PARENTAL FEEDING STYLES AND WEIGHT STATUS OF PRESCHOOL CHILDREN IN

CHILE: PERCEPTIONS AND INFLUENTIAL FACTORS

BY

MARCELA VIZCARRA-CATALAN

DISSERTATION

Submitted in partial fulfillment of the requirements

for the degree of Doctor of Philosophy in Community Health
in the Graduate College of the
University of Illinois at Urbana-Champaign, 2020

Urbana, Illinois

Doctoral Committee:

Associate Professor Andiara Schwingel, Chair

Professor Kelly Bost
Assistant Professor Naiman Khan
Associate Professor Sheryl Hughes, Baylor College of Medicine
Assistant Professor Patricia Galvez, Universidad de Chile
 ABSTRACT

Chile is currently one of the Latin American countries with the highest prevalence of

childhood obesity, where 34% of children under the age of six are categorized as obese or

overweight. Parents have an integral role in obesity prevention in preschool children as the

parents can create a home food and meal environment through feeding behaviors, and take

actions based on their perceptions of their child’s weight status. Parents’ feeding styles, parent

feeding practices, and factors influencing them are especially relevant to young children who are

developing eating behaviors. Although the Chilean guidelines of healthy eating among young

children have included a parenting perspective of feeding to promote healthy growth, there is

scarce evidence on the topic, especially from Chile. Therefore, the purpose of this dissertation

was to investigate parenting approaches to feeding and misperceptions of child weight status in

Chilean families with preschool children, focusing on the following objectives: (1) to examine

the moderating effect of parent feeding styles on the relation between underestimation of the

child weight status and child BMI z-scores; (2) to assess parent misperceptions of weight status

in young children; and the association of sociodemographic, anthropometric, and behavioral

factors with parent underestimation of child weight status; and (3) to explore what influences

parents’ feeding practices for their three- to five-year-old children.

Cross-sectional data was obtained from parents and their three- to five-year-old children

(n = 174), recruited from childcare centers located in low-income neighborhoods in Santiago,

Chile. Weight and height were measured from parents and children, questionnaires regarding

feeding styles and parent perceptions of child weight status were administered. An analysis of

variance was used to examine child BMI z-score differences between feeding styles. Multiple

linear regressions were conducted to test the moderating effect of parent feeding styles—

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demandingness and responsiveness—on the relation between underestimation of the child weight

status and child BMI z-scores. Frequencies of misperceptions were obtained by comparing the

perceived versus the objective child weight status; and multiple logistic regressions were

conducted to examine the factors associated with underestimation of child weight status. For

objective 3, we conducted photo-elicitation interviews with a purposively selected subset of 25

parents with diverse feeding styles. A thematic analysis with an inductive approach was

conducted to identify influences on parents’ feeding practices from parents’ perspectives.

Children of parents who had high demanding/low responsive feeding styles (M = .89, SD

= .90) had significantly lower BMI z-scores compared to children of parents who have low

demanding/low responsive feeding styles (M = 1.65, SD = 1.21). Parent underestimation of child

weight status (B = .88, p < .001), and parent demandingness (B = -.53, p < .001) were

independently associated with child BMI z-scores.

Underestimation of child weight status was 47% in the total sample, and 78% among

parents of overweight or obese children. Child BMI z-scores OR = 2.8 (95% CI: 1.91, 4.36), and

parents of boys OR = 4.5 (95% CI: 1.33, 15.46), were associated with higher likelihood of parent

underestimation of child weight status, while less screen hours exposure in the child OR = .52

(95% CI: .29, .93) was associated with lower likelihood of underestimation of child weight

status.

We identified three themes affecting parent feeding practices: (1) parent and child

characteristics and the feeding dynamics; (2) family complexity and challenges; and (3) parents’

health knowledge. In the first theme, parents’ previous experiences as well as the parents’

reactions to the child’s characteristics generated adjustments in how the parent fed their child. In

the second theme, interactions between family members (e.g., mothers, fathers, and

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grandparents) regarding the feeding of the child were complex. Moreover, family context

revealed limited income and time, which determined the availability of necessary food, and the

quality of food preparations. In the last theme, parents demonstrated knowledge of food and

health, with knowledge sources being from public childcare and healthcare centers as well as

from the Internet resources.

Our results suggest that childhood obesity prevention programs may improve efficacy by

considering parent feeding styles and addressing factors that can help parents to correctly

estimate the weight status of their young children. In addition, attention must be paid to the

uniqueness of parent-child interactions, the role of family members, and the family relationships

with community organizations, such as childcare centers and healthcare centers. These

organizations could develop a culturally-sensitive approach to enhance parents’ feeding practices

to promote healthy eating and development of Chilean children.

iv
 Acknowledgements

My dissertation reflects the support and generosity of wonderful people that have

encouraged me on this journey. First, I want to thank my family, especially my parents, Amanda

and Osvaldo; my sisters Andrea and Claudia; my brother, Osvaldo; and especially my husband,

Gastón. They have all shown me what it means to be unconditionally and endlessly loving

persistent. Their lives have made it clear to be relentless and resilient in life.

I am deeply thankful to my advisor, Dr. Andiara Schwingel, for her motivation, guidance,

openness, and creating an environment to work that was supportive and caring. Dr. Schwingel

encouraged me to develop independence and autonomy to develop my ideas, challenged me to

find answers to work my insights thoroughly, and grow as a researcher to “create a compelling

story.” She always was available and welcomed my questions and motivated me to work hard to

achieve my goals. I am very fortunate to work with her, as Dr. Schwingel has supported my

research goals, including writing applications for funding and having publications with her

supervision. As I am moving to the next stage of my academic career, I will always keep in my

heart and mind such a great mentor and will follow her example.

Also, I want to express my sincere gratitude to my mentors, especially to Dr. Kelly Bost,

Dr. Sheryl Hughes, Dr. Patricia Galvez and Dr. Naiman Khan, for dedicating your time and

energy in advising me to conduct my research and grow as a researcher. I am very fortunate to

have generous mentors that enthusiastically shared their knowledge and experiences in this

process to achieve my goals. Special thanks also go to Dr. Marilyn Parsons and Dr. Michael

Parsons, who had great patience and kindness in editing multiple drafts of my work and giving

me advice every time I needed it. My most profound admiration for both of them. Also, Maria

v
Papaioannou has been very kind and patient as English editor of my drafts, I truly admire her

detailed oriented work and time for helping me.

I am also thankful for the team of professionals who supported my research in Chile:

María Jose Stecher and “The Junta Nacional de Jardines Infantiles, JUNJI”, Yanina Rodríguez,

Carolina Navarro, Nicole Fermandois, María José Coloma, Paulina Molina, Ricardo Cerda and

Carmen Gonzalez; and especially all the families who were willing to participate in the project.

I am grateful to the members of the Aging and Diversity Lab (ADL), Dr. Wojtek

Chodzko-Zajko, Liliana Aguayo, Laura Quinteros, Rifat Binte Alam, and Adeyosola Oke (&

baby Grace), André Pereira Do Santos. In this research group, I found wonderful friends and

colleagues that helped me in practicing and improving my presentations and preparing

milestones in my graduate work. I want to also thank Julie Jenkins, who has always there to help

me in my processes with immense kindness and dedication.

I want to thank my family-friends in Champaign-Urbana: Patricia Galvez, Veronica

Vidal, Crina Cotoc, Marina Dessotti, Yi-Chen Lee, Selina Jihye, Shraddha Shende, Jorge

Rodríguez, Henry Angulo, Claudia Lagos, Oscar Lopez, Catalina Sandoval, Carla Fernandez,

Marina Dessotti, Katia Nakamura, Danil Massip, Sulagna Chakraborty, Jude Krushnowsky,

Fiorella Krushnowsky, Lenore Mathews, Sergio Contreras, Rocío Valdebenito, Ivan Flores and

Bart Witter. I have shared with them so many beautiful experiences and have been a true family

during my graduate journey.

Finally, many thanks to the following agencies for funding my graduate education:

CONICYT under Becas Chile Scholarship No. #72170608; and the Center of Latin American

studies through Tinker Fellowship. I much appreciate your support during my doctorate studies

and for allowing me to learn and collaborate with incredible scientists.

vi
 TABLE OF CONTENTS

Chapter 1. Introduction ........................................................................................................1

Chapter 2. Literature review ..............................................................................................13

Chapter 3. Study 1: Associations among parental feeding styles, underestimation of child

weight status and BMI z-scores in young children in Chile ............................86

Chapter 4. Study 2: Parents’ misperceptions of child weight status and factors associated

with underestimation of weight status of young children in Chile ................138

Chapter 5. Study 3: Examining parents’ perspectives on feeding their children: Insights on

childhood obesity in Chile ............................................................................180

Chapter 6. Integrated conclusion and future directions ...................................................242

Appendix A. Interview script and question guide ...........................................................245

vii
 Chapter 1

Introduction

In Chile, one in three children utilizing the public healthcare system is overweight or

obese, and the trend of childhood obesity has been slowly increasing from 9.6% in 2007 to

11.4% in 2016 (Ministerio de Salud de Chile, 2016b). In addition, in the most recent

representative national sample of the population who is 15 years of age or older, the prevalence

of individuals in the overweight or obesity category was 74% (Ministerio de Salud de Chile,

2017a). The prevalence of the overweight and obesity increases with age, obesity prevention in

preschool children is one of the priorities for the country (Ministerio de Salud, 2011).

Extended childhood exposure to unhealthy environments and inadequate behavioral and

biological responses to those settings can lead to obesity development (Robinson et al., 2012;

Ventura & Birch, 2008). In the home environment, parents can influence preferences and eating

habits of their preschool children with the potential to build stable habits (Ashcroft, Semmler,

Carnell, van Jaarsveld, & Wardle, 2008; Skinner, Carruth, Bounds, & Ziegler, 2002). The

interaction between a parent and a child during feeding is a relevant factor in terms of nutrition

and development, and such feeding practices can be modified to prevent childhood obesity and

also to avoid the loss of developmental potential (Bentley et al., 2014; Karp et al., 2014). Also,

unlike the eating habits of older children, young children depend more on their families to

develop their eating habits (Birch & Ventura, 2009). Early childhood constitutes a period of great

learning (Birch & Ventura, 2009), in which parents are helping the child to adjust adequately to

the values, beliefs, or norms in the sociocultural environment they live in (Hughes et al., 2006).

Based on the conceptualization of general parenting, the emotional climate created as a result of

a parental set of feeding behaviors is referred to as feeding style. Among feeding styles, the

1
indulgent and uninvolved feeding styles are associated with higher weight children and lower

quality of diet (Hankey et al., 2016; Vollmer & Mobley, 2013). On the other hand, the

authoritarian feeding style, which is highly demanding and unresponsive to the child’s needs, has

been associated with both lower child weight (Hughes et al., 2008; Tovar et al., 2015; Vollmer &

Mobley, 2013) and a healthier diet for the child (Patrick, Nicklas, Hughes, & Morales, 2005).

This evidence suggests that feeding styles are associated distinctively to weight-related

outcomes.

Although the associations between indulgent and uninvolved feeding styles and weight-

related outcomes in the child are consistent across studies (Vollmer & Mobley, 2013), most of

the research regarding feeding styles has been conducted in developed countries (Shloim et. al,

2015; Vollmer & Mobley, 2013). Despite the increasing prevalence of overweight and obesity in

Latin America (Black et al., 2013), the research in the feeding domain is scarce within the

region. Indeed, this subject is particularly important in Chile, where most of the population is in

the overweight or obese categories, and the chance of the country to curb children being

overweight by 2025 is only 7% (World Health Organization [WHO], 2014). Given that feeding

styles and feeding practices are influenced by cultural values, social norms, and food

environments (Birch & Fisher, 1998; Birch &Anzman, 2010), this family influence needs to be

explored to gain more insight to address childhood obesity in the crucial stage of the preschool

years.

Another sociocultural factor linked to weight-related outcomes and feeding styles is the

parental perceptions of child weight status (Flores-Peña et al., 2016). Particularly, the

underestimation of weight status is considered a relevant factor to prevent or treat childhood

obesity, and it is linked to parent feeding styles (Flores-Peña et al., 2016; Webber, Hill, Cooke,

2
Carnell, & Wardle, 2010; Yilmaz, Erkorkmaz, Ozcetin, & Karaaslan, 2013). For example,

Flores-Peña et al. (2014) found that parents who underestimated their child weight status when

their child was actually overweight or obese reported significantly less actions to improve the

weight status of their child than those who accurately identified the overweight or obese status.

Also, parents who underestimated their child’s weight status may tend to be less worried about

their actual weight (Tschamler, Conn, Cook, & Halterman, 2010). Thus, the current study fills

the gap in the literature by identifying parent feeding styles and evaluating their moderator roles

in the association between the underestimation of the child weight category and child weight

status. This is a starting point to understand parent-child interactions in the feeding situations of

Chilean families.

Underestimation of child weight status has been found to be the most relevant predictor

of childhood obesity (McKee, Long, Southward, Walker, & McCown, 2016). Also,

underestimation of overweight status among parents of preschoolers was estimated by 86%,

involving samples from diverse countries, such as the United States, [US], Germany, Australia,

and some countries in Latin America (Rietmeijer-Mentink et al., 2013). In Chile, research in the

underestimation of weight status in preschool children is limited. The underestimation of weight

status in parents of obese or overweight children was also high with 91% and 77%, respectively,

in a sample of both preschool and school age children (Heitzinger et al., 2014). According to

Heitzinger et. al., (2014) the underestimation of overweight status and obese status was 70% and

31%, respectively.

Factors related to underestimation of child weight status reported in the literature are

sociodemographic, anthropometric, and behavioral. Among these factors, child BMI and child

age (Howe, Alexander, & Stevenson, 2017; Hudson, McGloin, & McConnon, 2012), parent

3
education (Rich et al., 2005), child gender (Boutelle, Fulkerson, Neumark-Sztainer, & Story,

2004), and caregiver/parent weight status (Gauthier & Gance-Cleveland, 2016) have been

associated with underestimation of child weight status. Mixed evidence has been found in

sociodemographic variables, such as in parent education levels, in which there is a negative

association (Huang et al., 2007), or no association (Júlíusson, Roelants, Markestad, & Bjerknes,

2011) with underestimation of child weight status. However, there is limited research exploring

the factors associated with underestimation of child weight status. Therefore, the objectives of

this study are to assess parent misperceptions of weight status in young children; and to examine

sociodemographic and behavioral factors associated with parent underestimation of child weight

status in Chile. Learning about misperceptions of weight status, particularly underestimation and

factors associated with them, can help influential institutions to approach obesity from a

culturally competent perspective and improve the efficacy of programs aimed at families.

Feeding practices are goal-oriented strategies that parents employ to influence the types of

foods, mealtimes, serving sizes that children eat (Hughes et al., 2006; Darling & Steinberg,

1993) . Similar to feeding styles, feeding practices can be influenced by culture and context of

families (Hughes et al., 2006). These feeding practices have been classified into non-coercive

and coercive (Vaughn et al., 2016). Non-coercive feeding practices consist of parents organizing

the food environment and provide structure for the child to eat. These types of non-coercive

practices also consider the child’s developmental stage, thus promoting child competence,

autonomy, and independence (e.g., involving her/him to make decisions about food within

boundaries or defined structure) (Vaughn et al., 2016). In contrast, coercive feeding practices,

such as restricting foods, pressure to eat, or bribing the child with foods are feeding practices

centered on adults, and those practices do not create a positive relation with foods and self-

4
regulation when eating (Jansen, Mulkens, Emond, & Jansen, 2008; Vaughn et al., 2016).

Recently, the American Academy of Pediatrics (AAP) has recommended that parents and other

caregivers apply feeding practices that support a child’s development (American Academy of

Pediatrics, Association, Education, & Association, 2019), which demonstrates their advocacy for

the use of non-coercive practices/responsive practices.

Even though the research findings point toward parent feeding practices as crucial for

preventing or treating childhood obesity in preschool years (Birch, 2016; Piernas & Popkin,

2010), in Chile there is scarce research on parents’ influences for the feeding practices that they

use with their child. To date, national data only corroborates that young children are eating

unhealthily and that there are socioeconomic disparities in quality of diet. For example, the

National Survey of Food Intake has reported that children between the ages of two and five

consume low amounts of vegetables and have a high intake of sugar from sugar-sweetened

drinks and sweets (Universidad de Chile, 2014). In addition, families from low- and middle-

socioeconomic status present a lower index of healthy eating compared to those from higher

socioeconomic status (Universidad de Chile, 2014). More importantly, it has also been reported

that obese preschool children attending childcare centers have an excessive energy intake during

the weekends (Vasquez, Salazar, Andrade, Diaz, & Rojas, 2004), which shows that parents’

feeding practices need to be studied as the practices provide valuable information to improve or

develop family-centered programs to fight childhood obesity.

This study works to fill the research gap on parent feeding practices in Latin America,

with an emphasis on Chile, and in so doing, helps us to understand the multiple reasons why

parents do or do not promote healthy eating habits in their young children. Specifically, this

study explores parents’ perspectives in feeding their pre-school children in Chilean low-income

5
families as those perspectives can provide valuable information to improve or develop family-

centered programs to fight childhood obesity.

6
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Economos, C. D. (2015). Low demanding parental feeding style is associated with low

consumption of whole grains among children of recent immigrants. Appetite, 95, 211–218.

https://doi.org/10.1016/j.appet.2015.06.006

Universidad de Chile. (2014). Encuesta Nacional de Consumo Alimentario. Santiago. Retrieved

from http://www.minsal.cl/sites/default/files/ENCA-INFORME_FINAL.pdf

Vasquez, F., Salazar, G., Andrade, M., Diaz, E., & Rojas, J. (2004). Ingesta alimentaria de

preescolares obesos asistentes a los jardines infantiles de la JUNJI. Revista Chilena de

Nutricion, 31(2). https://doi.org/http://dx.doi.org/10.4067/S0717-75182004000200004

Vaughn, A. E., Ward, D. S., Fisher, J. O., Faith, M. S., Hughes, S. O., Kremers, S. P. J., …

Power, T. G. (2016). Fundamental constructs in food parenting practices: A content map to

guide future research. Nutrition Reviews, 74(2), 98–117.

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Ventura, A. K., & Birch, L. L. (2008). Does parenting affect children’s eating and weight status?

International Journal of Behavioral Nutrition and Physical Activity, 5(15), 1–12.

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Vollmer, R. L., & Mobley, A. R. (2013). Parenting styles, feeding styles, and their influence on

child obesogenic behaviors and body weight. A review. Appetite, 71, 232–241.

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Webber, L., Hill, C., Cooke, L., Carnell, S., & Wardle, J. (2010). Associations between child

weight and maternal feeding styles are mediated by maternal perceptions and concerns.

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Hospitalaria, 28(3), 741–746. https://doi.org/10.3305/nh.2013.28.3.6358

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 Chapter 2

Literature Review

Childhood Obesity

Approximately 38 million children under the age of five were categorized as overweight

worldwide in 2017 (UNICEF, WHO & WBG, 2018). This particular trend has increased from

4.9% in 2000 to 5.6% in 2017, mainly affecting low and middle-income countries (UNICEF,

WHO & WBG, 2018). In Latin America and the Caribbean, the prevalence of overweight or

obesity in five-year-old children or younger has increased from 6.8% to 7% in the period

between 2000 to 2017 affecting nearly four million children (UNICEF, WHO & WBG, 2018).

Excessive weight in children is a public health problem in Chile, ranking fourth in Latin

America with the highest prevalence of overweight in children under five-years old (FAO &

OPS, 2017). One out of three children five years old or older are categorized as overweight or

obese (Departamento de Estadísticas e Información en Salud, 2015). In Chile, obesity prevalence

of preschool children, who are between two and five years old, increased from 5% to 8.2% in the

decade between 1995 and 2005 (Vio, Albala, & Kain, 2007). Currently, the prevalence of obesity

in the group of four to five years old is 21.3% and 22.1%, respectively. This prevalence was

obtained from a large sample of children attending 9,500 public and subsidized schools

belonging to the National Board for School Assistance and Scholarships in Chile (Ministerio de

Educación, 2017). Meanwhile, in spite of a recent reduction of 2.6% and 2.8% in both groups of

four and five years old children, the prevalence of obesity remains high (Ministerio de

Educación, 2017).

Health concerns related to childhood obesity and prevention. Obesity in childhood

affects multiple aspects of health involving physical, emotional, social, and life span issues. The

13
risk of high adiposity in adulthood increases when a child as early as two-years old has been in

the 95th percentile or higher of Body Mass Index (BMI) for the corresponding age (Freedman et

al., 2005). In addition, obese children are at increased risk of high blood pressure and

dyslipidemia (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007). In terms of psychological

issues, childhood obesity has been associated with low self-esteem (Griffiths, Parsons, & Hill,

2010) and discrimination (Puhl & Brownell, 2001). Thus, efforts to promote a healthy weight in

preschool years are necessary due to the negative implications on multiple domains of child

development in the short- and long-term.

Further support for this need is given by longitudinal studies, which have reported that

addressing weight imbalance in preschool years is more successful than in school years

(Danielsson et al., 2012; Reinehr, Kleber, Lass, & Toschke, 2010). Food-related learning at this

developmental stage allows enriching experiences for children, mainly associated with eating

behaviors and socio-cultural aspects (Arredondo et al., 2006; Leann L. Birch & Anzman, 2010).

Besides, appetite traits and food eating patterns have the potential to last several years (Ashcroft

et al., 2008; Northstone & Emmett, 2008). Evidence suggests that children experience small to

moderate changes related to appetite traits between 4 and 11 years old (Ashcroft et al., 2008). In

contrast, the manner that children interact with food in terms of satiety responsiveness decreases

over time (e.g., eating slowly, being fussy, getting full easily or eating less in conditions of

emotional arousal), while food responsiveness traits increase (i.e., enjoyment of food, or

overeating in response to emotional arousal) (Ashcroft et al., 2008). The authors of this study

further argue that although genetic factors may also be involved, parent-child interactions could

have a role in the child’s development of appetite traits. Thus, paying attention to the dynamics

between parent and child interactions in the food environment is relevant since children tend to

14
maintain their eating traits while they grow up while at the same time they can have eating

behaviors that become more responsive to non-nutritional stimuli. In addition to the continuing

predominant appetite traits, eating patterns from three- to nine-year- old children remain

significantly stable (Northstone & Emmett, 2008).

Development and energy self-regulation of preschoolers. Preschool children between two

and five years old undergo processes in different domains of their development. These processes

require attention to promote healthy weight. Children in this age group are becoming more

autonomous and responsive to their socio-cultural and physical environment; still, they are

highly dependent on parents and other caregivers (Berk & Meyers, 2016). Preschool children

may experience reduced appetite due to slowed growth and therefore reject more newly

introduced foods compared to infants (Addessi, Galloway, Visalberghi, & Birch, 2005; Berk &

Meyers, 2016). As a consequence, parents may misinterpret the appetite reduction and food

rejection for an abnormality, leading to specific feeding practices like pressuring the child to eat

(Laura Webber, Cooke, Hill, & Wardle, 2010a).

Furthermore, findings from different studies indicate that preschool children have the ability

to regulate their food energy intake by responding to their internal signals of hunger and satiety

(Frankel et al., 2012; Leann Lipps Birch & Deysher, 1985; Leann Lipps Birch & Deysher, 1986).

This ability has been named self-regulation of energy intake and may be influenced by the

socializing process during food-related interactions between parents and children (Frankel et al.,

2012). It has been proposed that parents or other caregivers alter children’s ability to self-

regulate their energy intake by applying food restrictions; in turn, this restrictions leads the child

to eat excessively when the opportunity arises (Fisher & Birch, 1999; Birch, Fisher, & Davison,

2003).

15
 Restrictive parental feeding and excessive eating in the child have been found to be a result

of the increased attention of the child toward unhealthy foods, which leads to an altered self-

regulation of eating (Rollins, Savage, Fisher, & Birch, 2016). This paradigm is based on

associations between higher child weight and controlling feeding practices mainly applied by

parents from middle income White families in developed countries, where childhood obesity has

already been recognized as a health issue by parents (Hughes et al., 2006). Parental feeding

styles in diverse ethnicities have shown different associations between feeding and child weight

status and child’s eating behavior. These differences may be related to dimensions of feeding

unrelated to child concerns related to obesity (Hughes et al., 2006). For example, the

authoritarian feeding style, considered a controlling feeding applied with children has been

associated with lower child weight in children from low income minority groups in the US

(Hurley, Cross, & Hughes, 2011). Qualitative characteristics of feeding interactions with the

child influence child weight status. For example, previous research has shown a positive

association with higher quality of diet in preschool children when parents applied feeding

practices involving child autonomy, competence, and relatedness (Shim, Kim, Lee, Strong, &

Team, 2016).

