that child finish his or her plate
    • Child cannot go to store or eat sweets or desserts until he or she eats
    • Scolds child for not eating well
    • Uses going out to eat with child as a reward
    • Forceful feeding style.
  2. Mother Accomodating
    • Offers other foods when child refuses to eat
    • Waits until child has appetite to give him or her something to eat
    • Passive feeding style
  3. Other
    • Gives child vitamins
    • Child participates in preparation of meals
    • Child takes food from refrigerator or pantry between meals
    • Active feeding style.

Statistical Analysis

  • Student T-test and chi-square analysis (examining the relationship of each independent variable to risk of overweight and overweight status)
  • Logistic regression (evaluating the independent effects of these variables on weight status).
Data Collection Summary:

Timing of Measurements

  • Preschool-age children and mothers were measured using standardized.

Dependent Variables

  • BMI.

Independent Variables

  • Children’s dietary intake
  • Level of parental acculturation
  • Household size
  • Income
  • Education
  • Occupation
  • Participation in food assistance and nutrition education program
  • Early infant-feeding practices
  • Health history of the child.

Control Variables

  • Mother’s feeding style (controlling vs. accommodating)
  • Previous medical diagnosis of overweight or anemia
  • Age.
Description of Actual Data Sample:

  • Initial N: 238
  • Attrition (final N): 204
  • Age: Three to five years, (mean age ± standard deviation) 4.4 ± 0.8 years
  • Ethnicity: At least one parent self-identified as Latino, Mexican-American, Mexican or Hispanic
  • Location: Kern, Monterey, Fresno and Tulare counties, California.
Summary of Results:
  • 65.5% of the mothers were “less acculturated” as Spanish-dominant, based on the difference between the English and Spanish proficiency scores.
  • About 80% of the households were food insecure, and 30% of the households reported child hunger.

Variables Positively Related to Child’s Overweight Status Included

  • Household income
  • Mother’s BMI
  • Child’s birth weight
  • Juice intake as a proportion of total daily energy.

Mean percentage of energy intake coming from juice: 7.8±5.6 for BMI in the 85th percentile vs. 6.1±5.3 for BMI<85th percentile (P=0.03); 8.3±5.9 for BMI in the 95th percentile and 6.4±5.3 for BMI<95th percentile (P=0.04).

Variables negatively related to overweight status included current participation in WIC, other nutrition education programs and vegetable intake as a proportion of total daily energy.

Of the child-feeding strategies, only "child takes food from refrigerator or pantry between meals" was negatively associated with overweight status.

Author Conclusion:

The association of high birth weight and maternal obesity with overweight among preschool-aged Mexican-American children indicates that very early intervention may be needed to reduce the risk of overweight in this population.

Referral of eligible women, infants and children to the WIC program may be a useful strategy for early prevention in low-income Latino populations.

The results of this study suggest that biological and socioeconomic factors are more associated with overweight in Mexican-American preschool-aged children than most of the self-reported child-feeding strategies.

Funding Source:
Reviewer Comments:


  • Findings are consistent with other research in Latino and other populations.
  • Controlled for previous diagnosis of medical conditions (anemic and overweight).


  • Results of this study cannot be generalized.
  • Fathers' anthropometric data was self-reported.
  • Accuracy of variables derived from FFQ and self-reported child-feeding strategies is low and unlikely to perform as well as the biological and other socioeconomic variables.
  • Cross-sectional design.
  • No data on whether or not mothers participated in WIC during their pregnancies or only enrolled their children in the program more recently.

Other Comments

  • Influences of seasonality on dietary intake (study occurred from February to May).
  • Fruit juice is not defined.
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? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  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? ???
  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.) ???
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? ???
  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? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? N/A
  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? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  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)? Yes
  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