Family as agents of change. Family can influence child weight outcomes through a wide

range of factors involving genetics, environment, and habits although these influences are

difficult to discern from one another (Brown, Halvorson, Cohen, Lazorick, & Skelton, 2016).

According to previous studies, the risk of becoming obese in middle childhood is seven times

higher when the child had an early onset of overweight and the two parents were obese. On the

other hand, the risk of becoming obese is 12 times higher for children between 2 and 15 years

old with the two obese parents (Pryor et al., 2015; Whitaker et al., 2010). Although obesity

16
predisposition is influenced by genes, it has been found that the environment plays a key role on

the increasing prevalence of obesity (Yazdi et al., 2008), where the child’s home is a major

influential environment.

Therefore, family and home environment are crucial for generating meal structure, food

exposure, food preferences, and feeding interactions that favorably impact the diet of the child

(Birch, 2016; Rosenkranz & Dzewaltowski, 2008). Family meals have been negatively

associated with childhood obesity and better diet quality (Tovar et al., 2013; Gable & Lutz,

2000) whereas home food environment can influence obesity development in the child by food

availability as it shapes the access to eating. In addition, home food environment fits the way

parents interact with their children to (dis)encourage the consumption of foods (SM Gerards &

SP Kremers, 2015). Thus, depending on their characteristics, parents can act as a protective

factor or as a barrier to develop healthy food habits and prevent obesity in the child.

Responsive feeding. This is defined as the “caregiver guidance and recognition of the

child’s cues of hunger and satiety” (Hurley et al., 2011, p. 495). This type of feeding includes

interactions and styles, the feeding context, and how to act when the child refuses to eat (Engle

& Pelto, 2011). Parents who apply responsive feeding create an environment of learning and love

during meals, promote self-feeding behavior, and emotionally connect with the child (Engle &

Pelto, 2011). Thus, responsive feeding is considered the link between nutrition, development,

feeding styles and food practices (Engle & Pelto, 2011).

On the other hand, non-responsive feeding refers to: (i) excessive control exerted over the

child to eat, such as food restriction or pressure to eat; (ii) letting the child be the one who

dominates food-related interactions which results in indulgent feeding; and (iii) parental

disregard during feeding (Black & Aboud, 2011; Hurley et al., 2011). When non-responsive

17
feeding occurs, the child may not only learn to disconnect with their internal cues of satiety and

hunger, but may also interfere with their own development of autonomy and competence due to

the multiple number of opportunities that parent-child feeding interactions provide to achieve

these developmental outcomes (Black & Aboud, 2011).

International guidelines by WHO and UNICEF have stated that “complementary feeding

depends not only on what is fed, but also on how, when, where and by whom the child is fed”

(Kathyrn Dewey, 2001, p.14). Also, according to the benchmarks for nutrition in childcare

settings, caregivers should be aware of the children’s ability to identify their hunger and satiety

signals (Benjamin & Briley, 2011).

Socio-ecological Approach of Childhood Obesity: The Six-C’s Model

Socio-ecological models are frameworks including multiple levels, in which individual

and environment factors are related to explain influences and approach health related outcomes

such as behaviors (Sallis & Naville, 2015). Socio-ecological models are characterized by five

principles: (i) multiple levels of influence on health outcomes or health related-behaviors; (ii)

influences on health-related behaviors are interrelated across these levels; (iii) environmental

contexts are significant determinants; (iv) the models should be specific towards behavior- or

health-related outcomes; and (v) multiple level interventions should be more effective in

changing behaviors or health related outcomes compared to interventions addressing only one

level. In addition, multiple theories can be included in the levels of socio-ecological models to

coherently combine them in order to study influential factors on health-related outcomes of

interest in a broader context (Sallis & Naville, 2015). For instance, childhood obesity is a

complex health outcome involving diverse and multiple factors influencing its onset. These

factors can be specific to developmental stages in childhood and adolescence (Harrison et al.,

18
2007). An advantage of the socio-ecological models is that they acknowledge the complexity of

health-related issues. By identifying factors that influence behaviors in specific layers/spheres,

socio-ecological models contextualize these factors so as to explain health-related outcomes.

In line with the objectives of this study, the socioecological Six-C’s model is a useful framework

to explain child weight outcomes by identifying the layers in which the variables of interest are

theoretically situated as well as the potential associations between them. The following section

provides a description of this model followed by a review of the variables of interest within its

layers.

The Six-C’s model was developed by Harrison et al. (2011) to comprehensively address

weight imbalance from a developmental and ecological perspective based on Bronfenbrenner’s

ecological systems theory (Bronfenbrenner, 1979). The model approaches overweight and

obesity in the child considering both heredity characteristics and the effects from the

environment and contributes to organize child and environmental characteristics in multiple

layers by visualizing zones with key factors related to child weight (Harrison et al., 2007) (see

Figure 2.1).

First, the biological and genetic factors are part of the cell layer while the child layer

refers to the characteristics as an individual and the behaviors that are mainly controlled by the

child. Meanwhile, the clan layer encompasses characteristics and dynamics within the family.

The factors constituting the social environment in which the child and family are immersed are

called the community layer, which includes people and conditions in schools and communities.

After this layer come institutions at the level of country or states that, offer or limit opportunities:

the country layer. Finally, socio-cultural factors taking place in specific contexts influencing

health and weight-related behaviors are referred to as the cultural layer (Harrison et al., 2007).

19
A significant aspect of this framework is the recognition of the developmental stage to

understand factors associated with weight imbalance (Harrison et al., 2007). Child weight

outcomes in preschool years and adolescence are influenced by various factors and their

perspectives according to the developmental stage. For instance, feeding behaviors of parents or

other main caregivers may have a larger effect in preschoolers due to their higher parental

dependency as compared to adolescents, who are more independent to make their decisions

related to food.

The following section provides information about specific factors within the layers of the

six-C’s model of interest in this study. In the clan layer, feeding styles and feeding practices

within the parenting paradigm will be explored; in the cultural layer, two aspects will be

examined. First, differences of parental feeding across socio-cultural groups. Second, perceptions

of child weight status and factors associated with these perceptions, as well as the link between

feeding and perceptions of child weight status found in the literature. In the country layer,

general characteristics, and the demographic and nutritional transition of Chile will be described

to contextualize this study.

The Clan Layer

Within this micro-level, family characteristics influence eating behaviors, nutritional and

weight-related outcomes (Rosenkranz & Dzewaltowski, 2008).Children and parents are engaged

several times a day during the act of feeding (Bentley et al., 2014). Parent-child interactions are

part of the family dynamics within nutrition-related opportunities and resources in combination

with nutrition-related practices (Harrison et al., 2007). These interactions in the food-related

context can affect developing eating habits in the child, which, in turn, can lead to (un)healthy

growth (Faith et al., 2012).

20
 Parental feeding is a modifiable factor that can influence child weight status and eating

behavior (Frankel et al., 2014; Clark, Goyder, Bissell, Blank, & Peters, 2007). Parent-child

interactions in the feeding context are considered as a non-inborn influence on self-regulation of

energy intake of children (Frankel et al., 2012). In addition to the potential role of parents to

influence the degree to which children are responsive to their internal cues of hunger and satiety,

culture, education, income, and food security also shape families’ characteristics to approach

feeding (Vaughn et al., 2016). Parent-child interactions in the feeding context have been

explored through several and multiple constructs due to the complexity of family meals (Shloim

et al., 2015). In the next section, feeding styles and practices will be reviewed framed in the

context of the parenting paradigm.

Parental feeding: Key constructs. From the broad range of family traits, there are three

key theoretical constructs related to parenting in the domain of feeding that are central in this

research: (i) parenting style; (ii) feeding style; and (iii) feeding practices (Kremers et al., 2013).

These constructs are part of the child’s socialization process guided by parents and are

conceptualized in terms of their direct or indirect effects on child eating with the potential to

affect their weight. In the following section, general parenting background is described to

contextualize feeding styles and feeding practices as parenting in the feeding domain.

Background of parenting styles typologies. Parenting styles refers to the emotional

climate generated as a result of the multiple attributes of parents conveyed through their

behaviors during the interaction with the child in everyday life situations (Darling & Steinberg,

1993). This construct was initially described by Baumrind (1971) as a characteristic of the

parent; however, the child is also active on their own development by influencing parents

through their characteristics, such as temperament (Darling & Steinberg, 1993). The construct

21
was operationalized into three types of parenting patterns according to the control applied by

parents: (i) permissive;(ii) authoritarian; and (iii) authoritative (Darling & Steinberg, 1993).

Baumrind’s typology of parenting styles was further expanded to four by Maccoby & Martin

(1983) through a model based on two processes labeled as demandingness and responsiveness

(Darling & Steinberg, 1993). Demandingness refers to the number and types of parental

demands, in which parents display control, maturity demands, and supervision. On the other

hand, responsiveness indicates how contingently are the reactions of parents toward the child’s

behavior and their affective and warm involvement (Maccoby & Martin, 1983).

In sum, the four parenting styles according to the combination of these two dimensions are

the: (1) authoritative parents (i.e., high in demandingness and high in responsiveness), who are

nurturing and affectively warm, but set boundaries; (2) the authoritarian parents (i.e., high in

demandingness and low in responsiveness), who restrict, apply punishments, and use power

assertive behaviors; (3) the indulgent parents (i.e., high in responsiveness, low in

demandingness), who are warm and accept the child’s behaviors and do not apply limits; and (4)

the neglecting parents (i.e., low in both dimensions), who are uninvolved and apply no

boundaries. These last two styles are categorized as permissive parenting styles due to their low

level of demandingness.

Parenting styles and child weight status. Parenting styles have been studied in relation to

child weight outcomes mainly in recent decades (Power et al., 2013; Wake, Nicholson, Hardy, &

Smith, 2007). Certain typologies of parenting styles have been associated with an increased risk

of obesity according to the different conceptualizations of this construct in the field.

In a cross-sectional study in a large sample in Canada, 35% of preschoolers and 41% of school-

aged children had higher obesity risk when parents were authoritarian compared to the

22
authoritative parenting style after adjusting for covariates (Kakinami, Barnett, Séguin, & Paradis,

2015). Important findings in this study were that obesity risk in non-poor preschool-aged

children was 44%, and also there was a 26% higher risk of obesity for children who had an

authoritarian and neglecting parenting style. The authors suggest that both parenting style and

poverty are associated with obesity risk in preschoolers; therefore, this contextual factor of the

family should be considered in further research.

To evaluate the association between parenting styles and obesity risk in the child, Olvera

& Power (2010) conducted a longitudinal study with Mexican mothers of four-to-eight-year-old

children from low socioeconomic status during a time span of four years. The authors concluded

that children whose mothers exerted an indulgent parenting style had a significantly higher risk

of becoming overweight compared to those children whose mothers reported other parenting

styles (Olvera & Power, 2010). This finding contrasts the results of Kakinami et al. (2015) and

the Study of Early Child Care and Youth Development. In this last study, children had 5 times

higher obesity risk in first grade when their parents were authoritarian compared with those who

had authoritative parents (Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006). Rhee et al.

(2006) and Kakinami et al. (2015) conducted similar research using large national samples; but,

due to the study’s cross-sectional nature, the direction of associations cannot be determined.

Another limitation in it was the lack of comparison between child weight status and parenting

styles across socioeconomic status and ethnicities. Although this limitation was counteracted by

Olvera & Power’s (2010) longitudinal study design, its sample size was small (only 69 Mexican

mothers and their children were considered). Thus, more longitudinal studies are needed to (1)

further understand the relationship between parenting styles and child weight status, and to (2)

recognize long-term effects of general parenting and the directions of these associations.

23
 Parenting styles and child eating behavior. Some studies have associated parenting

styles to child eating behaviors. In a controlled home-based randomized trial, parental warmth

was positively associated with children’s vegetable intake and negatively associated with

snacking (Xu, Wen, Rissel, Flood, & Baur, 2013). On the other hand, no significant associations

were found between general parenting styles and child eating behaviors in primary school-age

children, and only more direct parental feeding practices were associated with healthier eating

habits (Vereecken, Legiest, Bourdeaudhuij, & Maes, 2009). The authors argued that parenting

style may have been less influential when it was broadly operationalized, thus less capable of

identifying associations between child eating behaviors and general parenting compared to a

previous study with adolescents (Kremers, Brug, De Vries, & Engels, 2003).

Although some studies have found associations between general parenting and weight

status and eating behaviors in the child, inconsistencies in these associations have led to conceive

general parenting as too broad a construct to be a direct influence of eating behaviors or weight

in the child (Vollmer & Mobley, 2013). It has been found that parenting applied specifically to

the feeding domain and styles is a more direct influence on child weight outcomes in comparison

to general parenting styles (Hennessy, Hughes, Goldberg, Hyatt, & Economos, 2010). Further, it

has been proposed that parents may apply distinctive parenting styles according to the domain in

which parent-child interaction occurs such as in the feeding domain, in which parents may

behave on the basis of their concerns about the child weight status) (Costanzo & Woody, 1985).

Feeding styles. This construct refers to a stable set of feeding behaviors that create an

emotional climate to feed a child (Hughes et al., 2008). In order to account for cultural

differences in relation to feeding behaviors of American and minorities in the US toward three-

to-five-year-old children, Hughes et al. (2005) developed the Caregiver’s Feeding Style

24
Questionnaire (CFSQ). This feeding measure operationalizes feeding styles based on the

parenting paradigm applied to the feeding domain, in which the combination of high and low

levels in the responsiveness and demandingness dimensions determine the types of feeding styles

parent apply (Hughes et al., 2005).

In the feeding domain, responsiveness refers to encouraging the child to eat in a child-

centered manner, which is warm, nurturing, and accepting toward the child’s signals/responses

(e.g., praising the child for eating and promoting their independence). On the other hand,

demandingness refers to (dis)encouraging the child to eat in a parent-centered way. This

dimension is characterized by demands which ignore the child’s responses, thus controlling the

child to eat by external means (e.g. “clean your plate”) (Hughes et al., 2005). Similar to the

parental feeding styles expanded by Maccoby and Martin (1983), four feeding styles are

categorized according to the combination of high or low levels of demandingness and

responsiveness: (i) authoritative (high demandingness and high responsiveness); (ii) authoritarian

(high demandingness and low responsiveness); (iii) indulgent (low demandingness and high

responsiveness); and (iv) uninvolved (low demandingness and low responsiveness).

The CFSQ has been validated in low income parents/caregivers of children between three

and five years old. The questionnaire is available in English and Spanish versions, and it contains

19 questions: 12 questions on the parent-centered subscale, and seven questions on the child-

centered subscale (Hughes et al., 2005). These questions are measured on a five-point Likert

scale. The mean of all child- and parent- centered questions is used to determine demandingness,

since all feeding behaviors are applied to encourage the child to eat. Responsiveness is the ratio

between the mean of child-centered feeding directives divided by the mean of the total number

of questions. The median of each of the dimensions is used to determine if the levels are high or

25
low and the combination of both categorize the feeding styles (e.g., high level of demandingness

and high level of responsiveness refer to authoritarian feeding styles). Later, cutoff points have

been proposed based on the medians from samples of studies conducted in the US (Hughes et al.,

2012).

Feeding styles and child-weight related outcomes. Associations between the indulgent

feeding style and higher weight status in children between three and five years old have

consistently been found in cross-sectional studies (Shloim et al., 2015; Vollmer & Mobley,

2013). Using the CFSQ, the indulgent feeding style has been positively associated with BMI z-

scores of preschool children between three and five years old in cross sectional studies (Hughes

et al., 2008; Hennessy et al., 2010; Hughes et al., 2005). Also, in an observational study using the

CFSQ in Hispanic parents of preschoolers residing in the US, the indulgent feeding style was

associated with higher child weight only in boys (Hughes et al., 2011). The authors argued that a

higher prevalence of obesity exists among Hispanic boys compared to African American and

Hispanic girls in the US; thus, the indulgent feeding style may represent a higher risk for this

group. In a cross-sectional study with immigrant parents of two-to-six-years children, the

indulgent feeding style explained 26% of child BMI z-scores variability (Tovar et al., 2013).

Additional evidence comes from a recent longitudinal study of Hispanic mothers of preschoolers

followed up at 18 months. In this study, only the indulgent feeding style explained the increase in

child BMI z-scores over time after controlling by child BMI z-score in baseline (Hughes, Power,

O’Connor, Orlet Fisher, & Chen, 2016). Although this study considered a relatively small

sample size (129 mothers), it contributes to the area by examining the long-term effects of the

indulgent feeding style on early childhood.

26
 The uninvolved feeding style has also been positively associated with child weight in

cross-sectional studies. One study found that in a predominantly White sample, only uninvolved

feeding style was a moderator in the association between high levels of emotional overeating to

cope with negative emotions and BMI z-scores in preschool children (Hankey et al., 2016).

Some evidence has identified the authoritarian feeding style with a lower child BMI z-score than

the indulgent feeding style (Hughes et al., 2008). Additional studies in Hispanic parents of two-

to-eight-year-old children with parental feeding styles according to either high or low level of

demandingness, indicated that parents applying high demandingness were associated with the

lowest BMI z-scores in the child (Maliszewski, Gillette, Brown, & Cowden, 2017).

Feeding styles and child eating behavior. Among the feeding styles in low income

families, the authoritative style has been positively associated with a healthier diet in

preschoolers—such as consumption of fruits, vegetables, and dairy products (Patrick et al.,

2005)—and the best scores in the Healthy Index Eating during dinner (Arlinghaus et al., 2018).

Also, Papaioannou et al. (2013) examined associations between parental feeding styles and

feeding practices with fruit and vegetable intake in preschoolers from low socio-economic status.

The authors found a moderated effect of feeding styles. In this study, when indulgent parents

increased restriction practices, their children had a higher consumption of fruits and vegetables.

This evidence suggests that the modification of feeding styles and practices can be an avenue for

improving the diet of the child and potentially promoting a healthy weight.

Feeding practices. The different behaviors or rules from caregivers to their children

aimed at influencing the mode of eating, the food type, the food amount and eating schedules is

referred to as feeding practices (Van Der Horst & Sleddens, 2017). For instance, some parents

use feeding practices to increase the consumption of particular kinds of foods such as fruits and

27
vegetables, or reduce the intake of others such as unhealthy snacks. Blissett (2011) reported that

parents employ specific feeding practices according to their own concerns about their child’s

weight or appetite. Some examples of feeding practices are the following: pressure to eat, food

restriction, modeling or monitoring, parental involvement (Shloim et al., 2015), or autonomy

support, among others (Vaughn et al., 2016).

Among the multiple feeding practices identified in the literature, some practices have

received more attention, such as restriction, pressure to eat, and monitoring due to the extensive

use of the Child Feeding Questionnaire (CFQ) (Shloim et al., 2015). The frequent use of the

Restriction subscale of the CFQ in studies has resulted on measuring this construct consistently

(Vaughn et al., 2016). Depending on how feeding practices are conceptualized, they can be

classified in more than one type or have multiple dimensions linked to (un)protective weight-

related outcomes (Rodenburg, Kremers, Oenema, & van de Mheen, 2014; Shloim et al., 2015;

Vaughn et al., 2016). For example, restriction has been typically defined as an explicit limitation

to the access of foods, which are generally rich. On the other hand, covert restriction refers to a

limitation of food access and avoidance the food consumption. Still, in either case the child is not

aware of these restrictions (e.g., parents avoid bringing unhealthy foods home). Restriction can

imply limits in terms of specific foods or their amount, among others. Besides, the distinctions

between dimensions of feeding practices may have differential effects. For instance, covert

control has been associated with a stronger positive association with child BMI z-scores than in

overt restriction (Rodenburg et al., 2014).

Another example of feeding practices that are not related to a nutritional function are

emotional and instrumental feeding, respectively. While in the former parents try to influence

their child’s emotions using food, the latter presents parents with the alternative of using food as

28
a means to obtain something from the child (Susan Carnell, Benson, Driggin, & Kolbe, 2014).

These feeding behaviors are less studied than restrictive or controlling feeding practices.

Although some studies examining the use of food to regulate emotions have found associations

between emotional eating and a child’s tendency to overeat (Rodgers et al., 2013; Vaughn et al.,

2016). According to Vaughn et al., (2016), this association cannot be ascertained due to the

limited research assessing it.

.............. Food restriction/control. This feeding practice is characterized by parental restriction of

unhealthy food and has been correlated with higher levels of appetite and weight in the child

(Gu, Warkentin, Mais, & Carnell, 2017). Food restriction or control is one of the most studied

feeding practices (Hurley et al., 2011; Shloim et al., 2015).The restriction subscale of the CFQ

developed by Birch et al. (2001) has been used to define restriction in the field due to its wide

use. Nevertheless, this subscale also encompasses behaviors related to the use of foods as reward

to promote a good behavior, suggesting more refinement in the conceptualization of this feeding

practice may be needed (Vaughn, Tabak, Bryant, & Ward, 2013).

In a systematic review of the period 2010 to 2015 focusing on children between 4 and 12

years old, 14 studies reported a positive association between food restriction/control and child

weight, while four studies did not find any association. In relation to longitudinal studies, the

results were mixed. Two studies found no association with child weight. One of them found an

association with lower child weight in preschool age children, but not in 10-to-12-year-old

children, which suggests a protective effect of restriction at younger ages (Campbell et al., 2010).

Finally, results of one study on child appetite involving only mother-daughter dyads found out

that only girls whose mothers restricted all types of snacks were more eager to eat in the absence

of hunger. In contrast, the girls who had low inhibitory control to eat and unrestricted food

29
access to snacks had higher BMI and ate more in the absence of hunger (Rollins et al., 2016).

The results of this last study show in part the complexity of feeding practices in relation to child

characteristics, and how the environmental setting defined by the caregiver plays a significant

role in early childhood.

Pressure to eat. This feeding practice refers to the situation when parents pressure or

insist that the child eat more foods, healthy foods, specific types of snacks, or finish a meal, even

when the child has communicated that they do not want to eat (Gevers, Kremers, de Vries, & van

Assema, 2014). Cross-sectional studies have mostly found a negative association between this

feeding practice and child weight (Blissett & Haycraft, 2008; Hurley et al., 2011; Powers,

Chamberlin, Van Schaick, Sherman, & Whitaker, 2006; Shloim et al., 2015; Tschann et al.,

2013). In longitudinal studies, results are inconsistent. Gubbels et al. (2011) used a stimulation of

healthy intake scale instead of the subscale of the CFQ of pressure to eat. A negative association

was found between the stimulation of healthy food intake and child BMI at seven years old after

controlling by baseline BMI at five years old, indicating that encouragement to eat healthy can

lead to a healthier child weight status (Shloim et al., 2015). In another longitudinal study in

school-aged children, it was found that higher BMI in the child predicted a reduction in parent

pressure to eat after controlling by scores at baseline (Webber, Cooke, Hill, & Wardle, 2010b).

Monitoring child intake. This feeding practice involves parental tracking of relevant

foods that children eat, such as the number and types of snacks by asking the child what she/he

has eaten during the day (Gevers et al., 2014). Monitoring can be measured by a subscale in the

CFQ (Birch et al., 2001). This feeding practice has not been associated with child weight in most

cross-sectional and longitudinal studies published in 2010 – 2015. Furthermore, those studies

which have identified associations with child weight found negative association with child

30
weight depending on the conceptualization of this feeding practice (Vaughn et al., 2016; Shloim

et al., 2015). In a review of Vaughn et al. (2016) which proposes a map of feeding-related

conceptualizations and interrelated factors, the researchers indicate that monitoring has been

positively associated with fruits and vegetables and negatively associated with unhealthy snacks

(Mcgowan, Croker, Wardle, & Cooke, 2012). In contrast, desirable eating behaviors (fiber and

sugar intake) in preschoolers were associated with parent monitoring only in children who were

not picky eaters and were not hungry (Gubbels et al., 2011). This last finding reflects the

importance of tailoring feeding practices to child characteristics to lead to healthier dietary

outcomes.

Culture Layer

This macro-level is associated with socio-cultural aspects present in communities or other

more distal contexts that influence the environment closer to the child (Rosenkranz &

Dzewaltowski, 2008). In this layer, food availability, family income, and even culture may have

the potential to equally influence food intake (Dettwyler, 1989; Rosenkranz & Dzewaltowski,

2008). Cultural aspects are reflected at the micro-level of family since traditions and customs

involve food as a vital aspect of everyday life (Rosenkranz & Dzewaltowski, 2008). Qualitative

research has identified the motivations that drive mothers when feeding their children. These

motivations are related to making them happy, healthy, and well-fed (Johnson, Sharkey, & Dean,

2011). Parents’ beliefs and attitudes in relation to mealtimes and how children should be

nourished are examples of cultural aspects that may influence how parents interact with their

children in food-related contexts (Gable & Lutz, 2000). Moreover, perceptions about child

weight status or appetite and concerns associated to these perceptions may affect the manner

parents feed their children (Webber et al., 2010a).

31
 Cultural differences in feeding styles and feeding practices. Different family

characteristics such as race, ethnicity, or socio-economic status have gained more attention to

explain their effects on feeding practices (Hurley et al., 2011;Vaughn et al., 2016). Cultural

particularities may carry out a variety of feeding practices (Hennessy et al., 2010; Hughes et al.,

2005) as a result of different motivations. For example, Immigrant Asian-Indian parents have

been reported to pressure their children to eat as a way to promote respect toward having food

available even when parents had never experienced food insecurity. They also pressured their

children to eat with the purpose of avoiding food waste (Momin, Chung, & Olson, 2013).

Traditions, cultural identity and religion have been proposed as important factors influencing

why parents use specific feeding practices (Momin et al., 2013).

Specific feeding practices or styles have been found to be more frequent between parents

from different ethnicities or races in studies using feeding measures of self-report (Blissett &

Bennett, 2013; Musher-Eizenman, de Lauzon-Guillain, Holub, Leporc, & Charles, 2009) and

observation of video-recordings (Power et al., 2015). For example, African American parents

were more likely to apply an uninvolved feeding style, while Hispanic parents were more likely

to have engage in indulgent feeding (Hughes et al., 2005). Ethnic differences among feeding

styles have also been identified among immigrants who have resided less than 10 years in the

US. Among the immigrant groups, the most prevalent feeding style of Haitian mothers was the

authoritarian (42%), unlike the feeding style in Brazilian and Hispanic mothers where this

feeding style was only 34% and 21%, respectively (Tovar et al., 2012). On the contrary, the

indulgent feeding style was more frequent in the Hispanic group (49%) than in the Brazilian

group (34%) and the Haitian mothers (21%) (Tovar et al., 2012).

32
 Differences in parental feeding among ethnic groups have been identified using the

CFSQ. This instrument was developed to capture more feeding patterns of groups with diverse

cultural backgrounds and in low socio-economic groups—not only the highly-controlled feeding

style identified in White populations (Hughes et al., 2005; Hughes et al., 2008). For instance, a

positive association between BMI z-scores of preschool children and indulgent feeding style has

been reported in a sample of 718 low-income families including African American, Hispanics

and White parents (Hughes et al., 2008). Thus, the development of instruments that capture

socio-cultural diversity related to parental feeding contributes to a better understanding of this

field (Hurley et al., 2011)

Differences at the level of feeding practices have also been found across races and

ethnicities. One study compared food restriction and monitoring of food among middle-class

groups of Afro-Caribbean, White German and White British (Blissett & Bennett, 2013). Afro-

Caribbean parents applied food restriction to control weight more frequently and had the lowest

frequency of food monitoring while British and German parents had similar frequencies of these

two practices. The British parents applied the lowest pressure to eat. Besides, the associations

with weight-related outcomes according to feeding practices also varied. For instance, only the

group of Afro-Caribbean parents showed significant correlations between child BMI standard

deviations and restriction to child weight. The authors concluded that feeding practices varied

across culture groups and that these variations were more characteristic among groups that have

different cultures with concurrent similar environment in terms of geographic location and food

(Blissett & Bennett, 2013).

Another study comparing cultural differences of feeding practices between France and

the US also reported distinctive feeding behaviors in caregivers of four-to-six-year-old children

33
(Musher-Eizenman et al., 2009). French parents restricted and monitored their children to eat

more often than did parents from the United States. The authors assert that feeding behaviors

among French parents may be linked to beliefs related to the parental role in helping the child

maintain a healthy weight, which may not be as relevant to American parents as in the French

culture. On the other hand, American parents used food for non-nutritive purposes more

frequently than French parents did. The authors conclude that these feeding behaviors may be

associated to the high prevalence of childhood obesity in the United States.

Although some studies have explored feeding styles and feeding practices in groups with

different cultural backgrounds, the research on feeding styles and practices regarding culture on

developed countries is still limited. For example, a systematic review found only 14 studies

regarding feeding and its links with weight status and child eating behavior in Asia in the period

2000 to 2015 (Lindsay et al., 2017); in a recent review, 31 studies were identified, most of them

conducted in the US and Europe (Shloim et al., 2015).

Feeding practices and feeding styles in Latin America and Chile. Parents face several

challenges that are unique to the developmental stage of preschool years, and their awareness of

their role is crucial to promote healthy, long-lasting developing habits in their children. To

provide guidance to parents regarding how to feed their children, the World Health Organization

(WHO) and the Pan American Health Organization (PAHO) promote responsive feeding since

children are breastfed (). Despite being encouraged by international organisms, little is known in

Latin American countries about feeding practices and styles.

Several countries in Latin America and the Caribbean have experienced a nutritional

transition from undernutrition to overweight and obesity from 1990 to 2010; this transition is

characterized by a trend in the reduction of the number and prevalence of stunting in children (R.

34
E. Black et al., 2013). Countries like Nicaragua, Guatemala, Peru, and Bolivia are some of the

countries currently facing a double burden of stunting and obesity in the region (R. E. Black et

al., 2013). As such, the prevalence of stunting affects the socio-economical groups with less

income unequally. On the other hand, countries such as Chile is mainly affected by excessive

weight since it has the lowest level of child undernutrition in Latin America (Albala, Vio, Kain,

& Uauy, 2002).

Given those trends, a small number of studies have considered child feeding issues in

Latin America; for example, Chile (Mulder, Kain, Uauy, & Seidell, 2009; José Luis Santos et al.,

2009), Brazil (Freitas et al., 2018; Mais, Warkentin, Latorre, Carnell, & Taddei, 2015; Novaes,

Franceschini, & Priore, 2008; Warkentin, Mais, Latorre, Carnell, & Taddei, 2016), and Mexico

(Flores-Peña et al., 2016). Most of these studies are cross-sectional, but the study of Mulder et al.

(2009) considered a longitudinal analysis with retrospective data of parents and their school-age

children. In most of the studies, validated measures of feeding practices were used, and only one

study used a measure to examine feeding styles. In addition, one case-control study using

parental self-report of feeding was conducted in a small sample of 50 normal weight and 50

obese children between six and eight years old, but its measure was not validated (Novaes et al.,

2008). Meanwhile, two studies with validated measures of feeding practices in Brazil have been

reported (Mais et al., 2015; Warkentin et al., 2016).

Most of those studies found an association between feeding practices and feeding styles

with child weight status or risk of obesity/overweight. Only one study with a longitudinal

analysis did not find any association between parental restrictive/controlling feeding practices

and child BMI z-scores after controlling by BMI z-score in baseline in school-aged children

(Mulder et al., 2009). On the other hand, one study found a positive correlation of food

35
restriction and a negative correlation of pressure to eat with child BMI z-scores in preschool

children (José Luis Santos et al., 2009). In the case-control study conducted by Novaes et al.,

(2008), constant limitation of food was associated with three times more likelihood of a child to

be obese compared to normal weight children. The risk of being overweight was associated with

food restriction in boys between 6 and 10 years old (Costa, Pino, & Friedman, 2011) and

between 2 and 8 years old (F. R. Freitas et al., 2018). Furthermore, only one study identified an

association between the uninvolved feeding style in preschool children and child BMI (Flores-

Peña et al., 2016).

In summary, a very limited number of studies have been conducted to understand

caregivers’ feeding in Latin America, and those which do mainly explore feeding practices in

school-age children. Further exploration of feeding practices and styles across cultures in Latin

American countries and their association with diet quality and weight-related outcomes are

needed. The cultural, historical, and nutritional context of countries can contribute to promote the

best practices according to the nutrition situation: double burden of undernutrition and obesity or

a post-nutrition transition.

Perceptions of Child Weight Status and its Potential Link with Parental Feeding

Parent-child interactions are greatly influenced by contextual factors in which culture

plays a role in shaping parental beliefs and perceptions toward the child in different

developmental stages (M. M. Black & Aboud, 2011). It has been further suggested that specific

parental perceptions and concerns about child weight play a role on parental feeding practices

(Laura Webber et al., 2010a). In a study conducted in Vietnam, parents who perceived their

children as thin applied more pressure to eat, but parents were more controlling with children

36
who had higher BMI z-scores and were perceived as heavier (Do, Eriksson, Tran, Petzold, &

Ascher, 2015).

Perceptions of child weight status. According to a recent systematic review of

underestimation of overweight or obesity in children, 62% of parents did not recognize the

weight status of their children and the underestimation was 86% in parents of two-to-six-year-old

children (Rietmeijer-Mentink, Paulis, van Middelkoop, Bindels, & van der Wouden, 2013).

Several factors have been associated with underestimation of child weight status, such as

television screen time exposure (Heitzinger et al., 2014; Zhang et al., 2018), higher child weight

(Maynard, Galuska, Blanck, & Serdula, 2003), child’s gender (Eckstein, 2006), child’s age

(AlHasan, Breneman, Lynes, & Callahan-Myrick, 2018; Howe et al., 2017), parental education

(Eckstein, 2006; Towns & D’Auria, 2009), and parent weight status (Gauthier & Gance-

cleveland, 2016).

Perceptions of child’s health and behaviors may be affected by parents’ cultural

background, in which the country of birth and socio-economic status may be involved (Peña,

Dixon, & Taveras, 2012; Natale et al., 2015). Some studies have found ethnic differences

regarding the parental perception of the child’s weight status. In these parents estimate the

child’s weight status as normal when the child actually has overweight or is obese (Peña et al.,

2012). For instance, African American mothers from low socio-economic groups identified

larger body sizes as normal in their children compared to White and Hispanics with similar

socio-economic background (Gu et al., 2017; Sherry et al., 2004). The lack of awareness related

to heavier weight status in the child may lead to less concern of parents to adopt healthier

behaviors to promote healthy eating in the child. Another factor that may lead to less concern is

the parental belief that excessive weight in the child is not an issue because the growth process

37
would eventually correct this condition; thus, these types of beliefs can reduce the potential of

parents to improve feeding behaviors and other lifestyle habits that promote a healthy growth

(Peña et al., 2012).

Studies examining the parental perception of child weight status in Chile are scarce. Only

three studies have been reported with cross-sectional design and were conducted in school and

preschool ages (Bracho & Ramos, 2007; Diaz, 2002; Heitzinger et al., 2014). One of the studies

was conducted in the region with the highest prevalence of obesity in the country, and

participants were 795 parents and their children from school and preschool ages (Heitzinger et

al., 2014). The underestimation of child weight status was the most common perception of child

weight status (53.6%), followed by accurate perception (41.8%), and only a small percentage of

parents who overestimated the weight status of their children (4.7%). Among the seven factors

included to be associated with the risk of underestimating child weigh status, only child’s age

and parental perception of the child having high appetite were negatively associated with an

underestimation of child weight status.

In a study with a small sample of 69 children between zero and six years old attending the

Chilean public health care system, parents were verbally asked about their perception of their

child weight status (Diaz, 2000). The results revealed that most of the parents of obese children

(64%) perceived them as normal weight or a little overweight (Diaz, 2000). On the other hand,

findings from a study conducted in mothers and their preschool children indicated 42% of

underestimation of child weight status. Parents of children who were obese and overweight

children the underestimation of child weight was 87% and 73%, respectively (Bracho & Ramos,

2007). In addition, parents with an accurate perception of child weight status were less likely to

have children in the category of overweight. In a sample of 129 mothers and school-aged

38
children, perceptions of child weight status were assessed by using a set of seven figures of body

image per sex according to BMI. The authors reported that 54% of parents identified their

children as thinner than the actual body size of their children (Nuño, Hevia, Bustos, Florenzano,

& Fritch, 2017). Still, research regarding perceptions of child weight status in preschool children

between three and five years old in Chile is scarce.

Country Layer

The country layer groups several factors of feeding styles and feeding practices of parents

of preschool children that can be shaped by the geo-political region in which a population is

living. In this layer, the context of Chile will be described to contextualize the research.

The context of Chile. Chile is located in South America, conformed by 16 regions

(Gobierno de Chile, n.d.-c) with a population of 17,574,003 inhabitants. Most of them live in

urban areas (87%), and the Metropolitan Region is the most populated region of the country with

7,112,808 inhabitants. Classified as a high-income country, economic growth has led to reducing

poverty levels from 7.3% to 1.3% in the period between 1990 and 2016 (The World Bank, 2016).

However, Chile is ranked fifth among countries with the highest income inequality in the world

(Organization for Economic Co-operation and Development, 2018).

Demographic, epidemiological, and nutritional transition. Rapid changes in

demographic, epidemiological and nutritional have occurred in the last decades. Currently, Chile

is in an advanced demographic transition, characterized by a low fertility rate, a low mortality

rate and a life expectancy similar to that of developed countries (Central Intelligence Agency,

2017). The fertility rate is 1.3 (Ministerio de Salud, 2018a) while the general mortality rate is 5.6

and the infant mortality rate is 7.4 (Ministerio de Salud, 2018c). The estimated life expectancy

between 2015 and 2020 is 79.8 years for both sexes (Ministerio de Salud, 2018b), gaining an

39
extra 24 years of life expectancy during the period between 1950 and 2015 (Instituto Nacional de

Estadísticas, 2017).

Several improvements in education and health care have been possible thanks to

economic growth and technology, especially since the 1990s. Sanitary and health services, health

care programs in combination with higher levels of education were some key improvements to

reduce infectious diseases and reduce mortality rates (Cecilia Albala et al., 2002). Currently,

non-communicable diseases are the leading cause of death with cardiovascular diseases and

tumors accounting for more than half of the deaths in the country (Departamento de Estadísticas

e Información en Salud, 2015). A shift from infectious to non-communicable diseases and aging

population characterizes the current health situation in Chile.

The economic growth in combination with demographic and social changes have

influenced the transition from undernutrition to high rates of obesity in Chile (Cecilia Albala et

al., 2002; Popkin, Adair, & Ng, 2012). This change occurred rapidly compared to other countries

in Latin America (C Albala, Vio, Kain, & Uauy, 2001). Unhealthy eating patterns and lack of

physical activity were particularly key in this transition (Cecilia Albala et al., 2002; Popkin,

Adair, & Ng, 2012). Dietary changes were characterized by a higher consumption of refined

carbohydrates, sugars, fats and animal-derived foods (Cecilia Albala et al., 2002; Popkin et al.,

2012). In addition, the urbanization process has decreased the possibility of growing fruits and

vegetables in kitchen gardens; in turn, the larger supply of unhealthy low-priced products has

also influenced the eating habits of children and adults.

The National Survey of Food Consumption in Chile (Universidad de Chile, 2014) has

found that preschool children consume only 40% of the daily recommended servings of fruits

and vegetables (Median = .143g, ranging from 89g to 223g per day). A high intake from sweet

40
treats and sugary soft drinks starting at preschool age through adulthood (29 years old) is

worrying. Sugary soft drinks consumption is higher in urban areas than in rural areas (which is

expected since most of the population live in urban areas (median = 21, 2g/day in rural areas,

while in urban areas median = 13,2g/day, p < .001)).

These changes occurred over a short period of time and have negatively affected how

Chilean families eat and the nutritional situation of the population, especially those from lower

socioeconomic status. The current nutritional situation of the population of 15-years or older is

alarming, as 40% are overweight and 34% are obese according to the latest national health

survey (Instituto Nacional de Estadísticas, 2018). The groups most affected by excessive weight

are those with lower educational level, reaching 80% of the group with eight or fewer years of

education.

Parents and grandparents, who were in constant alert decades ago to prevent malnutrition,

are now facing a very different scenario, which is characterized by the supply of high-energy

food. Due to the fast nutritional transition in Chile (Albala et al., 2001), the hallmark of

malnutrition by deficit may hinder consciousness about the negative effects of excessive weight

in children in the present. It has been proposed that this lack of parental awareness and their

influence on feeding practices arises from the need to protect children from undernutrition rather

than from hoping to prevent childhood obesity (Santos et al., 2009). While these studies shed

some light on the issue, research about beliefs and attitudes toward feeding practices or styles of

Chilean parents is still scarce. The high prevalence of the overweight condition among adults

encourages obesity prevention in childhood when lifestyle habits are forming. More attention to

promote healthy eating habits since childhood is needed, in which parental or other main

caregiver’s involvement is key to face this challenge.

41
 In addition, the wide range of available unhealthy foods in Chile is challenging for

parents whenever they have to choose better food options. A law has recently been implemented

to promote healthy eating among children. This law consists of limiting the food marketing that

targets children under the age of 14 as well as the offer of unhealthy foods in schools (Gobierno

de Chile, 2017). Also, the law enforces the use of labels to inform families about the nutritional

characteristics of foods. Although this law has been implemented since 2016, unhealthy food is

still ubiquitously available and parents need support to create a healthy food interaction with

their children and the food context for their children (Hart, Raynor, Osterholt, Jelalian, & Wing,

2011). In addition, the implementation of this measure is yet too recent to assert its influence on

nutritional outcomes and eating behaviors in the Chilean population, particularly in children.

Chilean families have shown an important role in the food and energy intake of preschool

children attending childcare settings managed by the government. Two studies found that

preschool children surpassed their energy requirements while they were under the watch of their

families after school hours and during weekends (Vasquez, Salazar, Andrade, Diaz, & Rojas,

2004 Vásquez, Salazar, Rodríguez, & Andrade, 2007). These findings provide evidence that the

family setting is fundamental on quality of diet and its effect on weight status, and that the way

they interact with their children in association with foods is important. The nutritional needs for

preschool children during the childcare hours are regulated by a government policy to cover

energy and nutritional needs of children during childcare hours (Ministerio de Education, 2019).

Nevertheless, parents’ feeding styles and feeding practices acquire great relevance in a macro

environment where the opportunities to eat unhealthily are multiple, as it occurs in Chile.

Understanding the cultural environment and contextual factors that affect parental

feeding practices in Chile may also be helpful to understand family dynamics in a food-related

42
context. In Chile, more efforts are needed to prevent childhood obesity in preschool years due to

the specific developmental processes with the potential to promote better health-related

outcomes in this age group. Focusing in preschool years is particularly relevant for Chile because

most of the interventions or programs have been aimed at preventing or treating obesity in

school-aged children (Popkin et al., 2012). A reduction in preschool children attending public

and subsidized schools has shown a small decrease of obesity, which suggests this age group is

sensitive to prevent obesity (Ministerio de Educación, 2017). Focusing on the interactions

between parents and children in the food context provides an avenue of possibilities to support

families not only in the food their children need to eat, but also in how parents are interacting

with their preschoolers in the food context to promote a healthy growth in Chile.

43
 Figures

Figure 2.1

Six-Cs Model: A developmental socio-ecological model to approach childhood obesity adapted

from Harrison et al. (2007)

44
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 Chapter 3

Study 1: Associations among parental feeding styles, underestimation of child weight status

and BMI z-scores in young children in Chile

Abstract

Low demanding/high responsive and low demanding/low responsive feeding styles as

well as underestimation of child weight status have been associated with higher BMI z-scores

and low quality of diet in children. However, there is scarce research of these factors and their

associations in Chile, a country with one of the highest overweight prevalence in children under

five years old in Latin America and where this trend is increasing as children get older. Thus, the

objective of this study was to identify feeding styles and to examine the moderating role of

feeding styles in the association between underestimation of child weight status and child BMI z-

scores. A total of 174 parents and their three-to-five year old children were recruited from

childcare centers offering early education programs in Santiago, Chile. Weight and height of

parents and their children were measured and questionnaires were administered in face-to-face

interviews. Dimensions of demandingness and responsiveness were calculated to categorize

parent feeding styles by combining high/low levels of each of the dimensions. An analysis of

variance was used to examine child BMI z-score differences between feeding styles. Multiple

linear regressions were conducted to test the moderating effect of parent feeding styles—

demandingness and responsiveness— on the relation between underestimation of the child

weight status and child BMI z-scores. Significant differences of child BMI z-scores were found

between high demanding/low responsive (M = .89, SD = .90) and low demanding/low

responsive feeding styles (M = 1.65, SD = 1.21). Only parent underestimation of child weight

status (B = .88, p < .001) and demandingness (B = -.53, p < .001) were associated with child

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BMI z-scores. Parents who underestimated weight status in their child had children with higher

BMI z-scores, while more demanding parents had children with lower BMI z-scores. Our results

suggest that childhood obesity prevention programs may increase effectiveness by considering

feeding styles and underestimation of child weight status of children in preschool years.

Introduction

Only three other countries in Latin America and the Caribbean have a higher prevalence

of overweight in children under five years old than Chile (Organización de las Naciones Unidas

para la Alimentacion y la Agricultura [FAO], Organización Panamericana de la Salud [OPS],

Programa Mundial de alimentos [WFP], 2019). One in three children in Chile is in the

overweight or obese categories (34.8%) and the trend of obesity has been slowly increasing from

7.1% in 2005 to 11.7% in 2017 (Ministerio de Salud de Chile, 2018b). Obesity among preschool

children is a public health concern, given the higher risk of maintaining this condition in later

stages of life (Robert C. Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). Additionally, 72% of

the population that is over 15 years old is overweight or obese (Ministerio de Salud de Chile,

2017a). Because the prevalence of overweight and obesity increases with age, obesity prevention

in preschool children is one of the priorities for the country in the current decade (2010–2020)

(Ministerio de Salud de Chile, 2010a). This priority has been reinforced by a national policy of

food and nutrition that considers as central factors the improvement of environments related to

food, including families, communities and public spaces within the socio-cultural context of

Chile (Ministerio de Salud de Chile, 2017b).

Parents are considered key actors in preventing or treating childhood obesity within the

context in which their families live (Moore, Wilkie, & Desrochers, 2017). In the home

environment, parents can influence preferences and eating habits of their preschool children

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(Ashcroft, Semmler, Carnell, van Jaarsveld, & Wardle, 2008; Skinner, Carruth, Bounds, &

Ziegler, 2002). The interaction between parent and child during feeding is a relevant factor in

terms of nutrition and development and it may be modified to prevent childhood obesity, and

also to avoid the loss of developmental potential (Bentley et al., 2014; Karp et al., 2014). Parent-

child feeding interactions are particularly relevant for preschool children attending public

childcare programs. Although these children have an appropriate nutritional and energy intake

for their age and hours during childcare hours, it has been reported that many have an excessive

energy intake when parents and other caregivers feed them at home (Vásquez et al., 2007).

Therefore, we need to understand how parents address feeding their child at home.

Based on the conceptualization of general parenting, a set of feeding behaviors following

patterned characteristics is referred to as a caregiver feeding style, while feeding

practices/behaviors are conceptualized as having specific goals, such as modeling the child to eat

fruits, restricting specific foods, or pressuring the child to eat (Hughes et al., 2005; Vollmer &

Mobley, 2013). Feeding styles reflect a food domain-specific parenting style (Power et al., 2013)

based on the dimensions of responsiveness and demandingness. Responsiveness refers to

whether parents adopt child-centered feeding strategies (e.g., encouraging eating by reasoning,

arranging foods, adjusting foods to facilitate eating) (Hughes et al., 2005). Demandingness refers

to the degree of encouragement that parents apply to feed the child, by using child-centered

feeding or parent-centered feeding strategies (e.g., pushing the child to eat through hurrying up,

telling the child to eat, disapproving when the child does not eat) (Hughes et al., 2005).

According to the level of these two dimensions of feeding the child, there are four feeding styles:

(i) high demanding/high responsive; (ii) high demanding/low responsive; (iii) low

demanding/high responsive; and (iv) low demanding/low responsive (Hughes et al., 2005).

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Among feeding styles, the low demanding/high responsive and low demanding/low responsive

styles have been associated with higher child weight and lower quality of diet (Tovar et al., 2015;

Tovar et al., 2012; Vollmer & Mobley, 2013). These associations have been found to be

consistent across studies but most of the research regarding parenting styles in the feeding

domain has been conducted in developed countries (Shloim et. al, 2015; Vollmer & Mobley,

2013).

Parent feeding styles and feeding practices are linked to cultural values, social norms,

parental styles, and food environments (Birch & Fisher, 1998; Birch & Anzman, 2010). Previous

research has indicated that parents who underestimate overweight children do not apply specific

measures to counteract this health condition (Flores-Peña et al., 2014). The perception of weight

status in the child is a socio-cultural factor, which has been associated with the approach that

parents apply when feeding a child. On the one hand, Faith et al. (2004b) have proposed that

perceiving obesity proneness in the child is associated with parent restriction of the child’s

eating. Additionally, Webber et al. (2010) hypothesized that parental perception of a child being

underweight may lead to making demands of the child, such as pressuring the child to eat. On the

other hand, Yilmaz et al. (2013) reported that Turkish parents allowed their children to eat with

little constraints when they underestimated their child’s body size. Although pressure to eat was

frequently used in Mexican parents of two-to-six years old children, those parents who correctly

categorized their child in the overweight category did not apply this pressure (Salinas Martínez et

al., 2019). Thus, parents may exert a set of feeding behaviors for different purposes that are

related to the parents’ perception of their child’s weight status and may vary according to culture

and context (Birch & Fisher, 1998; Birch &Anzman, 2010).

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 Theoretical and empirical relations of underestimation of weight status in preschool

children and feeding styles and its effect on the weight status of preschoolers requires more

research in Latin America. Context and history may play a role in both the perception of child

weight and feeding styles, especially in Chile, where a fast change in nutrition occurred and 55%

of parents underestimate obesity in their children (Ministerio de Educación de Chile, 2018).

Despite the increasing prevalence of overweight and obesity in Latin America (Black et

al., 2013), research in the feeding domain from the perspective of how children are fed and its

associations with underestimation of child weight status is limited. This subject is particularly

relevant in Chile, where the leading nutritional public health concern is obesity, and its

prevention from early childhood is crucial.

Based on the existing evidence about the association between feeding styles and

underestimation of child weight status, we hypothesize that children whose parents

underestimate child weight status and employ low demanding/high responsive and/or low

demanding/low responsive feeding styles would be positively and significantly associated with

higher child weight status (BMI z-scores). The present study addresses two main objectives: (1)

to identify parent feeding styles of preschool children and child BMI z-scores differences

according to parent feeding styles; and (2) to evaluate the moderating effect of feeding styles in

the association between underestimation of child weight status and weight status of preschool

children in Chile.

Methods

Study Overview

The current study analyzed data from two cross-sectional studies with convenience

samples to investigate parent socialization of child eating and misperceptions of child weight

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status. The first study was a pilot study to pre-test the Caregiver's Feeding Style Questionnaire

and verify the lexical appropriateness and interpretation of the items of this instrument in Chile

(e.g., “verduras” “vegetable” in English is commonly used instead of “vegetales” in Chile). The

second study was developed to increase the sample size of the first study and to explore

influences on feeding practices among parents of preschool children attending childcare centers

and residing in low-income neighborhoods in Chile. Both studies were implemented according to

the guidelines from the Declaration of Helsinki, and all procedures involving human

subjects/patients were approved by the Institutional Review Board at the University of Illinois at

Urbana-Champaign (approval number 17659 and 19014). Written informed consent was

obtained by parents and assent from the preschool children.

Participants

Criteria of inclusion. Parents or other family members who spend most of the time with

a child (three to five years old, both boys and girls, with no history of physical or mental

disabilities that may affect normal growth) out of school hours, and interact with her/him during

meal-times such as lunch or dinner.

Study site and participant recruitment. This study was conducted in Santiago, the

capital of Chile. Childcare settings from the Metropolitan Region of Santiago in neighborhoods

from areas of medium to high priority based on the Social Priority Index [Índice de Prioridad

Social] (Secretaría Regional Ministerial de Desarrollo Social R.M., 2017) were invited to

participate in the study. Fifteen out of 37 invited childcare settings agreed to participate (40.5%

of childcare settings response rate). The Index uses three dimensions to categorize the level of

vulnerability of the neighborhoods, which include multiple socio-economic variables such as

income, education and health conditions of individuals residing in neighborhoods. An invitation

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was sent to the childcare principal through email with an attached informative flier, asking to

circulate it in the childcare setting to invite parents/caregivers. One private childcare setting and

fourteen settings publicly managed by the National Board of Childcare Settings (Junta Nacional

de Jardines Infantiles, JUNJI) agreed to participate in this study. In particular, JUNJI is managed

by the Chilean Government (Gobierno de Chile, n.d.-a) and provides early education and meal

services from 8:00 am to 4:30 pm in the childcare settings. The socio-economic level of the

families ranged from low to medium, but children from the most vulnerable families are the

priority to receive these services. A total of 174 caregiver-child dyads participated in the study.

Data was collected in the form of interviews in face-to-face meetings at a place

convenient for the participants. The majority of caregivers preferred to be interviewed in

childcare settings. Interviews were conducted by research team members and included the

administration of questionnaires about: (i) feeding styles; (ii) perceived child weight status; (iii)

socio-demographic and behavioral information; and (iv) anthropometric measures of parents and

children. Most of the primary caregivers responsible for feeding their children were parents;

thus, parents terminology will be used throughout this study.

Procedures and measures. The team of interviewers consisted of two dietitians and one

nurse who were native Spanish speakers from Chile and had training in interviewing and

conducting anthropometric measures for children and adults.

Weight and height of caregivers and children were obtained according to standardized

protocol, in which they were asked to be weighed with light clothes (Ministerio de Salud de

Chile, 2014). The height was recorded to the nearest 0.1 cm and weight was recorded to the

nearest 0.1 kg. Weight was measured using Seca 769 electronic column scale, maximum

capacity 200 kilograms, and height was measured with a Seca 220 telescopic measuring rod

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attached to a Seca 769 electronic column scale (Seca Company, 2020).

Weight status in adults. Weight and height measures were used to calculate BMI and

categorize the weight status of parents according to BMI cut-off points for adults (underweight,

normal weight, overweight and obese) (WHO, 2018). This measure was obtained to inform about

parent weight categories of the sample. Also, parent BMI was used as a control variable in

multiple linear regression analyses given that this variable has been associated with child weight

status (Dev, McBride, Fiese, Jones, & Cho, on behalf of the STRONG Kids R, 2013).

Weight status in children. The BMI z-scores according to age (under 5) and sex were

calculated using the software WHO Anthro, version 3.2.2 (WHO, 2011). The software WHO

AnthroPlus. Version 1.0.4 was used to obtain BMI z-scores according to age and sex in children

older than 5 years because the version 3.2.2 does not yield BMI z-scores in children between 5

and 5 years 11 months. The BMI z-scores were obtained by two dietitians independently and

each value was compared to check for accuracy. Also, two dietitians categorized the nutritional

status according to child growth references used for children under 5-years-old and the child

growth references for 5-19-years for children between 5 years and 5 years 11 months (WHO,

2019b, 2019a). The agreement between the two dietitians was 97%. The information of the five

cases with discrepancies of child weight category was checked and discussed by both dietitians.

Feeding Styles. To identify feeding styles, the Spanish version of the CFSQ was used. This

self-report measure has been validated in low-income Hispanic parents of three-to-five-years-old

children and Haitian, Brazilian or Latino descendants who are caregivers of three-to-twelve years

children living in the US (Tovar, Hennessy, Pirie, Must, Gute, Hyatt, Kamins, Hughes, Boulos,

Sliwa, Galvao, et al., 2012; Hughes et al., 2006). The CFSQ consists of 19 items measured on a

five-point Likert scale ranging from never to always (Hughes, Power, Orlet Fisher, Mueller, &

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Nicklas, 2005). The development reliability and validity of the instrument has been previously

reported (Hughes et al., 2006; Hughes et al., 2005)

The Spanish version of the CFSQ was adjusted in a pilot study for use in Chile. The

adjustment of this instrument consisted of revising the items after consulting with three experts

and followed by cognitive interviews of eleven caregivers, ten parents and one grandmother of

children attending childcare centers from JUNJI. The involvement of a panel of experts and

cognitive interviews was based on studies using these procedures (Bowden et al. 2002;

Derscheid, Kim, Zittel, Umoren, & Henry, 2014).

The dimensions of demandingness and responsiveness determined parents’ feeding styles.

Demandingness refers the degree of parents encouraging the child to eat (e.g. saying to the child

“Hurry up and eat your food”) and child-centered feeding practices (e.g. complementing the

child to eat foods). This dimension was measured through the mean of the 19 items of the

questionnaire. Responsiveness refers to whether this encouragement considers the child’s needs

and responses during eating or not (in a sensitive or insensitive manner). The responsiveness

dimension was obtained through the ratio between the mean of the child-centered items and the

mean of the 19 items (Hughes et al., 2005).

The median of the scores of each of the dimensions of the sample (n = 174) was used to

determine high or low levels on demandingness and responsiveness (Hughes et al., 2005). The

median for demandingness and responsiveness in this sample was 2.89 and 1.25, respectively.

Previous studies have reported similar values of medians for demandingness and responsiveness

(Hughes et al., 2012; Tovar et al., 2012). Parent-child dyads with scores equal to or lower than

the median were considered to have low levels, while values higher than the median were

considered high levels (Hughes et al., 2005). Four feeding styles were categorized according to

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the levels low or high in the dimensions of demandingness and responsiveness: (i) high

demanding/low responsive; (ii) high demanding/high responsive; (iii) low demanding/high

responsive; and (iv) low demanding/low responsive (see Figure 3.1).

In our study, Cronbach’s Alpha value for parent-centered items was .83, and .58 for child-

centered items. Among the child-centered items, only the eighth item (“Allow the child to choose

the foods he or she wants to eat for dinner from foods already prepared”) was identified for

removal to increase internal reliability from .58 to .61.

Perceptions of child weight status. This perception was obtained verbally based on the

item regarding perceived child weight for children between three and five years old of the Child

Feeding Questionnaire (Birch et al., 2001). The question asked to parents was “How do you

perceive your child’s weight?” and they selected one of the four options to answer this question

(i) underweight, (ii) normal, (iii) overweight, or (iv) excessive overweight or obese. These

options were given in place of the original item because parents learn these categories for

classifying child weight status during the regular healthcare appointments for children between

two and six years old.

Underestimation was defined as an incongruence between the perceived child weight status

and perceived child weight status, in which the parent selected a lower child weight category

than the objective category based on the child growth standards used in Chile (WHO, 2019b;

WHO 2019a).

Statistical Analyses

Demographic characteristics were described by means, standard deviations, frequencies,

and percentages. Normal distribution was assessed in continuous variables. The significance

level set for all analysis was .05. An a priori statistical power analysis was performed with

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GPower3.1. With α = .05, power = .80, the projected sample size needed to detect and effect size

= .15 for a multiple linear regression analysis with 10 predictor was n = 118.

Kruskal-Wallis H test. This test was used to compare child BMI z-scores between the

groups of parents with each of the four feeding styles. This non-parametric test was used to

complement the Analysis of variance (ANOVA). The assumption of normal distribution assessed

with the Shapiro Wilk test to conduct a one-way analysis of variance (ANOVA) was not met in

the low demanding/high responsive group (p = .046).

Regression analyses. Preliminary steps to explore data distribution, correlations between

explanatory independent variables, and outliers in child BMI z-scores as the outcome variable,

were performed before conducting the multiple linear regression (MLR). Bivariate regression

analyses between the explanatory variables and child BMI z-scores were conducted to identify

significant associations between control variables and the outcome variables to obtain the fittest

MLR model to explain child weight status in this sample size. The preliminary control variables

considered for the multiple regression analyses were child sex (Reilly et al., 2005), child age

(Hughes et al., 2008), parent education (Lamerz et al., 2005), parent BMI (Danielzik,

Czerwinski-Mast, Langnäse, Dilba, & Müller, 2004), and family status as single/two-parent

family (Power et al., 2015; Dev, McBride, Fiese, Jones, & Cho, on behalf of the STRONG Kids

R, 2013). The latter was considered a binary variable, where a two-parent family was coded as 0

and single parent family was coded as 1. Education was coded thus: 1 having none, some or

completed elementary school; coded 2 as having some high school; and 3 having some post-

secondary education, including vocational, college or graduate education. Most of the population

25-years and older said their high school level was the highest educational level attained in Chile

(Instituto Nacional de Estadísticas, 2018). Thus, having some or completing high school

96
separated the lowest and highest levels of education attained by the participants. Control

variables were kept in the multiple linear regression when they were significantly associated with

the outcome variable, child BMI z-scores, in the bivariate regression analyses.

The moderating effect of feeding styles on the association between underestimation of

child weight status and child BMI z-scores (Figure 3.2) was tested in regression analyses using

IBM SPSS version 24 (IBM, 2018). In order to conduct the regression analyses, the feeding

styles variable, which consisted of four categories, was dummy coded. The high demanding/high

responsive feeding style was used as a comparison reference, given that previous research has

reported that this feeding style has been associated with the best weight related outcomes in the

child (Patrick et al., 2005; Hughes et al., 2008). This dummy codification produced three

independent variables, added to the analyses in the second block, after controlling for parent

BMI as this variable was included in the first block. Three interaction terms were created

between feeding styles and underestimation of child weight status: high demanding/low

responsive X underestimation; low demanding/high responsive X underestimation; and low

demanding/low responsive X underestimation. Only significant control variables were included

to obtain the best fitting model to examine the moderating effect of the feeding styles in the

association between the underestimation of child weight status and child BMI z-scores. In order

to take into consideration the sample size, the researchers conducted model regression with each

of the interaction terms separately. To check multicollinearity in the models of the multiple

linear regression, variance of inflation factors (VIF) were examined (Liu, Kuang, Gong, & Hou,

2003).

The objective of the study was to explore the moderating role of feeding styles in the

relation between underestimation of child weight status and child BMI z-scores. Consequently,

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we also conducted regression analyses, including the parent dimensions of demandingness and

responsiveness. These dimensions were included in the models as continuous variables to test

whether these dimensions have a role in moderating the relation between underestimation of

child weight status and child BMI z-scores. Two interaction terms were created between the

feeding dimensions and underestimation of child weight status: responsiveness X

underestimation, and demandingness X underestimation.

Results

Descriptive characteristics of the sample and feeding styles. Overall, the average age of

parents was 32 years old (SD = 8.6) and 92.5% were mothers. Half of the parents reported that

they attended or completed high school (50.6%) and more than half were currently employed

(59.2%). Most parents (93.7%) were Chilean and 76.4% were overweight or had obesity. The

average parent BMI was 29.2 (SD = 5.71). The average age of children was 3.6 years old (SD

=.7); 41.2% of the sample were girls and 52% were in the overweight or obesity categories.

Among parents, 15.5% were categorized as high demanding/high responsive, 34.5% high

demanding/low responsive, 35.6% low demanding/high responsive, 14.4% low demanding/low

responsive. Table 3.1 provides information on the caregivers and children’s characteristics.

Comparison of child weight status across parental feeding styles. A Kruskal-Wallis H

test showed a trend in child BMI z-scores between the four feeding styles (χ2 (3) = 7.36, p = .06),

with a mean rank of 91.5 for the high demanding/high responsive feeding style, 75.01 for high

demanding/low responsive feeding style, 90.48 for low demanding/high responsive feeding style,

and 105.76 for low demanding/low responsive feeding style.

According to ANOVA test there was a significant association between feeding styles on

child BMI z-scores at p < .05 level of significance [F (3, 170) = 3.34, p = .02]. Levene’s Test

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indicated that the variances were homogeneous (p = .22). Post Hoc comparisons using the Tukey

HSD test indicated that the mean of the high demanding/low responsive (M = .89, SD = .97) and

low demanding/low responsive feeding styles (M = 1.65, SD = 1.20) significantly differed.

Means, medians and interquartile ranges are showed in Table 3.2.

Moderating role of feeding styles on the relation of underestimation of weight status and

child BMI z-scores. Preliminary analysis flagged three BMI z-scores as outliers in two feeding

styles according to 1.5 interquartile range approach. These three cases were checked for

accuracy. One of outliers had a BMI z-score of 4.18 and belonged to the low demanding/high

responsive feeding style (see Figure 3.3 and 3.4). The other two outliers had BMI z-scores of 4.5

and 4.6 and were part of the low demanding/low responsive feeding style. To examine whether

feeding styles, underestimation of child weight status and the interactions between these two

variables explained the variance of BMI z-scores in preschoolers, we conducted simple linear

regression and MLR analyses with the total sample, and without the three outliers. These outliers

had child BMI z-scores higher than 4, but less than 5 SD, indicating severe overweight. Analyses

of other studies have included children with ± 5 SD of child BMI z-scores. Hankey, Williams, &

Dev. (2016) included children with less than -5 SD, while other researchers have excluded those

flagged as outliers with less than -5 SD or more than 5 SD (José Luis Santos et al., 2009). In our

study, the BMI z-scores flagged as outliers were 4.2 (parent low demanding/low responsive), 4.5

and 4.6 (low demanding/high responsive). The children with these high BMI z-scores had

parents with feeding styles related to higher weight status (low demanding/high responsive and

the low demanding/low responsive feeding styles) in the literature (Tovar, Hennessy, Pirie, Must,

Gute, Hyatt, Kamins, Hughes, Boulos, Sliwa, Galvao, et al., 2012; Hurley, Cross, & Hughes,

2011).

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 Correlations between socio-demographic, underestimation, and anthropometric variables

of the total sample and of the sample without outliers are shown in Table 3.3 and 3.4,

respectively. Child BMI z-scores and the high demanding/low responsive feeding styles were

negatively correlated (rho = -.18, p < .05), while the low demanding/low responsive feeding style

(r = .15, p < .05) and underestimation of child weight status (rho = .50, p < .01) were positively

correlated with child BMI z-scores (Table 3.3). In the sample without outliers (Table 3.4), the

high demanding/low responsive feeding style was negatively correlated (r = -.16, p < .05), and

underestimation was positively associated with child BMI z-scores (r = .51, p < .01). Parent BMI

was positively correlated with child BMI z-scores in the sample with outliers (rho = .29, p < .01),

and without outliers (rho = .29, p < .01). The dimensions of demandingness and responsiveness

were significantly correlated with each other (r = -.58, p < .01) (see Table 3.3).

Simple linear regressions were calculated to examine child BMI z-scores associated with

parent education, employment status, parent age, family status, parent BMI, child age and child

sex, as known covariates. From the results of the simple linear regressions involving the total

sample (Table 3.5) and the sample with no outliers (Table 3.6), analyses for both samples

indicated that among other covariates, only parent BMI was significantly and positively

associated with child BMI z-scores. This variable explained 6.7% in the analyses involving the

total sample (R2 = .07, F (1,172) = 12.43, p = .001 (Table 3.5) and 8% of the variance of the

child BMI z-scores in the sample with no outliers (R2 = .08, F (1, 169) = 15.30, p < .001) (Table

3.6). There were no other control variables significantly associated with child BMI z- scores.

Thus, this variable was the only one included in the multiple linear regression as a control

variable to obtain the fittest model for the sample size. In the simple linear regression in the total

sample, there was a trend in the association between the low demanding/low responsive feeding

100
style (p = .09) and child BMI z-scores (R2 = .06, F (3,170) = 3.34, p < .05) (see Table 3.7), in

which the low demanding/low responsive feeding explained .50 of the variance of child BMI z-

scores was not significant (B = .50, p = .09). This trend between this feeding style and BMI z-

scores in the simple linear regression was not found in the sample without the outliers (R2 = .034,

F (3,167) = 1.99, p = .12) (B = .25, p = .38) (see Table 3.8).

Results of the multiple linear regression analyses to examine the relation of feeding

styles, underestimation of child weight status, and the interactions between feeding styles and

underestimation of child weight status on child BMI z-scores, are shown in Table 3.9 for the total

sample and Table 3.10 for the analysis without outliers. After controlling for parent BMI, one

significant main effect was observed in the multiple regression analyses of the total sample and

in the sample without outliers. In model 3, the underestimation of child weight status explained

16% of the variance of the child BMI z-scores above and beyond feeding styles and after

controlling by parent BMI in the regression analyses with the total sample (F (5,163) = 12.15, p

< .001, R2 = .27, R2 adjusted = .25) (see Table 2.9). Parents who underestimated their child

weight category had .88 higher BMI z-scores in their child (B = .88, p < .001). Similarly, in

model 3 of the sample without outliers (Table 3.10), child BMI z-scores were positively

associated with underestimation of child weight status. A 19% additional variance is explained

by underestimation of child weight status above and beyond what was explained in the second

model, involving parent BMI and feeding styles (F (5,160) = 12.94, p < .001, R2 = .27, R2

adjusted = .25) (see Table 3.10). For parents who underestimated the weight status of their child,

the child BMI z-scores increase .88 (B = .88, p < .001).

In model 2 of the total sample, a significant association was found between the low

demanding/low responsive feeding style (B = .57, p = .05) with the outcome variable (Table 3.9).

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Feeding styles explained 6% the variance of child BMI z-scores above and beyond parent BMI

(F (4, 164) = 4.89, p = .001, R2 = .11, R2 adjusted = .09). This trend was maintained after including

underestimation of child weight status in model 3 (B = .52, p = .06). No significant main effects

were found for feeding styles in the MLR analyses in the sample without outliers. Interaction

terms were not significantly associated with child BMI z-scores. Therefore, associations of

underestimation of child weight status with child BMI z-scores were not moderated by high

demanding/low responsive, low demanding/high responsive and low demanding/low responsive

feeding styles. The underestimation of child weight status remained a significant explanatory

variable of child BMI z-scores after entering interaction terms.

The regression analyses to assess the moderating effect of responsiveness and

demandingness in the relation between underestimation and child BMI z-scores indicated that

interactions terms (underestimation X demandingness and underestimation X responsiveness)

were not significantly associated with the outcome variable (Table 3.11). In model 4 (Table

3.11), demandingness was significantly associated with child BMI z-scores (B = -.39, p = .003)

and accounted for 5% the variance of child BMI z-scores above and beyond parent BMI (F (2,

171) = 11.2, p < .001, R2 = .12, R2 adjusted = .11), but responsiveness was not significantly

associated with child BMI z-scores in model 3 (B = .42, p = .31). Underestimation was entered in

model 5 and was significantly associated with child BMI z-scores (B = .93, p < .001). Taken

together parent BMI, demandingness, and underestimation explained 29% of the variance in

child BMI z-scores, which indicates that by adding underestimation of child weight status, 17%

of additional variance of child BMI z-scores is explained above and beyond what was explained

in model 4.

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 Discussion

The main objectives of this study were to identify feeding styles and child weight

differences between them; and to test the moderating role of feeding styles in the association

between underestimation of child weight status and child BMI z-scores in a sample of families

from predominantly low-income neighborhoods in Chile. The majority of parents were

categorized as either high demanding/low responsive or low demanding/high responsive feeding

style. The high demanding/low responsive parents had children with lower BMI z-scores

compared to the children of parents with low demanding/low responsive feeding style. We found

no evidence for a moderating effect of feeding styles when examining relations of

underestimation of child weight status to children’s BMI z-scores. However, parents who

underestimated child weight status and the low demanding/low responsive parents tended to have

children with higher BMI z-scores, demanding parents had children with lower BMI z-scores.

In our study, a larger frequency of parents who have high demanding/low responsive or

low demanding/high responsive feeding styles is similar to other studies including low-to-middle

income families (Tovar et. al, 2012; Hennessy, Hughes, Goldberg, Hyatt, & Economos, 2012;

Hughes et al., 2008; Hughes et al., 2005). Many parents mainly apply control/make demands

when they feed their children. Other parents are highly responsive/affectionate but apply little

control or demands in the feeding situation. Both types of parent feeding styles try to handle the

feeding situation through strategies, by being agreeable or controlling, which may lead to

distinctive child weight outcomes.

Contrary to our hypothesis, there was no moderating role of feeding styles in the relation

of underestimation of child weight status and child BMI z-scores; the variability of child BMI z-

scores was explained mostly by the underestimation of child weight status, demandingness

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dimension and parent BMI. These variables suggest biological and environmental aspects related

to higher weight in preschoolers. Regarding parent BMI, it has been previously reported that

overweight and adiposity in parents have been linked with similar weight-related conditions in

children (Vinciguerra et al., 2019; Starling et al., 2015; Whitaker et al., 1997). The association

between parent BMI and child BMI has been explained by the habits, contexts and genes shared

by parents and children (Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., &

Bhadoria, 2015).

Mixed results in association between underestimation of child weight categories and

child BMI z-scores exists in previous research. Similar to our results, Brazilian and Greek

parents who underestimated child weight had children with increased BMI z-scores (Freitas,

Silva, Teles, Peixoto, & Menezes, 2015; Manios, Kondaki, Kourlaba, Vasilopoulou, &

Grammatikaki, 2009). However, Chinese parents who underestimated the weight status of their

child had children with lower BMI z-scores (Zhang et al., 2018). These mixed results have been

explained by the methods utilized to identify parent misperceptions and inappropriate

comparisons of factors associated with underestimation of child weight status in age ranges that

differ due to development differences (Lopes, Santos, Pereira, & Lopes, 2013). More research

for clarifying the mechanisms involved in this association considering child age and populations

from different backgrounds and context is needed since these mechanisms may vary (Lopes et

al., 2013). Life style behaviors regarding child weight and nutritional status that parents

encourage may be affected from childhood according to parent misperceptions of child weight

status. For instance, Zhang et al. (2018) reported that Chinese parents who underestimated the

overweight category of their child gave them more sweetened beverages than those who

correctly perceived child weight status.

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 Although main effects of feeding styles on child BMI z-scores were not found in the

regression analyses with no outliers, the low demanding/low responsive feeding style almost

reached significance when the analyses were conducted in the total sample (including the three

extreme child BMI z-scores). Another study including participants from diverse ethnicities and

low income families have also found that children of permissive parents have higher BMI z-

scores (Hughes et al., 2007) and unhealthy diets (Hoerr et al., 2009). This trend may suggest that

children of parents who are permissive or unsupportive in the feeding situation do not learn to eat

healthy and food sizes that are adequate for their age, leading to higher risk of becoming

overweight (Fiese & Bost, 2016; Hoerr et al., 2009).

Furthermore, our results indicated that the dimension of demandingness was negatively

associated with child BMI z-scores. Concordantly, high demanding/low responsive parents have

children with lower weight compared to low demanding/low responsive parents. Contrary to our

results, a previous study has reported a positive significant relation between responsiveness and

child BMI z-scores in Latino mothers, but not so for demandingness (Hidalgo-Mendez, Power,

Fisher, O’Connor, & Hughes, 2019). Supporting our results, in a predominantly Latino sample

using the same instrument as in our study, high demanding/low responsive parents had children

with lower weight when compared to the children of low demanding/high responsive parents

(Hughes et al., 2008). Also, Olvera & Power (2010) reported that children of Mexican-American

parents adopting a high demanding/low responsive parenting style had the lowest risk of

becoming overweight in three years.

Nevertheless, as is illustrated in findings from a study whose sample was predominantly

White middle-class families (Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006), the high

demanding/low responsive parents had children with higher risk of being overweight. Thus,

105
differences in the associations between parent feeding styles and the dimensions of parenting in

the feeding domain (responsiveness and demandingness) may vary according to cultural/ethnic

background and contexts where families live (Power et al., 2013). Our study suggests that the

high demanding/low responsive parenting, and simply being demanding, do not necessarily have

a negative influence on child weight, especially when parents encourage the child to try new

foods.

Having a high demanding feeding style may be crucial for parents who want to encourage

a healthy family diet. Parents who are motivated to feed their children with better quality foods

in the first years of life may need to make more effort to encourage healthy eating in their

children when contexts everywhere offer unhealthy food. However, more research is needed to

confirm goals and motivations behind parenting in the feeding domain as part of the mechanisms

leading to specific child weight outcomes. Chilean parents and those from other Latin American

countries may react differently to nutritional challenges and the contexts where they live.

Limitations of the study. Although this study offers evidence regarding parent feeding

toward preschoolers in Latin America, some limitations need consideration. First, the cross-

sectional nature of the study restricts causal inferences and the direction of the associations.

Second, although parents could ask questions during the face-to-face interview, the data

collected was reported instead of observed. Thus, parents may have answered according to what

they thought was expected from them regarding their feeding behaviors rather than what actually

occurred (Sitnick, Ontai, & Townsend, 2014). Third, the CFSQ is a validated measure in Spanish

speaking populations from low-income families but its internal reliability measured through

Cronbach’s alpha in the child-centered feeding strategies of the CFSQ was .58. This value does

not reach .60, which is considered acceptable for exploratory analyses (Vaughn et al., 2013).

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However, Cronbach’s alpha value is sensitive to the number of items of a questionnaire; it is

lower when the number of items is small and increases with a larger number of items (Tavakol &

Dennick, 2011). Lastly, the convenience sampling method used in this study and including

families primarily from low socio-economic status due to the recruitment strategy, limits the

generalizability of the results. Nevertheless, it provides valuable insights about feeding styles and

associations with sociocultural factors, the underestimation of child weight status, and their

connection with child weight status in Chile.

Conclusions and Implications

Our findings suggest that parents in Chile are predominantly high demanding/low

responsive and low demanding/high responsive in feed style with children ages three to five

years. Parents who underestimated their child weight category and those who were highly

demanding were independently associated with higher BMI z-scores in their children. Parent

demandingness, but not responsiveness, was associated with lower BMI z-scores.

Our study has expanded evidence from a previous study focused on highly

directive/demanding feeding practices toward preschool children (Santos et al., 2009). These

authors reported that restriction was positively correlated, and pressure to eat was negatively

correlated with child BMI z-scores in boys and girls (Santos et al., 2009). These results describe

correlations only between feeding behaviors in a directive spectrum to influence the child to eat,

while additional feeding patterns that form a broader feeding styles include: (i) being responsive

and directive; (ii) being indulgent with no hard limits; and (iii) no involvement (Hughes et al.,

2008). A more extensive array of feeding styles used in our study improves our understanding of

the typologies of patterned feeding strategies parents adopt in different socio-economic, culture,

ethnicity/race, and context situations. In line with this claim, Ventura, Gromis, & Lohse (2010)

107
found that feeding practices and styles differed in groups according to racial and ethnic

characteristics. For instance, most East Asian mothers were categorized as low demanding/high

responsive compared to black parents and black parents were more demanding when interacting

with the child in the feeding situation.

Children of parents who are low demanding/low responsive may be at risk of becoming

overweight. Parents may not support and guide their children to eat healthily and the right

amounts for their age to promote an adequate self-regulation of appetite. The high

demanding/low responsive feeding style seems to be a better feeding style as it is associated with

lower child BMI z-scores in context of Chile. Other studies have also argued that demandingness

(referring to dis/encouraging a child to eat as in our study) increases the quality of the diet (Hoerr

et al., 2009). Healthcare providers can be aware of child weight differences according to feeding

styles and include in their nutritional guidance not only prescriptions regarding child feeding, but

take into consideration how parents feed their children at home to improve their professional

guidance to promote healthy eating in young children.

Chile and other Latin American countries can improve their nutritional programs to

determine the best feeding practices leading to a healthy weight and nutrition of the child by

considering the feeding style of parents at home. Other studies have found that feeding practices

can have a different dietary outcome depending on the feeding styles in which parent-child

interact in the feeding situation (Papaioannou et al., 2013). However, more research needs to be

done to know the role of feeding practices within overarching feeding styles on weight-related

outcomes in young children, who are expanding their eating preferences and are learning from

their families.

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 Identifying feeding styles among parents of preschoolers and evaluating their association

with child BMI z-scores is a starting point to understand parent-child interactions in the feeding

situation of families in Chile. Efforts in understanding the role of parent feeding styles, in which

parent and child characteristics, home food environment, and the context can interact, require

more research to promote healthy weight status in preschool children in Chile. For instance, in a

sample of predominantly White parents, Hankey et al. (2016) found that preschoolers with high

scores of emotional overeating whose parents had a low demanding/low responsive feeding style

had higher BMI z-scores. Thus, other aspects such as child eating characteristics, home food

availability, and dietary habits (Frenn, Kaugars, Garcia, & Garnier-Villarreal, 2019) in the

family, in the presence of specific feeding styles may be part of mechanisms leading to weight-

related outcomes in the child.

Furthermore, our results suggest that parent accuracy of child weight status may be a

relevant factor in family dynamics regarding child weight. Clarifying mechanisms involved in

the association between underestimation of child weight status and child BMI z-scores could

provide valuable information to promote healthy weight in three-to-five-year-olds. Parents’

misperceptions in specific child developmental processes in preschool years may influence the

way they perceive the weight status of their children. Consequently, the parents’ reactions to

these misperceptions will need further research because they may lead to lifestyle behaviors that

are unsupportive to a child’s healthy diet and weight.

Given that feeding styles and underestimation of child weight status were factors

independently associated with child BMI z-scores, concern regarding child weight status may

also be considered in investigating potential links with feeding styles instead of with

underestimation of child weight status. Santos et al. (2009) found that mothers’ concerns with

109
child weight were positively correlated with BMI z-scores and waist-to-height-ratio in Chilean

preschoolers. Concerns regarding child weight may be associated with parent feeding practices

and other lifestyle changes to maintain a healthy weight in the child instead of underestimation

of child weight status. More research is warranted to further explore whether feeding styles and

concerns about child weight status play a role on explaining child weight status of preschoolers.

Parenting styles in the specific domain of feeding in the socio-cultural context of Chile

and Latin America require further research to better understand differences in weight-related

outcomes in preschool years. This research contributes to the development of culturally sensitive

programs to improve the family environment to promote healthy weight after preschool years.

On the one hand, integrating how parents approach feeding their children with what children eat

and its influences on child weight can increase the effectiveness of health programs. On the other

hand, parent perception of child weight status constitutes a relevant factor for clinicians, as a

correct perception of child weight status provides opportunities to guide parents to promote

healthy lifestyle behaviors in the family and eventually in their sociocultural environment as

well.

110
 Tables
Table 3.1
Socio-demographic, nutritional characteristics and underestimation overall and by feeding style
in the 174 parent-child dyads

Characteristics Total High demanding/ High demanding/ Low demanding/ Low demanding/
participants high responsive low responsive High responsive Low responsive
n = 174 27 (15.5%) 60 (34.5%) 62 (35.6%) 25 (14.4%)
Parents
Age in years (Mean ± SD) 32 (8.6) 30.4 (8.7) 30.3 (6.5) 33.8 (8.9) 33.6 (11.3)
Educational attainment, n (%)
No schooling 2 (1.1) 1 (3.7) 0 1 (1.6) 0
Elementary 26 (14.9) 5 (18.5) 4 (6.7) 12 (19.4) 5 (20)
High school 88 (50.6) 13 (48.1) 39 (65) 25 (40.3) 11 (44)
Vocational 33 (19) 4 (14.8) 12 (20) 14 (22.6) 3 (12)
Higher education 25 (14.4) 4 (14.8) 5 (8.3) 10 (16.1) 6 (24)
Work status, N (%)
Currently working n (%) 103 (59.2) 17 (63) 36 (60) 34 (54.8) 16 (64)
Type of caregiver, n (%)
Mother 161 (92.5) 26 (96.3) 57 (95) 55 (88.7) 23 (92)
Father 7 (4) 0 3 (5) 4 (6.5) 0
Grandparent 5 (2.9) 1 (3.7) 0 2 (3.2) 2 (8)
Aunt 1 (.6) 0 0 1 (1.6) 0
Marital status n (%)
Single parent family 58 (33.3) 12 (44.4) 22 (36.7) 17 (27.4) 7 (28)
Nationality n (%)
Chilean 163 (93.7) 27 (100) 54 (90) 60 (96.8) 22 (88)
a 11 (6.3) 0 6 (10) 2 (3.2) 3 (12)
Others
Weight statusb, N (%)
Underweight 2 (1.1) 0 0 1 (1.6) 1 (4)
Normal 39 (22.4) 5 (18.5) 20 (33.3) 11 (17.7) 3 (12)
Overweight 66 (37.9) 9 (33.3) 17 (28.3) 24 (38.7) 16 (64)
Obese 67 (38.5) 13 (48.1) 23 (38.3) 26 (41.9) 5 (20)
c 29.2 (5.7) 30.71 (5.8) 28.3 (5.6) 29.8 (6.1) 28.06 (4.7)
BMI (Mean ± SD)
Children
Age in years (Mean ± SD) 3.6 (.7) 3.8 (.9) 3.6 (.7) 3.5 (.5) 3.6 (.7)
Child gender, n (%)
Girls 72 (41.4) 14 (51.9) 24 (40) 26 (41.9) 8 (32)
d
Categorization weight status
Underweight 2 (1.1) 1 (3.7) 1 (1.7) 0 0
Normal weight 80 (46) 9 (33.3) 36 (60) 28 (45.2) 7 (28)
Overweight 58 (33.3) 11 (40.7) 17 (28.3) 20 (32.3) 10 (40)
Obese 34 (19.5) 6 (22.2) 6 (10) 14 (22.6) 8 (32)
e
Perceived child weight status
Correct perception 87 (50) 11 (40.7) 34 (56.7) 33 (53.2) 9 (36)
Underestimation 82 (47.1) 15 (55.6) 20 (40) 28 (45.2) 15 (60)
Overestimation 5 (2.87) 1 (3.7) 2 (3.3) 1 (1.6) 1 (4)
SD: Standard Deviation
a
Others: South American or Caribbean countries and participants speak Spanish (Peru, Colombia, Venezuela,
Paraguay, Bolivia, Dominican Republic)
b
Parent weight status for adult population based on Body Mass Index (BMI), underweight (BMI lower than 18.5),
normal weight (BMI between 18.5 and 24.9), overweight (BMI between 25 and 29.9), and obese group (BMI above
30) (WHO, 2018).
c
BMI: Body Mass Index (m/kg2)

111
d
Categorization of weight status according to WHO Growth Standards (2006) for children of five years old or
younger, and WHO Growth Standards (2007) for children between five years and one month and 5 years and 11
months
e
Perceived child weight status: Correct perception = parent perception of child weight status matches the objective
child weight status, Underestimation = Parent perceive the child weight status in a lower category compared to the
objective category of child weight status, overestimation = Parent perceive the child weight status in a higher
category compared to the objective category of child weight status

Table 3.2
Caregivers’ dimensions of feeding styles and differences in child BMI z-scores according to
feeding styles (n = 174)

Feeding styles n (%) Responsiveness Demandingness Child BMI z-scores Median (IQR)
Mean ± SD Mean ± SD Mean ± SD Total sample
High demanding/ 27 (15.5) 1.34 (.01) 3.09 (.23) 1.15 (.97) 1.40 (1.60)
high responsive
High demanding/ 60 (34.5) 1.11 (.09) 3.46 (.34) .89 (.90) .83 (1.29)
low responsivea
Low demanding/ 62 (35.6) 1.47 (.13) 2.34 (.40) 1.29 (1.18) 1.09 (1.42)
high responsive
Low demanding/ 25 (14.4) 1.13 (.09) 2.44 (.26) 1.65 (1.21) 1.51 (1.44)
low responsivea
Total sample 1.28 (.19) 2.86 (.61) 1.18 (1.08)
Data are presented as mean ± SD (Standard Deviation), and median (IQR, interquartile range)
a
p < .05 significant mean differences between the High demandingness/low responsive and the Low
demandingness/low responsiveness feeding style

112
Table 3.3

Correlations between participants’ characteristics, underestimation of child weight status and

parent feeding styles of the total sample

Variable 1 2 3 4 5 6 7 8 9 10 11 12 13
1. Child BMIa z-score (n = 174) -

2. High demanding/low -.18* -

responsive (n = 174)
3. Low demanding/ high .04 -.54** -

responsive (n = 174)
4. Low demanding/low .15* -.30** -.31** -

responsive (n = 174)
5. Demandingness (n = 174) -.20** .75** -.66** -.32** -

6. Responsiveness (n = 174) .09 -.68** .75** -.32** -.58** -

7. Underestimationa (n = 169) .50** -.10 -.04 .11 -.01 .03 -

8. Parent’s age (n = 174) .11 -.11 .17* .02 -.15* .04 -.02 -

9. Employmentb (n = 174) .01 .01 -.07 .04 .07 -.06 .07 -.03 -

10. Parent’s BMIc (n = 174) .29** -.12 .08 -.07 -.08 .17* .09 .14 -.10 -

11. Family statusd (n = 174) -.08 .05 -.09 -.05 .11 -.05 -.06 -.11 .07 .02 -

12. Child’s age (years) (n = 174) -.07 .02 -.08 -01 .03 .02 -.07 -.002 .02 -.09 -.05 -

13. Child’s gendere (n = 174) -.002 -.02 .01 -.08 .07 .09 -.12 .02 -.04 .06 .15 .02 -

Spearman correlations between continuous variables with no normal distribution and point biserial correlations
between nominal and continuous variables.
*
Correlation is significant at the .05 level
**
Correlation is significant at the .01 level
a
0 = Accurate estimation of child weight status, 1 = Underestimation of child weight status
b
0 = Employed, 1 = Unemployed
c
BMI Body Mass Index (m/kg2)
d
0 = Two-parent family, 1 = One parent family
e
0 = Boy, 1 = Girl

113
Table 3.4

Correlations among participants’ characteristics, underestimation of child weight status and

parent feeding styles in the sample with no outliers

Variable 1 2 3 4 5 6 7 8 9 10 11
1. Child BMI z-score (n=171) -

2. High demanding/low -.16* -

responsive (n=171)
3. Low demanding/high .05 -.55** -

responsive (n=171)
4. Low demanding/low .11 -.29** -.29** -

responsive (n=171)
5. Underestimationa (n=166) .51** -.10 -.05 .12 -

6. Parent’s age (n=171) .14 -.12 .16* .06 -.02 -

7. Employmentb (n=171) .003 .01 -.08 .05 .08 -.03 -

8. Parent’s BMIc (n=171) .29** -.12 .08 -.07 .08 .14 -.09 -

9. Family statusd (n=171) -.08 .05 -.11 -.02 -.06 -.11 .06 -.02 -

10. Child’s age (years) (n=171) -.10 .03 -.08 -.02 -.08 .01 .02 -.09 -.05 -

11. Child’s gendere (n=171) .02 -.03 .01 -.06 -.12 -.01 -.04 .07 .15* .03 -

Spearman correlations between continuous variables with no normal distribution and point biserial correlations
between nominal and continuous variables.
*
Correlation is significant at the .05 level
**
Correlation is significant at the .01 level
a
0 = Accurate estimation of child weight status, 1 = Underestimation of child weight
b
0 = Employed, 1 = Unemployed
c
BMI Body Mass Index (m/kg2)
d
0 = Two-parent family, 1 = One parent family
e
0 = Boy, 1 = Girl

114
Table 3.5

Simple linear regression analyses between control variables and child BMI z-scores as outcome
variable total sample (n = 174)

Variables 95% CI
B (SE) β R R2 F p [Lower, upper]
Model 1 .07 0.01 .46 .63
Constant 1.07 (.21) < .001 [.67, 1.48]
High school .74
.08 (.24) .04 [-.39, .54]
(ref. elementary education)
Higher education .22 (.25) .09 .39 [-.28, .71]
Model 2 .09 .01 1.49 .22
Constant .81 (.32) .01 [.18, 1.44]
Parent age .01 (.01) .14 .22 [-.01, .03]
Model 3 .26 .07 12.43 .001
Constant -.26 (.42)* .54 [-1.08, .57]
Parent BMI .05 (.01)* .26 .001 [.02, .08]
Model 4 .08 .01 1.21 .27
Constant 1.25 (.10)* < .001 [1.05, 1.45]
Family status -.19 (.18) -.08 .27 [-.54, .15]
Model 5 0 0 .04 .84
Constant 1.16 (.13)* < .001 [.91, 1.42]
Employment status .03 (.17) .02 .84 [-.30, .37]
Model 5 .04 0 .29 .59
Constant 1.43 (.46)* .002 [.51, 2.34]
Child age -.07 (.13) -.04 .59 [-.32, .18]
Model 6 .02 0 .06 .81
Constant 1.2 (.11)* < .001 [.99, 1.41]
Child gender -.04 (.17) -.02 .82 [-.37, .29]
a
BMI: Body Mass Index (M/Kg2)
b
0 = Two-parent family, 1 = One parent family
c
0 = Employed, 1 = Unemployed
d
0 = Boy, 1 = Girl

115
Table 3.6

Simple linear regression analyses between control variables and child BMI z-scores as outcome
variable with no outliers (n = 171)

Variables
95% CI
B (SE) β R R2 F p
[Lower, upper]

Model 1 (n = 171) .04 0 .12 .89

Constant 1.07 (.19) < .001 [.70, 1.45]
High school (ref.
.04 (.22) .02 .86 [-.40, .48]
elementary education)
Higher education .11 (.23) .05 .65 [-.36, .57]
Model 2 (n = 171) .14 .02 3.50 .06
Constant .59 (.29) .05 [.01, 1.17]
Parent age .02 (.01) .14 .06 [-.001, .03]
Model 3 (n = 171) .29 .08 15.30 <.001
Constant -.34 (.38) .37 [-1.10, .41]
Parent’s BMIa .050 (.01) .29 .03 [.03, .08]
Model 4 (n = 171) .09 .01 1.34 .25
Constant 1.19 (.09) < .001 [1.00, 1.38]
Family statusb -.18 (.16) -.09 .25 [-.51, .13]
Model 5 (n = 171) .02 0 .04 .90
Constant 1.11 (.12) <.001 [.88, 1.35]
Employment statusc .02 (.16) .01 .90 [-.29, .33]
Model 5 (n = 171) .04 0 .29 .06
Constant 1.57 (.43) .05 [.72, 2.41]
Child age -.12 (.12) -.08 .06 [-.36, .11]
Model 6 (n = 171) .03 0 .14 .71
Constant 1.1 (.10) < .001 [.90, 1.30]
Child genderd .06 (.16) .03 .71 [-.25, .37]
a
BMI: Body Mass Index (M/Kg2)
b
0 = Two-parent family, 1 = Single parent family
c
0 = Employed, 1 = Unemployed
d
0 = Boy, 1 = Girl

116
Table 3.7

Simple linear regressions between feeding styles, dimensions of parent feeding styles,
underestimation of child weight status and child BMI z-scores as outcome variable with total
sample

Variables 95% CI
B (SE) β R R2 F p
[Lower, upper]
Model 1 (n = 174) .24 .06 3.34 .02
Constant 1.15 (.21) <.001 [.75, 1.56]
High demanding/low responsive -.26 (.25) -.11 .29 [-.75, .23]
Low demanding/high responsive .14 (.25) .06 .57 [-.34, .63]
Low demanding/low responsive .50 (.30) .16 .09 [-.08, 1.08]
Model 2 (n = 169) .44 .20 40.92 < .001
Constant .75 (.10) < .001 [.55, .96]
Underestimation .95 (.15) .44 < .001[.66, 1.24]
Model 3 .24 .06 10.84 .001
Constant 2.42 (.39) <.001[1.66, 3.18]
Demandingness -.43(.13) -.24 .001 [-.69, -.17]
Model 4 .11 .01 .14 .14
Constant .40 (.53) .46[-.66, 1.46]
Responsiveness .61 (.42) .11 .14[-.21, 1.43]
a
Cases of overestimation were excluded in the analyses. 0 accurate estimation of child weight status, 1
underestimation of child weight status

Table 3.8

Simple linear regressions between feeding styles and underestimation of child weight status and
child BMI z-scores as outcome variable with no outliers

Variables
95% CI
B (SE) β R R2 F p
[Lower, upper]
Model 1 (n = 171) .19 .03 1.98 < .001
Constant 1.15 (.19) < .001 [.77, 1.53]
High demanding/low responsive -.26 (.23) -.12 .26 [-.71, .20]
Low demanding/high responsive .09 (.23) .05 .69 [-.36, .55]
Low demanding/low responsive .25 (.28) .08 .38 [-.31, .81]
Model 2 (n = 166) .47 .22 46.13 < .001
Constant .71 (.10) < .001 [.52, .90]
Underestimationa .93 (.14) .47 < .001 [.66, 1.20]
a
Cases of overestimation (5 out of 174) were excluded in the analyses, 0 accurate estimation of child weight
status, 1 underestimation of child weight status

117
Table 3.9

Multiple linear regression analyses testing the moderating effect of feeding styles between the
underestimation of child weight status and child BMI z-scores in total sample (n = 169)

Variables R2 95% CI
B (SE) β R R2 adjusted
F p
[Lower, upper]
Model 1 .23 .05 .05 9.33 .003
Constant -.06 (.42) .89 [-.90, .78]
Parent BMI .04 (.01) .23 .003 [.02, .07]
Model 2 .33 .11 .09 4.89 .001
Constant -.13 (.49) .79 [-1.08, .83]
Parent BMI .04 (.01) .23 .002 [.02, .07]
High dem/low resp .20 (.25) -.09 .42 [-.68, .29]
Low dem/high resp .11 (.24) .05 .65 [-.37, .59]
Low dem/low resp .57 (.29) .19 .05 [-.01, 1.15]
Model 3 .52 .27 .25 12.15 <.001
Constant -.50 (.44) .27 [-1.37, .38]
Parent BMI .04 (.01) .21 .003 [.01, .07]
High dem/low resp -.07 (.22) -.03 .77 [-.51, .37]
Low dem/high resp .17 (.20) .08 .34 [-.23, .57]
Low dem/low resp .21 (.22) .09 .06 [-.22, .64]
Underestimation .88 (.15) .41 <.001 [.60, 1.17]
Model 4 .53 .28 .25 10.30 < .001
Constant -.55 (.45) .22 [-1.43, .33]
Parent BMI .04 (.01)* .23 .003 [.01, .06]
High dem/low resp .08 (.27) .04 .77 [-.45, .60]
Low dem/high resp .22 (.22) .10 .31 [-.21, .66]
Low dem/low resp .51 (.27) .17 .06 [-.02, 1.04]
Underestimation .99 (.18) .46 < .001 [.64, 1.34]
High dem/low resp X underestimation -.31(.31) -.10 .31 [-.92, .29]
Model 5 .53 .28 .24 8.67 < .001
Constant -.58 (.42) .20 [-1.48, .32]
Parent BMI .04 (.01) .21 .003 [.01, .06]
Authoritarian 1.26 (.29) .06 .66 [-.45, .70]
Indulgent .30 (.29) .14 .30 [-.27, .87]
Uninvolved .50 (.27) .16 .06 [-.03, 1.03]
Underestimation 1.07 (.27) .50 <001 [.54, 1.61]
High dem/low resp X underestimation -.40 (.37) -.13 .28 [-1.12, .33]
Low dem/high resp X underestimation -.15 (.36) -.05 .68 [-.87, .56]
Model 6 .55 .30 .24 7.67 < .001
Constant -.59 (.48) .22 [-1.53, .35]
Parent BMI .04 (.01) .21 .003 [.01, .06]
High dem/low resp .14 (.32) .06 .68 [-.33, .95]
Low dem/high resp .52 (.42) .17 .34 [-.31, 1.36]
Low dem/low resp 1.09 (.37) .51 .22 [-.35, 1.83]
Underestimation 1.09 (.37) .51 .004 [.35, 1.82]
High dem/low resp X underestimation -.41 (.45) -.13 .36 [-1.30, .47]
Low dem/high resp X underestimation -.17 (.44) .06 .71 [-1.04, .71]
Low dem/low resp X underestimation -.04 (.54) -.01 .95 [-1.11, 1.04]

118
Table 3.9 (Cont.)

Variables R2 95% CI
B (SE) β R R2 Adjusted
F p
[Lower, upper]
Model 7 .52 .27 .25 10.07 < .001
Constant -.49 (.45) .28 [-1.37, .40]
Parent BMI .04 (.01) .21 .003 [.01, .07]
High dem/low resp -.07 (.23) -.03 .76 [-.51, .37]
Low dem/high resp .18 (.27) .08 .51 [-.35, .70]
Low dem/low resp .52 (.27) .17 .06 [-.01, 1.04]
Underestimation .86 (.18) .40 < .001 [.50, 1.22]
Low dem/high resp X underestimation .06 (.30) .02 .83 [-.53, .66]
Model 8 .52 .27 .25 10.11 < .001
Constant -.48 (.45) .29 [-1.36, .41]
Parent BMI .04 (.01) .21 .003 [.01, .07]
High dem/low resp -.07 (.22) -.03 .75 [-.51, .37]
Low dem/high resp .21 (.22) .09 .35 [-.23, .64]
Low dem/low resp .39 (.38) .13 .30 [-.35, 1.13]
Underestimation .86 (.16) .40 < .001 [.55, 1.16]
Low dem/low resp X underestimation .20 (.42) .53 .64 [-.64, 1.04]
dem: demandingness
resp: responsiveness

119
Table 3.10

Multiple linear regression analyses testing the moderating effect of feeding styles between the
underestimation of child weight status and child BMI z-scores without outliers (n = 166)

Variables R2 95% CI
B (SE) β R R2 Adjusted F p [Lower,
upper]
Model 1 (n = 171) .26 .07 .06 11.78 .001
Constant -.16 (.39) .69 [-.93, .61]
Parent BMI .05 (.01) .26 .001 [.02, .07]
Model 2 (n = 171) .31 .10 .07 4.26 .003
Constant -.14 (.45) .76 [-1.03, .75]
Parent BMI .04 (.13) .26 .001 [.02, .07]
High dem/low resp .20 (.22) -.10 .39 [-.65, .25]
Low dem/high resp .06 (.22) .03 .78 [-.38, .51]
Low dem/low resp .31 (.28) .11 .26 [-.24, .87]
Model 3 (n = 166) .54 .29 .27 12.94 < .001
Constant -.50 (.40) .22 [-1.31, .30]
Parent BMI .04 (.01) .23 .001 [.02, .06]
High dem/low resp -.07 (.20) -.03 .75 [-.47, .34]
Low dem/high resp .17 (.20) .08 .40 [-.23, .57]
Low dem/low resp .25 (.25) -.09 .32 [-.24, .74]
Underestimation .88 (.13) .45 < .001 [.62, 1.15]
Model 4 (n = 166) .54 .29 .27 11.01 .27
Constant -.55 (.41) .17 [-1.36, .25]
Parent BMI .04 (.01) .23 < .001 [.02, .06]
High dem/low resp .08 (.24) .04 .74 [-.40, .56]
Low dem/high resp .18 (.20) .09 .37 [-.21, .58]
Low dem/low resp .24 (.25) .08 .34 [-.25, .73]
Underestimation .99 (.17) .50 < .001 [.66, 1.32]
High dem/low Resp X
-.31(.15) .15 .27 [-.87, .24]
underestimation
Model 5 (n = 166) .55 .30 .27 9.61 < .001
Constant -.65 (.42) .12 [-1.47, .17]
Parent BMI .04 (.01) .22 .001 [.02, .06]
Authoritarian .20 (.27) .10 .46 [-.33, .72]
Indulgent .37(.27) .18 .17 [-.15, .90]
Uninvolved .23 (.25) .08 .37 [-.27, .72]
Underestimation 1.19 (.25) .60 < .001 [.70, 1.70]
High dem/low resp X
-.52(.34) -.18 .13 [-1.19, .15]
underestimation
Low dem/high resp X
-.36(.34) -.14 .28 [-1.02, .30]
underestimation

120
Table 3.10 (Cont.)

Variables R2 95% CI
B (SE) β R R2 Adjusted F p
[Lower, upper]
Model 6 (n = 166) .55 .30 .26 8.40 < .001
Constant -.60 (.43) .17 [-1.45, .26]
Parent BMI .04 (.01) .22 .001 [0.02, .06]
High dem/low resp .14 (.30) .07 .65 [-.45, .72]
Low dem/high resp .31 (.30) .15 .30 [-.28, .90]
Low dem/low resp .08 (.40) .03 .84 [-.70, .87]
Underestimation 1.09 (.34) .55 .002 [.42, 1.76]
High dem/low resp
-.41 (.41) -.15 .31 [-1.22, .39]
Xunderestimation
Low dem/high resp
-.26 (.41) .01 .53 [-1.06, .54]
Xunderestimation
Low dem/low resp
.24 (.51) .07 .64 [.77, 1.24]
Xunderestimation
Model 7 (n = 166) .54 .29 .26 10.74 <.001
Constant -.52 (.41) .21 [-1.26, .34]
Parent BMI .04 (.01) .23 .001 [.02, .06]
High dem/low resp -.06 (.21) -.03 .76 [-.47, .34]
Low dem/high resp .31 (.30) .15 .40 [-.25, .74]
Low dem/low resp .25 (.25) .08 .32 [-.70, .87]
Underestimation .91 (.17) .46 < .001 [.58, 1.24]
Low dem/high resp
-.08 (.28) -.03 .79 [-.63, .47]
Xunderestimation
Model 8 (n = 166) .54 .30 .27 11.09 < .001
Constant -.46 (.41) .26 [-1.26, .34]
Parent BMI .04 (.01) .23 .001 [.02, .06]
High dem/low resp -.08 (.20) -.04 .71 [-.48, .33]
Low dem/high resp .16 (.20) .08 .42 [-.23, .56]
Low dem/low resp -.07 (.36) -.03 .84 [-.77, .63]
Underestimation .82 (.14) .41 <.001 [.53, 1.10]
Low dem/low resp
.51 (.40) .14 .21 [-.29, 1.30]
Xunderestimation
a
Model was conducted only with interaction term High dem/low resp X underestimation
b
Model was conducted only with interaction term Low dem/high resp X underestimation
c
Model was conducted only with interaction term Low dem/low resp X underestimation
dem: demandingness
resp: responsiveness

121
Table 3.11

Multiple linear regressions testing the moderating effect of the demandingness and
responsiveness dimension in the association of underestimation of child weight status on child
BMI z-scores

Variables R2 95% CI
B (SE) β R R2 Adjusted F p
[Lower, upper]
Model 1 (n = 174) .23 .05 .05 9.33 .003
Constant -.06 (.43) .89 [-.90, .78]
Parent BMI .04 (.01) .23 .003 [.02, .07]
Model 2 (n = 169) .49 .24 .23 40.24 <.001
Constant -.36 (.39) .36 [-1.19, .40]
Parent BMI .04 (.01) .20 .003 [.01, .06]
Underestimation .92 (.15) .43 <.001 [.63, 1.21]
Model 3 (n = 174) .27 .07 .06 6.7 .002 [.02, .08]
Constant -.26 (.42) .54 [-1.08, .57]
Parent BMI .05 (.01) .26 .001 [-1.95, .50]
Responsiveness .42 (.41) .08 .31 [-.39, 1.22]
Model 4 (n = 174) .34 .12 .11 11.20 <.001
Constant .99 (.57) .09 [-.15, 2.12]
Parent BMI .05 (.01) .26 .001 [.01, .07]
Demandingness -.39 (.13) -.22 .003 [-.65, -.14]
Model 5 (n = 169) .54 .29 .28 22.41 < .001 [.65, 1.21]
Constant .91 (.52) .08 [-.12, 1.95]
Parent BMI .03 (.01) .18 .007 [-.63, -.18]
Demandingness -.41 (.12) -.23 .001 [.65, 1.21]
Underestimation .93 (.14) .44 <.001 [.65, 1.21]
Model 6 (n = 169) .54 .29 .27 14.11 .001
Constant .72 (.61) .24 [-.48, 1.93]
Parent BMI .04 (.01) .23 .001 [.02, .06]
Underestimation 1.34(.68) .63 .05 [-.01, 2.69]
Demandingness -.34 (.16) -.19 .04 [-.66, -.02]
Underestimation X
-.14 (.24) .20 .54 [-.61, .32]
demandingness
Model 7 (n = 169) .49 .24 .23 .57 .45
Constant -.68 (.57) .004 [-.23, 3.53]
Parent BMI .04 (.01) .20 .004 [.01, .06]
Underestimation .92 (.15) .43 <.001 [1.0, 1.01]
Responsiveness .28 (.37) .05 .45 [-.45, 1.01]
Model 8 (n = 169) .49 .24 .23 .60 .44
Constant -1.06 (.76) .09 [-2.55, .44]
Parent BMI .04 (.01) .10 .004 [.01, .06]
Underestimation 1.65 (.96) .77 .09 [-.24, 3.54]
Responsiveness .57 (.52) .10 .28 [-.47, 1.60]
Underestimation X
-.57 (.74) -.35 .44 [-2.03, .89]
responsiveness
Model 9 (n = 174) .33 .11 .09 5.05 .007
Constant 2.09 (1.03) .05 [.05, 4.1]
Parent BMI .04 (.01) .22 .003 [.01, .07]
Responsiveness -.53 (.49) -.10 .28 [-1.50, .44]
Demandingness -.49 (.16) -.28 .003 [-.81,-.18]

122
Table 3.11 (Cont.)

Variables R2 95% CI
B (SE) β R R2 Adjusted F p
[Lower, upper]
Model 10 (n = 169) .55 .30 .28 44.80 < .001
Constant 2.04 (.92) .03 [.01, .07]
Parent BMI .04 (.01) .19 .004 [.01, .06]
Responsiveness -.65 (.44) -.12 .14 [-1.52, .21]
Demandingness -.53 (.14) -.30 <.001 [-.81,-.25]
Underestimation .94 (.14) .44 <.001 [.66,1.22]
Model 11 (n = 169) .55 .29 .28 .01 <.001
Constant 1.98 (1.11) .08 [-.22, 4.17]
Parent BMI .04 (.01) .19 .004 [.01, .06]
Responsiveness -.61 (.60) -.11 .31 [-1.8, .58]
Demandingness -.53 (.14) -.30 <.001 [-.82, -.24]
Underestimation 1.03 (.94) .48 .27 [2.88, .02]
Underestimation X
-.07 (.73) -.04 .92 [-1.50, 1.36]
responsiveness
Model 12 (n = 169) .55 .30 .28 .18 .67
Constant 1.86 (1.01) .07 [-.13, 3.85]
Parent BMI .04 (.01) .19 .004 [-.85, -.11]
Responsiveness -.63 (.44) -.12 .16 [-1.50, .25]
Demandingness .48 (.19) -.27 .01 [-.23, .56]
Underestimation 1.22 (.69) .57 .08 [-.77, .63]
Underestimation X
-.10 (.24) -.14 .68 [-.57, .37]
demandingness
Model 13 (n = 169) .55 .30 .28 .36 .55
Constant 1.37 (1.50) .92 [-1.59, 4.33]
Parent BMI .04 (.01) .20 .004 [.01, .06]
Responsiveness -.38 (.72) .60 .60 [-1.79, 1.03]
Demandingness -.42 (.23) -.24 .06 [-.87, .03]
Underestimation 1.97 (1.8) .92 .28 [-1.61, 5.54]
Underestimation X [-2.21, 1.40]
-.40 (.91) -.25 .66
responsiveness
Underestimation X [-.77, .41]
-.18 (.30) -.25 .55
demandingness

123
 Figures

Figure 3.1

Assessing the moderating role of feeding styles in the association between caregiver’s
underestimation of child weight status and child BMI z-scores

Figure 3.2

Four types of feeding styles according to Hughes et al. (2005). Figure adapted from Shloim et al.
(2015)

124
Figure 3.3

Box plot of BMI z-scores of preschoolers according to feeding styles in the total sample (n =
174)

125
Figure 3.4

Box plot of BMI z-scores of preschoolers according to feeding styles in the total sample with no
outliers (n = 171)

126
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 Chapter 4

Study 2: Parents’ misperceptions of child weight status and factors associated with

underestimation of weight status of young children in Chile

Abstract

Misperceptions of child weight status influence the prevention or treatment of childhood

obesity, especially underestimation of weight status in young children. Little is known about

misperceptions and the factors associated with underestimation of child weight status in Latin

American countries, particularly those widely affected by obesity such as Chile. Thus, the

objectives of this study are to (1) assess parent misperceptions of weight status in young children

and 2) to examine socio-demographic, anthropometric, and behavioral factors associated with

parent underestimation of child weight status in Chile. Parents were asked about their

perceptions of child weight status and socio-demographic and child behavioral factors in face-to-

face interviews. Weight and height were measured from parents and their children. Frequencies

of misperceptions were obtained by comparing the perceived versus the objective child weight

status. Multiple logistic regressions were conducted to examine the factors associated with

underestimation of child weight status. Underestimation of child weight status was 47% in the

total sample, and 78% among parents of overweight or obese children. Child BMI z-scores OR =

2.8 (95% CI: 1.91, 4.36), less screen hours exposure in the child OR = .52 (95% CI: .29, .93),

and boys OR = 4.5 (95% CI: 1.33, 15.46) were associated with parent underestimation of child

weight status. The results of this study can help inform childhood obesity programs aimed at

improving parent estimates of their child weight status in preschool years and increase healthcare

professionals’ attention to parents of heavier children, child sedentary behaviors, and child

gender to effectively address misperceptions of child weight status.

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 Introduction

Child overweight and obesity is a major global problem affecting 40 million children in

developed and developing countries (United Nations Children’s Fund [UNICEF], World Health

Organization [WHO] & World Bank Group [WBG], 2019). Although Chile has the lowest

undernutrition prevalence in Latin America (Organización de las Naciones Unidas para la

Alimentacion y la Agricultura [FAO], Organización Panamericana de la Salud [OPS], Programa

Mundial de alimentos [WFP], 2019), overweight and obesity starting in preschool years are a

growing public health concern. Overweight during preschool years has been reported as a risk

factor tracking overweight to the beginning of adolescence (Pryor et al., 2015). Prevalence of

overweight or obesity increases with age for children between one-month and six-years-old

(Ministerio de Salud de Chile, 2016b). The latest public report with a representative sample of

children attending schools indicated that approximately 50% of children between four and five

years old are overweight or obese (Ministerio de Educación de Chile, 2018). The prevalence of

obesity in girls at age four is 21.5% and in boys 25.8%, and higher for five year old children

(22.2% in girls and 27% boys) (Ministerio de Educación de Chile, 2018).

These findings have led researchers to focus attention on parents, who are considered to

play a key role in children developing healthy lifestyle behaviors (Faith et al., 2012; Black &

Aboud, 2011). Preschool children are in a developmental stage in which they learn most from

their environment (Birch & Anzman, 2010). Thus, parents who underestimate child weight

status, especially those whose children are overweight or obese, may not take actions to promote

healthy life style (Birch & Anzman, 2010). For example, Flores-Peña et al. (2014) found that

parents who underestimated overweight or obesity in their children reported significantly less

actions to improve the weight status of their child, than did those who accurately identified

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overweight or obesity. Also, parents who underestimate their child’s weight status may tend to

be less worried about their actual weight (Tschamler, Conn, Cook, & Halterman, 2010) and this

misperception has been found to be the most relevant predictor of childhood obesity (McKee,

Long, Southward, Walker, & McCown, 2016). If parents are not able to correctly identify their

child’s weight, the adoption of behaviors that promote healthy weight status may not be initiated

until the child shows significant physical limitations (Jain et al., 2001). A correct perception of

child weight status is particularly important in preschool years, since children who are in the

process of developing weight-related habits are becoming more independent and are open to

learn from their environment (Birch & Anzman, 2010).

Perceptions of child weight status are an environmental influence within the culture of a

population and can affect families’ beliefs related to child weight (Harrison et al., 2007).

Meanings are given to information obtained through our senses and lead to the creation of

judgements about others and oneself (Lara-García, Flores-Peña, Esquivel, Sosa-Briones, &

Cerda-Flores, 2011). Beliefs about what is normal weight are reflected in parental perceptions,

which can vary across socio-economic status, culture, or ethnicity (Baker & Altman, 2015;

Hughes et al., 2006; Sherry et al., 2004). For instance, caregivers who were born in South

America, Central America or Hispanic speaking Caribbean countries are less likely to correctly

categorize the weight status of their child. Similarly, Latino parents have been found to identify

their child’s weight status less accurately than non-Latino parents (Huang et al., 2007).

The context and history of Chile is especially important in understanding the nutrition

situation the country currently faces. Nutritional challenges at public health level evolved from a

high prevalence of undernutrition toward obesity in a rapid pace (Albala, Vio, Kain, & Uauy,

2002). The increase of obesity and overweight prevalence has been explained in part by Chile’s

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supplementary programs focused on preventing undernutrition, in which there is no proper

adjustment to the current nutrition situation. Also, the economic growth and changing lifestyles

of the population have played a role to the increase of obesity in the country (Atalah, Amigo, &

Bustos, 2014). Countries have reacted differently to the trading agreements with a high supply of

unhealthy nutrients such as sugar (Basu, 2015), and nationwide obesity has been predicted from

the types of food families buy (Dunstan et al., 2019). Although the Chilean population has been

affected by overweight and obesity in recent decades and this nutrition situation has become a

major problem, parents may still not be concerned by childhood obesity as much as by

undernutrition in the child (Santos et al., 2009). However, there has been limited research in

Chile about the underestimation of child weight status and the factors associated with it.

A systematic literature review and meta-analysis of research of underestimation of child

weight status included 78 studies, most of which were conducted in USA, Europe and some

countries from Oceania and Asia (e.g., Australia, New Zealand and China) (Lundahl, Kidwell, &

Nelson, 2014). Only four studies reported child weight status misperceptions in LatinAmerica;

they were conducted in Mexico, Brazil and Argentina. In this meta-analysis, Lundahl et al.

(2014) found that underestimation of child weight status was estimated in a proportion of one out

of seven parents of normal weight children, while it was 50.7% for parents of overweight or

obese children. In spite of knowing that parents frequently underestimate their child’s weight

status, only in the last two decades has more attention been given to the factors associated with it

(Towns & D’Auria, 2009). This research is particularly scarce in parents of several Latin

American countries, like Chile

Factors related to underestimation of child weight status reported in the literature are

socio-demographic, anthropometric, and behavioral. Among these factors, child BMI and age

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(Howe, Alexander, & Stevenson, 2017; Hudson, McGloin, & McConnon, 2012), parent

education (Rich et al., 2005), child gender (Boutelle et al., 2004), and caregiver/parent weight

status (Gauthier & Gance-Cleveland, 2016) have been associated with underestimation of child

weight status. Mixed evidence have been found in socio-demographic variables such as in parent

education level, in which a negative association (Huang et al., 2007) or no association (Júlíusson

et al., 2011) with underestimation of child weight status.

In regard to behavioral aspects of children potentially associated with underestimation of

child weight status, perceptions of their child’s appetite or of how physically active they are can

influence parent perceptions and concerns about it (Gopinath, Hardy, Baur, Burlutsky, &

Mitchell, 2012; Lindsay, Sussner, & Peterson, 2011; MacFarlane, Crawford, & Worsley, 2010;

Webber, Hill, Cooke, Carnell, & Wardle, 2010). For instance, parents who perceive a lack of

appetite in the child may be concerned about their child’s weight status (Webber et al. 2010).

Also, it has been reported that Latino parents said that children who are active will not have

weight problems (Foster & Hale, 2015).

Given that child characteristics may play a role in parent’s accuracy to identify their child

weight status, further studies are warranted. Also, although multiple studies have reported a

frequent underestimation of child weight status, they have been mainly conducted in developed

countries (Tompkins, Seablom, & Brock, 2015; Lundahl et al., 2014). Because there are many

contextual and individual factors that can be associated with the perceptions of weight status

among parents of preschoolers, more research is needed in Latin America where overweight

trends have been increasing (UNICEF, WHO & World Bank Group, 2019). As Chile is one of

the countries most affected with this public health issue, and little is known about misperceptions

of child weight status and their explanatory factors in the Chilean context, the objectives of this

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study are the following: (1) to assess parent misperceptions of weight status in young children

and 2) to examine socio-demographic, anthropometric and behavioral factors associated with

parent underestimation of child weight status in Chile. Learning about misperceptions of weight

status, particularly underestimation and factors associated with it can help approach obesity from

a culturally competent perspective and improve the efficacy of programs aimed at families.

Methods

The analysis of the data of this study was based in data collected two cross-sectional

studies. Parents were recruited from June to August 2017 and from October 2018 to January

2019, during two studies aimed at exploring feeding styles and its influences on parents of

preschoolers attending child-care centers. The first study was aimed at adjusting the caregiver

feeding style questionnaire and exploring associations with underestimation of child weight

status. The second study was conducted to increase the sample size and further explore

influences on feeding styles among Chilean children.

This study was approved by the University of Illinois at Urbana-Champaign Institutional

Review Board (Approval Numbers 17659 and 19014) and JUNJI (Junta Nacional de Jardines

Infantiles, JUNJI). Consent from all participants and assent from children was obtained prior to

data collection.

Study Sample

Participants included 174 parents and their children. They were recruited from 14 child-

care centers in Santiago, Chile, (either a private childcare center or the National Board of Child-

care Centers managed by the Chilean Government). JUNJI consists of a country-wide

educational program for preschool children, which also offers meals to the children. This

program serves mostly low-to-middle income families, while the private childcare center

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involved families from middle socio-economic level. Thus, the socio-economic level among

participants was in low-to-middle range. Inclusion criteria consisted of: (a) children ranging

between three to five years old and five years and eleven months old, who were attending

childcare settings located in low-to-middle income neighborhoods located in Santiago; (b) no

history of physical or mental disabilities that may affect normal growth. Caregivers consisted of

parents or other family members who spend most of the time with the child out of school hours

and interact with the child during meal-times.

Procedures and Measures

Data included in this study was collected through face-to-face interviews involving

questionnaires. Interviewers were native Spanish speakers from Chile and had training in

interviewing and conducting anthropometric measures for children and adults. The

questionnaires included questions regarding socio-demographic and health information,

perceptions of child weight status, physical activity, screen hours, satiety responsiveness and

food responsiveness in the child. Data entry was independently checked for accuracy by two

researchers from the research team.

Anthropometric measures in children and caregivers. Weight and height of caregivers

and children were obtained according to a standardized protocol (Ministerio de Salud de Chile,

2014). Measures were conducted by Chilean dietitians and one nurse. The height was recorded to

the nearest 0.1 cm and weight was recorded to the nearest 0.1 kg. Weight and height were

measured using a Seca 220 telescopic measuring rod attached to a Seca 769 electronic column

scale (Seca Company, 2020). Body Mass Index (BMI) was calculated in adults dividing weight

in kilograms by height squared in meters. According to the WHO Growth Standard References,

weight-for-height guides the weight status classification in the child between one and five years

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old, while BMI z-score is used to categorize weight status in children five years and one month

old and older (WHO, 2019b, 2019a). In children between three and five years old, the BMI z-

scores were obtained by utilizing AnthroPlus software (WHO, 2011) version 3.2.2. Meanwhile,

the AnthroPlus version 1.0.4 was utilized only in children between five years and one month old

and five years and eleven months old. The categorization of child weight status was based on the

child growth references utilized in Chile (WHO, 2019b; WHO 2019a).

The BMI z-scores were obtained by two independent Chilean dietitians that were part of the

research team, and each value was compared to check for accuracy. Also, weight status was

categorized according to child growth references used for children under five years old and those

older than five years old (WHO, 2019b, 2019a). Discrepancies were discussed to determine the

actual weight status and BMI z-scores in the child.

Perceptions of child weight status. Caregiver’s perceptions were obtained from an item

of the subscale that assesses parent’s perception of child weight status (the item about the child

weight status between the ages three to five). This question was obtained from the Child Feeding

Questionnaire (Birch et al., 2001). Its four options to categorize child weight status were

modified to adjust to the classification of child weight status that healthcare professionals usually

discuss with the parents during the health care appointment: (i) underweight; (ii) normal; (iii)

overweight; or (iv) excessive overweight or obese.

Parent’s perceptions of child weight status were categorized as underestimation,

overestimation or accurate. Underestimation was defined as the mismatch between the weight

status category perceived by the parent and the objective child weight status. For instance,

underestimation was considered when the objective child weight status was normal, but it was

categorized by parents as underweight; the objective child weight status of overweight was

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categorized as normal weight by the parent; or a child with obesity was perceived as having

overweight or normal weight by the parent. Overestimation was defined when a parent perceived

the child weight category higher than the one objectively measured and obtained through WHO

2006 and 2007 Growth standards according to age and gender. For instance, a child that was

perceived as normal when the child had underweight or was perceived as overweight or obese

when the child was normal weight. Those parents whose categorization of the child weight

coincided with the one obtained from the growth standards, were categorized as having an

accurate perception of the weight status of their child.

Statistical Analyses

Frequencies, means and standard deviation (SD) of demographic, anthropometric and

behavioral variables are described in the total and a subsample of participants who reported

behavioral variables: screen hours, physical activity, and food satiety and food responsiveness.

Exploration of continuous variables was conducted involving histograms, kurtosis, skewness,

and Shapiro-Wilk Test to test normal distribution. A two-tail and significance level at .05 were

considered for all the statistical analyses, using IBM SPSS software for Windows Version 24.0

(IBM, 2018).

When the data was not normally distributed, the Mann-Whitney test was used to compare

mean ranks of continuous variables groups between the group of parents who underestimated

and those who accurately estimated child weight status in the total sample and the sub-sample of

participants with behavioral variables. Chi square tests were conducted to examine associations

of nominal and ordinal variables with underestimation of child weight status variable. Chi square

and Fisher Exact tests were conducted in the subsample (n = 81) of parents and their children to

explore associations between nominal variables.

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 Agreement between actual and perceived child weight status. Cohen’s Kappa was

used to determine the level of agreement between the caregiver’s perception of the child weight

status and the actual child weight status in the total sample.

Logistic regression analyses. Binary logistic regression was used because the outcome

variable is binary; the accurate perception of weight was coded with a 0 digit, while the

underestimation of weight was coded with a 1 digit. Simple and multiple logistic regression

analyses were conducted between potential variables associated with underestimation of child

weight status, as outcome variable. Five participants (2.9%), who overestimated the weight status

of their child, were excluded from these analyses because the focus of this research is

underestimation of child weight status.

Dependent variable: Underestimation of child weight status. Underestimation was

defined when the parent perceived a lower weight status in the child compared to the objective

categorization. The objective categorization was obtained from anthropometric measurements

according to WHO growth standards used in Chile for five years old children or younger, and for

those between five years and one month old and five years and 11 months old Chile (Ministerio

de Salud de Chile, 2018; WHO, 2019b; WHO, 2019a). The dependent variable is a dummy

variable, in which accurate perception of weight status was coded with a 0 digit, while

underestimation of weight was coded with a 1 digit.

Independent variables in the logistic regression. The selection of factors for examining

the association with underestimation of the weight status in preschool children was based on

evidence from previous studies. The independent variables tested on the risk of underestimating

child weight status in preschool children were child weight based on child BMI z-scores

(Warkentin, Mais, Latorre, Carnell, & Taddei, 2017), gender of the child (Garcia et al., 2019),

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age of the child (Garcia et al., 2019; Howe et al., 2017), parental education (Towns & D’Auria,

2009; Eckstein, 2006), and caregiver/parent weight status (Garcia et al., 2019; Gauthier &

Gance-Cleveland, 2016). Perceptions regarding behavioral factors in the child that have been

reported to be associated with underestimation are screen exposure hours of the child (Zhang et

al., 2018), and high appetite in the child (Heitzinger et al., 2014).

Child BMI z-scores. These anthropometric measurements were calculated with the

software WHO Anthro for Personal Computers, version 3.2.2 and 1.0.4 (WHO, 2011).

Parental education. This factor was obtained by asking “What was the highest education

level you have attained?”. Parents could reply if they had some or completed level of education.

Education level was defined as a three-level categorical variable in which: (i) having less or

completed elementary school was coded with a 1 digit; (ii) some or completed high school with 2

digit; and (iii) post-secondary education was coded with a 3 digit. This last category included

parents/caregivers with vocational education after high school, some or completed college and

graduate level. Three categories were created with high school as the middle category because

most of the adults in Chile have completed some or all of high school. Consequently, educational

levels below or above high school level, the most frequent level of education in Chile, provides

an appropriate classification in the context of the country (Instituto Nacional de Estadísticas,

2018).

Caregiver’s weight status. The caregiver’s weight status was classified according to the

BMI with the following categories: underweight (BMI < 18.5), normal (BMI between 18.5-

24.9), overweight (BMI between 25 and 29.9), and obese (BMI > 30) (WHO, 2018). The parent

weight status category was entered to the logistic analyses in three categories. Given that parents

with underweight were only two, this category was collapsed in the normal weight category.

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Thus, having a BMI of 24.9 m/kg2 or less was coded with a digit 1, and overweight coded with

digit 2 (BMI between 24.9-29.9), and the obese category with BMI of 30 m/kg2 or higher was

coded with digit 3.

Screen time and physical activity in the child. Both behavioral variables were obtained

by asking two questions from the Spanish version of the Family Nutrition and Physical

Activity Screening Tool (FNPA) (Ihmels MA, Welk GJ, Eisenmann JC, 2009). Screen time

was obtained by asking “How often does your child have less than 2 hours of screen time in a

day?” [Includes TV, computer, game system, or any mobile device with visual screens].

Physical activity was obtained by asking “How often does your child do something physically

active when he/she has free time?” The anchors for these two questions were: (1)

never/almost never; (2) sometimes; (3) often; and (4) very often/always. Both variables were

entered in the logistic analyses as numeric variables.

Child appetite. This behavioral factor was approached through the subscales of satiety

responsiveness and food responsiveness of the Child Eating Behavior Questionnaire (CEBQ)

(Wardle, Guthrie, Sanderson, & Rapoport, 2001). The items were translated to Spanish and back

translated to English to ensure the correct meaning of the questions involved in each subscale.

Satiety responsiveness was calculated through the mean of the following five items: (i) “My

child has a big appetite (reversed item)”; (ii) “My child leaves food on his/her plate at the end of

a meal”; (iii) “My child gets full before his/her meal is finished”; (iv) “My child gets full up

easily”; and (v) “My child cannot eat a meal if s/he has had a snack just before.” The Cronbach’s

alpha was .66 for this subscale. Food responsiveness was calculated through the mean of the

following five items: (i)“My child is always asking for food”; (ii) “If allowed to, my child would

eat too much”; (iii) “Given the choice, my child would eat most of the time”; (iv) “Even if my

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child is full up s/he finds room to eat his/her favorite food”; and (v) “If given the chance, my

child would always have food in his/her mouth.” Anchors were in a 5-point Likert scale (1 =

never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). The Cronbach’s alpha of the satiety

responsiveness subscale was .66, and it was .89 for the food responsiveness subscale.

Further exploration of behavioral factors in the child through a multiple logistic regression was

performed in a subsample because these behavioral variables (food responsiveness, satiety

responsiveness, physical activity and less than two screen hours) were collected in only one of

two periods of data collection included for this study.

Results

Parental perception of child weight status. The level of agreement between the

caregiver’s perception of child weight status and objective categorization of child weight status

was obtained through Cohen’s Kappa =.17, p < .001). Table 4.5 exhibits breakdowns of

objective versus perceived child weight status overall and by child gender. Only 1.1% of the

children were underweight, 46% were categorized normal weight and more than half were

overweight or obese.

In the total sample, including children with underweight, normal weight, overweight and

obesity, 47% of the parents underestimated their child weight status, while 50% accurately

estimated, and 2.9% overestimated child weight status. Parents of normal weight children tended

to accurately perceive their child weight status (85%), compared to parents of children with

overweight (22.4%) or obesity (17.6%). Taken together 78% of parents of children with

overweight or obesity underestimated the weight status of their child. Specifically, almost three

quarters of parents of children as overweight perceived their child as normal weight or

underweight, while 82.4% of children with obesity were perceived as overweight or normal

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weight. Five parents overestimated child weight status: two children were underweight, while

their parents found them normal weight, two normal weight children were perceived as

overweight, and one child with overweight was perceived as obese.

Disaggregated by gender, girls and boys with overweight were mainly perceived as

normal weight. This underestimation was 81.3% for parents of boys with overweight who were

perceived with normal weight, while this misperception was 57.7% in parents of girls.

Factors associated with underestimation of child weight status. The results of the

simple logistic regressions indicated that child BMI z-scores in the total sample (see Table 4.6)

and screen hours (see Table 4.7) were significant explanatory variables on underestimation of

child weight status. For each standard deviation increase in the BMI z-score, parents were 2.8

more likely to underestimate the weight status of their child (OR: 2.8, p < .001), and those

parents whose children spend less than two screen hours per day more often were less likely to

underestimate (OR: .64, p < .05), in other words, for children who had more often less than two

hours of screen hours per day, parents had 1.6 more odds of accurately estimating the child’s

weight status.

The results of the multiple logistic regression analyses in the total sample are shown in

Table 4.8. Only child BMI z-scores were significantly associated with underestimation of child

weight status (OR: 2.9, p < .001). There was a trend in child gender. Parents of boys were 89%

more likely to underestimate their child’s weight status (OR: 1.89, p = .08). Hosmer Lemeshow

status test indicated a good fit of the data (χ2 (8) = p > .05).

In the multiple logistic regression of 81 parent child dyads that included the variables

appetite, screen hours and physical activity in the child (see Table 4.9), indicated that child

gender, child BMI z-scores and screen exposure were significantly associated with

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underestimation. Parents of boys were four times more likely to correctly estimate child weight

status (OR: 4.3, p = .02). In this analysis, per each point increase in child BMI z-score, parents

were four times more likely to underestimate child weight status (OR: 4.98, p < .001), and

children having more often less than two hours of screen exposure had less odds of

underestimating child weight status (OR: .52, p < .05). The Hosmer Lemeshow test also

indicated good fit to data (χ2 (8) = p > .05). Demographics of the sub-sample of parents that

reported behavioral variables in the child are shown in Table 4.10.

Sample characteristics and bivariate analyses. Families in the total sample (n = 174)

were mostly Chilean-born (94%). Caregivers were mostly mothers (92.5%) with some high

school or post-secondary educational level (84%) and belonged to a two-parent family (67%)

(See Table 4.1). Only 2% of parents and children were underweight, while more than three

quarters of the parents and about half of children had overweight or obesity. All children were

aged three to five years old and were mainly boys (58.9%).

Mann Whitney test was used to identify differences in continuous variables between

parents who underestimated and those parents who accurately perceived child weight status. As

shown in Table 4.2, Mann-Whitney tests indicated there were no statistically significant

differences in the parent age (U = 3492.5, p = .82), parent BMI (U = 3217, p = .27), children’s

age (U = 3301, p = .35), satiety responsiveness (U = 845, p = .74), food responsiveness (U = 875,

p = .95), physical activity (U = 730, p = .36) between parents who underestimate and parents

who accurately estimate child weight status. A significant difference was found in the BMI z-

scores (U = 1496, p < .001) between the children whose parents underestimated child weight

status (Median = 1.6) and those who accurately perceived child weight status (Median = .58).

Screen hours exposure (U = 610, p = .04) also showed differences between children of parents

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who accurately perceived child weight (Median = 3) compared to parents of children who

underestimated (Median = 2).

Chi square tests in the total sample indicated that there was an association between parent

perceptions of child weight status and objective child weight status (2 (2) = 74.14, p < .001)

(See Table 4.3), and Chilean versus other immigrant families (2 (1) = 5.2, p = .02). No

association was found between parent perceptions of child weight status and weight status

categories in parents (2 (2) = 4.2, p = .12); child gender (2 (1) = 2.4, p = .12); parent education

(2 (2) = 1.7, p = .43), family status (one versus two parent family) (2 (1) = .50, p = .48),

employment status (2 (1) = .86, p = .35).

In the sub-sample of 81 participants, a significant association was found between child

gender (2 (1) = 2.4, p < .05), effect size V = .24; child weight status (2 (1) = 37.58, p < .001),

effect size V = .68 and underestimation of child weight status. A two-sided Fisher Exact test

indicated a trend in the association between nationality (Chilean parents and parents from other

Latin American countries) and underestimation of child weight status (p = .06). No other

significant associations with underestimation of child weight status was found in this sub-

sample.

Spearman and point biserial correlations between socio-demographic, underestimation of

child weight status, anthropometric and behavioral variables are shown in Table 4.4. Child BMI

z-scores (rho = .50, p < .001) and screen exposure less than two hours (rho = -.23, p < .05) were

significantly correlated with underestimation of child weight status. Given the sample with

behavioral data was small, only the variables that were significantly associated in the chi square

tests and correlations in the subsample were included in the multiple logistic regression including

behavioral variables of child appetite (food satiety and food responsiveness), screen exposure

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less than two hours, and physical activity.

Discussion

The objectives of our study were to assess parent misperceptions of the weight status of

young children in Santiago of Chile and to examine factors associated with parent

underestimation of child weight status. Our overall findings were that 47% of parents

underestimated the weight status category of their child, and 78% of parents underestimated the

weight category of children who were in the overweight or obese categories. Specifically, 75.8%

of parents of children in the overweight category and 82.4% of parents of children in the obese

category underestimated their child weight status. In concordance with our results, a high

frequency of underestimation in parents of preschool children has been observed in the limited

research conducted in Chile and other countries in Latin America. In Chile, 41% of the total

sample of mothers of two-to-five year old children (Bracho & Ramos, 2007) and 53.6% of

parents of 2 to 14 years old children underestimated their child’s weight status (Heitzinger et al.,

2014). Also, in Brazil 45% of parents underestimated the weight status of two-to-eight years old

children (Warkentin et al., 2017). The high frequency of underestimation is concerning,

especially for the health of children with obesity or are overweight.

A high proportion of parents of children who were overweight or had obesity in a more

extensive age range than in our study have been reported in Brazil (62.5%) (Freitas, Silva, Teles,

Peixoto, & Menezes, 2015), Argentina (87%) (Hirschler et al., 2006) and Mexico (98%) (Chávez

et al., 2016). The high level of underestimation in the study conducted by Chávez et al. (2016)

may relate to the images utilized to estimate parent perceptions of child weight status, which

have been validated in 6 to 12 years old children, but not in preschoolers.

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 Several studies in other countries have also found high frequency of underestimation. In

Australia, 85% of parents underestimated their child overweight status at five years (Sanne

M.P.L. Gerards et al., 2014). In Greece, 88% and 55% of parents misperceived the weight status

of children at risk of overweight and overweight categories, respectively (Manios, Kondaki,

Kourlaba, Vasilopoulou, & Grammatikaki, 2009), while in Italy, the underestimation of the

parents of overweight children was 48.5%, and 86.5% in parents of children categorized as obese

(Binkin, Spinelli, Baglio, & Lamberti, 2013). Overall, studies across the world have found that

parents of preschoolers underestimate most (Rietmeijer-Mentink et al., 2013). A systematic

review and meta-analysis found that underestimation of child weight status was salient regardless

the methods or the values of child BMI in the assessments of child weight status used and despite

differences in the methodology used to identify parent perception of child weight status (Lundahl

et al., 2014).

Multiple reasons have been given for the prevalence of underestimation of child weight

status reported in diverse regions. One of these reasons is that parents see robustness as a healthy

trait in a child (Sherry et al., 2004; Jain et al., 2001). African-American parents have indicated

that their children would eventually normalize their weight status as children become older

(Sherry et al., 2004). Also, it has been proposed that parents may misperceive child weight status

because of the context in which overweight and obesity prevalence is high (Rietmeijer-Mentink

et al., 2013). For instance, parents of children who are overweight or have obesity may

underestimate the weight category of their child less in areas where overweight or obesity is less

common (Binkin et al., 2013). Given the high prevalence of overweight and obesity in all age

groups in Chile, a potential explanation of the high frequency of underestimating child weight

status is that overweight and obesity in Chile is being normalized.

155
 A second objective of our study was to examine the factors associated with the

underestimation of weight status. We found that per each point increase of child BMI z-scores

parents were 2.8 times more likely to underestimate their child’s weight status. Also, in analyses

of a subsample, per each point of increase of the frequency of daily screen hours as less than two,

parents had lower odds to underestimate their child’s weight status. In additon, in the analyses of

the subsample, parents of boys were more likely to underestimate their child’s weight status; but

this was only a trend in the analysis in the total sample. There was no association of

underestimation with children’s eating behaviors.

In line with our results, a recent study conducted in Brazil found that child BMI z-scores

in a group of children between two and eight years old were positively associated with

underestimation of their weight status (Warkentin et al., 2017). But, contrary to our findings, in a

nationwide sample of parents in China, BMI z-scores were negatively associated with parent

underestimation (Zhang et al., 2018). It is possible that Latin American parents perceive that

heavier children have an adequate weight compared to parents from China who would perceive

less heavier children as acceptable. Also, in the USA, Maynard et al. (2003) found that increased

child BMI z-scores above the overweight threshold had lower odds of underestimating child

weight status. This last study suggested that when children surpassed the overweight threshold

the overweight status of their child was more obvious to parents.

The increase of child BMI z-scores associated with a higher likelihood of

underestimation may be because parents expect children to be much heavier in the narrow child

age range in our study. This finding may reveal a cultural aspect common in families of three to

five year old children linked to developmental changes that children undergo these ages. For

instance, children experience a gradual reduction of BMI to reach their lowest BMI (called nadir)

156
during these years. This BMI decrease is followed by an increase commonly occurring at five to

six years old (Cheng, Wen, Coletti, Cox, & Taveras, 2014; Whitaker, Pepe, Wright, Seidel, &

Dietz, 1998). This regular feature of child development may be unknown to parents and they

then perceive the BMI decrease negatively. The mismatch between the objective and perceived

child weight status involving children with different age ranges requires special attention due to

the different dimensions of child development (e.g., physical, social, emotional) (Lopes et al.,

2013). How parents react to these developmental differences may be also influenced by socio-

cultural aspects. Qualitative inquiries would be helpful to clarify these aspects linked to

underestimation of weight status of young children in Chile.

Further, child gender was associated with underestimation of child weight in the current

study. Similar to our study, the greater frequency of underestimation by parents of boys than of

parents of girls has been found in several studies (Zhang et al., 2018; Warkentin et al., 2017;

Black et al., 2015; Chaparro, Langellier, Kim, & Whaley, 2011). This finding has been explained

by gender-specific differences in body composition in the child or expectations about body

appearance for girls compared to boys (Hudson et al., 2012). However, there is no consensus that

there is more parent underestimation of boys than of girls. For instance, one study of Mexican-

heritage mothers found that parents of girls tended to underestimate more than parents of boys

(Garcia et al., 2019). In this study, Garcia et al. (2019) suggested that cultural norms play a role

in regard to gender because parents may assess the weight of girls more often than of boys.

Regarding child behaviors, parents were less likely to underestimate when children had

less time of screen exposure. Parents who estimate less screen exposure for their children may

also be more aware of the link between child screen time and weight status. In a qualitative

study, parents perceived screen hours as a negative influence on their children’s weight (Small,

157
Mazurek, Anderson-Gifford, & Hampl., 2009). These findings support the notion that parents

may be more aware of or concerned about the weight status of their children if they engage in

sedentary behaviors.

Regarding child eating behaviors, Heitzinger et al. (2014) found that parents of Chilean

children categorized as overweight or obese were less likely to underestimate when they

perceived the child to eat more than normal. This finding differs from our results in which no

association was found between underestimation and perceptions of child eating behaviors, such

as feeling full quickly when eating or being attracted by food. These differences may occur due

to the small sample of our study or differences on the items utilized to address child eating. The

CEBQ used in our study has not been validated in parents of preschool children of Latino

population. Thus, developing or using culturally appropriate instruments/items to measure eating

behaviors in preschoolers may be useful to explore the association of this factor with

underestimation of child weight status.

Our study did not find associations of parent weight status with underestimation of child

weight, agreeing with other researchers (Tabak, Schwarz, & Haire-Joshu, 2017). Contrary to our

results, Chaparro et al. (2011) found a slight negative association between parent BMI and

underestimation of child weight status. A possible reason why parent weight status is not

associated with underestimation is that overweight and obesity is widely spread in Chile in all

age groups. Consequently, parent’s weight status may not be a factor that may distinctively affect

parents’ perception of children’s weight status.

Limitations of the study. Although this study contributes to informing misperceptions

and factors associated with underestimation of child weight status in the context of Chile, it has

some limitations. For example, the current study focused on low-to-middle income parents and

158
their children, constraining the generalization of the results to this socio-economic groups. It is a

convenient sample with parents from vulnerable families who may tend to be less concerned

about issues in the nutritional domain. Also, the subsample to assess the association of children’s

behaviors with underestimation of their weight status was small. Although some authors have

indicated that parent labelling of child weight status may overestimate the frequency of parents

who underestimate their child weight status compared to visual images (Warkentin et al., 2017),

other authors have reported that this misperception is salient regardless the method utilized

(Lundahl et al., 2014).

Conclusions and Implications

In conclusion, the most important findings obtained in this study are: 1) approximately

half of parents underestimated the weight status of their young children and this misperception

was more prevalent in the parents of overweight and obese children; 2) increases in the child

BMI z-scores made it twice as likely that parents underestimate the weight status of their child;

3) less screen behavior of the child was associated with less underestimation of the parents; and

4) There was a trend in the total sample, in which parents underestimated the child weight status

of boys more than of girls.

The implications of this study are related to healthcare programs aimed at preventing and

treating obesity in young children. During health care appointments in primary healthcare

centers, dietitians, physicians, and nurses and other healthcare professionals need to be aware

that parents/caregivers often underestimate child weight status (Howe et.al., 2017). Although

children between three and five years old have an annual healthcare appointment in primary

healthcare centers in Chile, parents are often not aware of the actual weight status of their child.

159
 Healthcare appointments in primary health care centers are particularly relevant for

young children who have been categorized as overweight or obese. The parents of these children

are sent to nutritionists for dietary and nutritional advice. Given that parents of children in the

overweight or obese categories underestimate more, it is clear that this yearly appointment is not

enough to modify parent’s misperceptions of child weight status. In addition, parents who do not

perceive their child as overweight or obese may not follow nutritional advice or, if they do, they

may not consider the suggestions regarding lifestyle changes relevant. Consequently, the ways to

deliver information about child weight status requires a special focus for healthcare providers to

help parents identify an appropriate weight for children between three and five years old.

In addition, our study found that parents had decreased odds to underestimate when

children watch less than two hours per day more often, and underestimation was increased in

parents of boys and with increases of the child’s BMI z-scores. These findings may help the

development of programs and research that involve child behaviors that may be more helpful for

parents to accurately perceive child weight status. Also, healthcare providers may need to pay

more attention to heavier children and gender related aspects to better address underestimation of

weight status in young children. These findings can contribute to the development of culturally

competent programs involving organizations where child weight status and the risks of excessive

weight in young children can be effectively addressed.

Future directions. Given the high underestimation of child weight status, especially in

overweight or obese children, the investigation about the reasons of this misperception is needed.

Qualitative studies can help to obtain an in-depth perspective to identify factors and mechanisms

linked to underestimation of child weight status. Further research to explore factors associated

160
with underestimation of child weight status can help nurses, dietitians, and physicians to address

parental misperceptions as part of culturally competent programs.

161
 Tables
Table 4.1
Socio-demographic characteristics, nutritional variables and perceptions of child weight status
of the participants

Characteristics Total participants

n = 174
Parents
Age in years (Mean ± SD) 32 (8.6)
Educational attainment, n (%)
No schooling 2 (1.1)
Elementary 26 (14.9)
High school 88 (50.6)
Vocational 33 (19)
Higher education 25 (14.4)
Work status, N (%)
Currently working n (%) 103 (59.2)
Type of caregiver, n (%)
Mother 161 (92.5)
Father 7 (4)
Grandparent 5(2.9)
Aunt 1 (.6)
Marital status n (%)
Two parent family 116 (66.7)
Nationality n (%)
Chilean 163 (93.7)
Others 11 (6.3)
Weight statusa, N (%)
Underweight 2 (1.1)
Normal 39 (22.4)
Overweight 66 (37.9)
Obese 67 (38.5)
BMIb (Mean ± SD) 29.2 (5.7)
Children
Age in years (Mean ± SD) 3.6 (.7)
Child gender, n (%)
Girls 72 (41.4)
Categorization weight statusc
Underweight 2 (1.1)
Normal weight 80 (46)
Overweight 58 (33.3)
Obese 34 (19.5)
Perceived child weight status
Correct perception 87 (50)
Underestimation 82 (47.1)
Overestimation 5 (2.9)
a
Parent weight status according to WHO criteria for adult population based on Body Mass Index, underweight (BMI
lower than 18.5), normal weight (BMI between 18.5 and 24.9), overweight (BMI between 25 and 29.9), and obese
group (BMI above 30) (WHO, 2018).
b
BMI: Body Mass Index
c
Categorization of weight status according to WHO (2018)
Table 4.2

162
Table 4.2
Differences of parent BMI, parent age, child age, child BMI-z scores between parents with an
accurate or underestimated perception of child weight status (n =169)

Variables Accurate Median (IQR) Underestimated Median (IQR)

Accurate Underestimation
Parent BMI (n = 169) 28.9 (5.8) 28.1 (7.5) 29.7 (5.5) 29.2 (7.7)
Parent Age (n = 169) 31.8 (7.9) 30 (10) 32.1 (9.3) 30 (10)
Child age (n = 169) 3.6 (.7) 4 (1) 3.5 (.6) 3 (1)
BMI z-scores (n = 169) .7 (1) .6 (.7) 1.65 (1.21) 1.6 (1)
Satiety responsiveness (n = 84) 2.7 (.8) 2.5 (1.5) 2.7 (.9) 2.8 (1.4)
Food Responsiveness (n = 84) 2.6 (1.1) 2.4 (1.6) 2.7 (1.3) 2.4 (1.8)
Data are presented as mean ± SD, and median (IQR, interquartile range)

Table 4.3

Cross tabulation between frequencies of child weight status and perceptions of child weight
status

Perceived Child Objective child weight status Total

weight status
Normal Overweight Obese
weight
Accurate N 68 13 6 87
% 78.2 14.9 6.9 100
Underestimation N 10 44 28 82
% 12.2 53.7 34.1 100
Total count N 78 57 34 169
Total Percentage % 100 100 100 100

163
Table 4.4

Correlations among participants’ characteristics and underestimation of child weight status

Variable 1 2 3 4 5 6 7 8 9 10 11
1. Underestimationa (n = 169) -

Parent’s age (n = 174) -.02 -

2. Parent weight statusb (n = 174) .13 .11

3. Parent’s BMIc (n = 174) .09 .14 .94** -

4. Child’s age (n = 174) -.07 .002 -.10 -.09 -

5. Child’s genderd (n = 174) -.12 .02 .08 .06 .02 -

** ** **
6. Child BMI z-scorese (n = 174) .50 .11 -.27 .29 -.07 -.002 -

7. Food responsiveness (n = 84) -.01 -.02 -.03 .05 -.001 .23 .23* -

8. Satiety responsiveness (n = 84) .04 .09 .13 .07 .04 -.03 -.21 -.45** -
*
9. Screen exposure (n = 81) -.23 .06 -.08 -.03 .01 .19 .001 -.05 -.12 -

12. 10. Physical activity (n = 81) -.10 -.08 .03 -.01 -.14 .18 -.15 -.17 -.03 .28* -

Biserial point correlations were conducted for nominal variables and continuous variables: a0 = accurate perception
of child weight status, 1= underestimation of child weight status; b1 = Underweight and normal weight status (BMI
≥ 24.9 m/Kg2), 2 = overweight (BMI 24.9 - 29.9 m/Kg2), 3 = obese (BMI ≥ 30 m/Kg2) according to WHO (2018);
c
BMI (Body Mass Index) m/Kg2; d0 = boy, 1 = girl; eChild BMI z-scores were calculated using the software WHO
AnthroPlus based on World Health Organization Growth Standards 2006 and Growth reference 5-19 years adopted
in Chile (Ministerio de Salud de Chile, 2018; WHO, 2019b; WHO 2019a)
p* < .05, **p < .001

164
Table 4.5
Agreement between objective child weight status and caregiver’s perception of child’s weight
status of the total sample and by gender

Perceived Weight status

Weight status Underweight Normal Overweight Obese Actual weight status
category n (%) n (%) n (%) n (%) n (%)
Total (n =174) 13 (7.4) 125 (71.8) 29 (16.7) 7 (4) 174 (100)
Underweight 0 2 0 0 2 (1.1)
Normal 10 (12.5) 68 (85) 2 (2.5) 0 80 (46)
Overweight 3 (5.2) 41 (70.6) 13 (22.4) 1 (1.7) 58 (33.3)
Obese 0 14 (41.2) 14 (41.2) 6 (17.6) 34 (19.5)
Total
Boys (n = 102) 8 (5.8) 77 (76.9) 13 (13.5) 4 (3.8) 102 (100)
Underweight 0 1 0 0 1 (1)
Normal 7 (14.9) 39 (83) 1 (2.1) 0 47 (46)
Overweight 1 (3.1) 26 (81.3) 4 (12.5) 1 (3.1) 32 (31.4)
Obese 0 11 (50) 8 (36.4) 3 (13.6) 22 (21.6)
Girls (n = 72) 1 (1.4) 33(45.8) 26 (36.1) 12 (16.7) 72 (100)
Underweight 0 1 0 0 1 (1.4)
Normal 3 (9.1) 29 (87.9) 1 (3) 0 33 (45.8)
Overweight 2 (25) 15 (57.7) 9 (34.6) 0 26 (36.1)
Obese 0 3 (25) 6 (50) 3 (25) 12 (16.7)
Last column describes objective child weight status in the total sample and per child gender.

165
Table 4.6
Simple logistic regressions of the association between underestimation of child weight status and
each of the socio-demographic and anthropometric variables (n = 169)

Variables  SE Wald’s OR p value CI

 2

Parent’s age .01 .02 .08 .1 .78 .97, 1.04

Parent education (ref. completed
elementary school or less)
High school -.16 .44 .13 .85 .72 .36, 2.02
Higher education .29 .47 .38 1.34 .54 .53, 3.35
Parent’s weight status (ref. BMI ≤ 24.9)
Overweight .24 .42 .33 1.27 .57 .56, 2.87
Obese .70 .41 2.84 2 .09 .89, 4.52
Child’s age (years) -.23 .24 .91 .80 .34 .50, 1.27
Child’s gender (Ref. girls) .49 .32 2.39 1.63 .12 .33, 1.14
Child BMI z-scores 1.05 .20 27.2 2.8 < .001 1.92, 4.21
Parent weight status is based on Body Mass Index cutoff points for adults (m/Kg 2) WHO (2018). The reference
category includes underweight (BMI < 18.5) and normal weight (BMI ≤18.5 ≥ 24.9), overweight (BMI ≤ 25 ≥ 29.9),
obese (BMI ≥ 30)
Child BMI z-scores were calculated using the software WHO AnthroPlus based on World Health Organization
Growth Standards 2006 and Growth reference 5-19 years, which was adopted in Chile (Ministerio de Salud de
Chile, 2018; WHO, 2019b; WHO 2019a)

Table 4.7
Simple logistic regressions of the association between underestimation of child weight status and
each of the socio-demographic, anthropometric and behavioral variables (n = 81)

Variables  SE Wald’s OR p value CI

 2

Child’s gender (Ref. girls) .99 .47 4.5 2.7 .03 1.08, 6.73
Child BMI z-scores 1.14 .30 14.35 3.1 <.001 1.73, 5.64
Screen exposure -.44 .21 4.21 .64 .04 .42, .98
Physical activity -.21 .23 .80 .81 .37 .52, 1.28
Food responsiveness .03 .19 .03 1.03 .87 .72, 1.48
Satiety responsiveness .10 .27 .14 1.10 .65 .66, 1.86
Child BMI z-scores were calculated using the software WHO AnthroPlus based on World Health Organization
Growth Standards 2006 and Growth reference 5-19 years, which was adopted in Chile (Ministerio de Salud de
Chile, 2018; WHO, 2019b; WHO 2019a)

166
Table 4.8

Multiple logistic regression of the association between underestimation of child weight status
and socio-demographic and anthropometric factors (n = 169)

Variables  SE Wald’s OR p CI
 2

Parent’s age -.004 .02 .04 1 .85 .96, 1.04

Parent education (ref.
elementary)
High school -.23 .52 .19 .80 .66 .29, 2.22
Higher education .22 .56 .16 1.24 .69 .42, 3.75
Parent’s weight statusa (ref.
BMI ≤ 24.9)
Overweight -.18 .48 .14 .83 .71 .33, 2.13
Obese .19 .48 .16 1.21 .69 .48, 3.08
Child’s age -.16 .27 .34 .86 .56 .51, 1.45
Child’s gender (ref. girls) .64 .37 3.06 1.89 .08 .26, 1.08
b
Child BMI z-scores 1.06 .21 25.28 2.88 <.001 1.91, 4.36
a
1 = Underweight and normal weight status (BMI ≥ 24.9 m/Kg2), 2 = overweight (BMI 24.9 - 29.9 m/Kg2), 3 =
obese (BMI ≥ 30 m/Kg2) according to WHO (2018);
b
Child BMI z-scores were calculated using the software WHO AnthroPlus based on World Health Organization
Growth Standards 2006 and Growth reference 5-19 years, which are adopted in Chile (Ministerio de Salud de Chile,
2018; WHO, 2019b; WHO 2019a)

167
Table 4.9

Multiple logistic regression of the association between underestimation of child weight status
and socio-demographic factors, nutritional and behavioral factors (n = 81)

Variables  SE Wald’s OR p CI
 2

Child’s gender (ref. girls) 1.51 .62 5.83 4.53 .02 1.33, 15.46
Child BMI z-scores 1.61 .39 17.34 4.98 <.001 2.34, 10.59
Screen exposure -.65 .29 4.94 .52 .03 .29, .93
Physical activity .24 .32 .57 1.27 .45 .68, 2.35
Food responsiveness -.24 .30 .65 .78 .42 .43, 1.42
Satiety responsiveness .42 .43 .96 1.52 .32 .66, 3.54
Child BMI z-scores were calculated using the software WHO AnthroPlus based on World Health Organization
Growth Standards 2006 and Growth reference 5-19 years adopted in Chile (Ministerio de Salud de Chile, 2018;
WHO, 2019b; WHO 2019a)

168
Table 4.10
Socio-demographic, nutritional, and child behavioral characteristics of a subsample of parent-
child dyads in the multiple logistic regression (n = 81)

Characteristics Total participants

n = 81
Parents
Age in years (Mean ± SD) 32 (9.2)
Educational attainment, n (%)
Elementary or less 6 (7.4)
High school 40 (49.4)
Post-secondary education 35 (43.2)
Work status, N (%)
Currently working n (%) 55 (68)
Type of caregiver, n (%)
Mother 75 (92.6)
Father 3 (3.7)
Grandparent 3 (3.7)
Marital status n (%)
Two parent family 52 (64)
Nationality n (%)
Chilean 74 (91.4)
Others 7 (8.6)
Weight statusa, N (%)
Underweight 1 (1.2)
Normal 15 (18.5)
Overweight 32 (39.5)
Obese 33 (40.7)
BMIb (Mean ± SD) 30 (6.2)
Children
Age in years (Mean ± SD) 3.7 (.7)
Child gender, n (%)
Girls 34 (42)
Categorization weight statusc
Normal weight 38 (46.9)
Overweight 22 (27.2)
Obese 21 (25.9)
Perceived child weight status
Correct perception 41 (50.6)
Underestimation 40 (49.4)
Child BMI z-scores (Mean ± SD) 1.27 (1)
Screen hours 2.7 (1.1)
Physical activity 3.14 (.98)
Satiety responsiveness 2.7 (.88)
Food responsiveness 2.6 (1.2)
a
Parent weight status according to WHO criteria for adult population based on Body Mass Index, underweight (BMI
lower than 18.5), normal weight (BMI between 18.5 and 24.9), overweight (BMI between 25 and 29.9), and obese
group (BMI above 30) (WHO, 2018).
b
BMI: Body Mass Index
c
Categorization of weight status according to WHO (2018)

169
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 Chapter 5

Study 3: Examining parents’ perspectives on feeding their children: Insights on childhood

obesity in Chile

Abstract

Chile is currently one of the Latin American countries with the highest prevalence of

childhood obesity. Given that parents’ feeding practices shape their children’s lifelong eating

habits, addressing those practices is key to curbing this problem. Despite their importance,

studies on the influences of Chilean parents’ feeding practices are scarce. Hence, this study

explores the influences affecting feeding practices of preschool-aged children in Chile. We

conducted photo-elicitation interviews with 25 parents from families recruited in public childcare

centers in Santiago, Chile. Through a thematic analysis with an inductive approach, we identified

three themes affecting parent feeding practices: Parent and child characteristics and the feeding

dynamics, family complexity and challenges, and parents’ health knowledge. In the first theme,

parents’ previous experiences as well as the parents’ reactions to child characteristics generated

parent adjustments to feed their child. In the second one, interactions between family members

(e.g., mothers, fathers, grandparents) to feed the child were complex. Moreover, family context

revealed limited income and time, which determined the availability of necessary food, and the

quality of food preparation. In the last theme, parents demonstrated knowledge of food and

health, with public childcare and healthcare centers, as well as the Internet, as sources of

information. This study informs about parents’ most important influences that converge at the

family level on parent feeding practices. Attention to the uniqueness of parent-child interactions,

the role of family members and their context, and the family relationships with childcare and

healthcare centers are needed to fight the problem of obesity.

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 Introduction

In Chile, three out of ten children under the age of six years are in the overweight or obese

category (Ministerio de Salud de Chile, 2018), while undernutrition is the lowest in Latin

America (Organización de las Naciones Unidas para la Alimentación y la Agricultura [FAO],

Organización Panamericana de la Salud [OPS], Programa Mundial de alimentos [WFP], 2019).

In addition, two to five year old children who are overweight tend to have a higher likelihood of

maintaining this condition in adulthood (Freedman et al., 2005). Therefore, the time before

entering school is a key period to develop healthy eating habits (Birch & Ventura, 2009).

Although the goal of reducing obesity in preschool children has become a public health priority

(Ministerio de Salud de Chile, 2011), this goal has been difficult to achieve. The World Obesity

Federation [WOF] (2019) has estimated that despite the implemented government policies such

as food marketing regulation for children (Gobierno de Chile, 2017), Chile has only a 7% chance

of curbing childhood overweight prevalence by 2025 (World Health Organization [WHO],

2014).

Child eating behaviors are associated with childhood obesity, so identifying their

influences at multiple levels has been gaining attention to develop and create viable interventions

in specific populations (Story, Kaphingst, Robinson-O’Brien, & Glanz, 2008). Families play a

fundamental role in either preventing or leading the child to develop obesity due to biological,

behavioral and environmental influences (Moore et al., 2017). As opposed to the eating habits of

older children, young children depend more on their families (Birch & Ventura, 2009). Early

childhood constitutes a period of great learning (Birch & Ventura, 2009) in which parents are

helping the child to adjust adequately to the values, beliefs, or norms in the socio-cultural

environment in which they live (Hughes et al., 2006). Parent practices or parenting styles applied

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for dis/encouraging the child to eat are necessary for normal growth and development,

especially because a parent adjusts to the child when she/he has difficulties in eating whether

these are due to poor appetite, slow eating, or stress while eating (Qu et al., 2020).

Parents play a crucial role in obesity prevention and treatment. For instance, parent

involvement in educational programs has been linked to the improvement of preschoolers’ eating

habits at home (Williams et al., 2014) and child Body Mass Index (BMI) (Jang, Chao, &

Whittemore, 2015). Parents have also been considered agents of change for reducing the problem

of childhood obesity (Myles S. Faith et al., 2012), as they determine serving sizes, types of

foods, schedule and frequency of the meals/foods of preschool children (Birch & Anzman,

2010). These findings show that parent feeding decisions are crucial, since a poor dietary

environment and lack of stimulation of healthy eating habits affects the optimal development and

the genetic potential of the child as a result of overnutrition or undernutrition (Bentley et al.,

2014).

As important as parents deciding what and when their child eats, is how parents feed their

child, that is, knowing their feeding practices. Feeding practices are aimed at achieving food-

related goals, such as making the child to eat fruit (Vaughn et al., 2016). These feeding practices

can be classified into non-coercive and coercive. Non-coercive feeding practices consist of

parents organizing the food environment and providing structure for the child to eat. These types

of non-coercive practices also consider the child’s developmental stage, thus promoting child

competence, autonomy, and independence (e.g., involving her/him to make decisions about food

within boundaries or defined structure) (Vaughn et al., 2016). In contrast, coercive feeding

practices, such as restricting foods, pressure to eat, and bribing the child with foods, are feeding

practices centered on adults, and do not create a positive relation with foods and self-regulation

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when eating (Jansen, Mulkens, Emond, & Jansen, 2008; Vaughn et al., 2016). Recently, the

American Academy of Pediatrics APP has recommended that parents and other caregivers

apply feeding practices that support child’s development, (American Academy of Pediatrics et

al., 2019), which are non-coercive/responsive.

Even though the research findings point towards parent feeding practices as crucial for

preventing or treating childhood obesity in preschool years (Birch, 2016; Piernas & Popkin,

2010), in Chile there is scarce research on parents’ influences for parent feeding practices of their

child. To date, national data only corroborates that young children are eating unhealthily and that

there are socio-economic disparities in quality of diet. For example, the National Survey of Food

Intake has reported that two to five year old children consume low amounts of vegetables and

have a high intake of sugar from sugar-sweetened drinks and sweets (Universidad de Chile,

2014). In addition, families from low and middle socioeconomic status present a lower index of

healthy eating compared to those from high socio-economic status (Universidad de Chile, 2014).

More importantly, it has also been reported that obese preschool children attending childcare

centers have an excessive energy intake during weekends (Vasquez et al., 2004), which shows

that parents’ feeding practices need to be studied, as they provide valuable information to

improve or develop family-centered programs to fight childhood obesity.

This study seeks to fill the research gap on parent feeding practices in Latin America, and

in so doing, understand the multiple reasons as to why parents do or do not promote healthy

eating habits in their young children. Specifically, it explores parents’ perspectives in the

influences of feeding their pre-school children in Chilean low-income families, since those

perspectives can provide valuable information to improve or develop family-centered programs

to fight childhood obesity.

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 Methods

A qualitative approach using semi-structured interviews with a photo-elicitation technique

was used (Collier, 1957) to provide in-depth perspectives of parents feeding practices. Parents of

three to five years old children were recruited in Santiago, Chile. Prior to engaging in any

research activity, ethical approval of the protocol was obtained from both the Institutional

Review Board of the University of Illinois and from the host institution, National Board of

Association of Childcare Settings (Junta Nacional de Jardines Infantiles, JUNJI). The approval

letter was obtained for Protocol No. 19014 on August 13th, 2018.

Study Site and Recruitment

This study was conducted in Santiago de Chile, Metropolitan Region. Santiago is the

capital of Chile, and is the most populated area in the country with a population of 7,112,808

inhabitants (Instituto Nacional de Estadísticas, 2018). The study involved two areas of

Metropolitan Region according to JUNJI’s mapping: (i)“Provincia Cordillera” (Mountain

Province, in Spanish); and (ii) “Provincia Oriente” (East Province, in Spanish).

Parents and their children between three and five years old were recruited across 9 child

care centers part of the JUNJI’s network. This association of childcare settings managed by the

Chilean government offers free early education and meal services to children, prioritizing low-

and middle-income families.

An informative email was sent to invite principals of 11 childcare settings located in

“Provincia Cordillera” and “Provincia Oriente” that were part of JUNJI’s network in Santiago.

This email included an informative flyer of the study. Principals who agreed to participate,

posted the informative flyer on childcare boards. Parents received an invitation letter that briefly

explained the research, and the consent form was attached to the letter.

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 Participants were invited to a face-to-face interview once consent was given, and then

reviewed by the research team before starting any procedures. Participants provided their phone

number in their consent form to be contacted afterwards. A brief screening by phone was

conducted to check for the criteria of inclusion and allow parents to ask questions related to the

research before the interview had begun.

Sampling Methods and Participants

A purposive sample method was employed to select diverse types of participants

(Krathwohl, 2009), based on the inclusion criteria and diversity of feeding styles based on the

Caregiver’s Feeding Style Questionnaire (CFSQ) (Hughes et al., 2005). The CFSQ was used to

identify feeding styles that reflects how parents usually feed their child according to high or low

levels of the dimensions of demandingness and responsiveness (Hughes et al., 2005).

Demandingness refers to whether a parent stimulates/discourage the child to eat regardless adult-

or child- centered feeding practices (Hughes et al., 2005). Responsiveness refers to whether a

parent stimulates the child to eat considering or not their child’s needs or not (low or high levels

of responsiveness) (Hughes et al., 2005). Feeding styles involve adult-centered and child-

centered feeding practices to determine demandingness and responsiveness (Hughes et al., 2005).

Thus, this study purposively selected parents with feeding styles coupling high and/or low levels

of both dimensions to expand the exploration of factors influencing parents to feed their children

in the particularities of their contexts and experiences. Consequently, we explored the influences

on feeding practices of 25 parents with different feeding styles to expand the understanding of

these factors. Four participants did not finish the study due to lack of time and one of them was

not possible to contact again.

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 Consequently, parents were selected to understand the influences that leads parents to

choose feeding practices and styles within the context of Chile. A total sample size of 25 parents

categorized into one of the four feeding styles, high demanding/high responsive, high

demanding/low responsive, low demanding/high responsive, or low demanding/low responsive,

were included in this study and interviewed with photo-elicitation.

Inclusion criteria. Participants included adult (18 years or older) parents or a legal

guardian of preschoolers, residing in Chile, who spend most of the time with the child outside of

school and interact with them in food related contexts (e.g., during dinner). In a pilot study we

previously conducted, 95% of the caregivers were parents. Thus, clearly, parents are the most

important caregiver in relation to feeding, and that is the reason this study is focused on parents

instead of other caregivers, such as grandparents.

Preschoolers included children between three and five years old, who did not have health

conditions that may affect their growth (e.g., food intake affected by cerebral palsy or impaired

nutrient absorption). This age group was selected due to the interest to capture factors

influencing parental feeding toward children who are normally developing in this stage.

Procedures for data collection. The project was conducted between October 2018 and

January 2019. The data were collected in two steps (see Figure 5.1). The first step consisted of an

individual face-to-face-interview to collect socio-demographic information, and anthropometric

measures. In the second step, parents were asked to take photos of the feeding interactions with

their children, and then invited to participate in a second individual interview using photo-

elicitation and a guide of questions.

A disposable camera with availability of 27 photos was provided to each of the

participants. The cameras allowed participants who had limited access to technology to

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participate, and also to obtain the same quality of photos (Galvez et al., 2017). The participants

were asked to take pictures during a period of seven days, but it took up to 21 consecutive days.

Telephone calls were used to remind parents about taking photos and to check for problems. Five

parents of girls and one parent of a boy did not continue participating after receiving the camera

to take the photos. Thus, the final group included parents of more boys than girls.

After the picture taking period was finished, the pictures were developed. To start the

interviews, participants were asked to choose seven pictures from their picture set. Then, the

SHOWeD technique was used during the in-depth interview (Johnson, Sharkey, Dean, Alex

McIntosh, & Kubena, 2011). This technique provides a way to start the conversation and obtain

data that goes beyond what is observable (Johnson, Sharkey, Dean, et al., 2011). The technique

consisted of the questions: What do you See in this picture?; What is Happening in this picture?;

How does this relate to Our life?; Why does this problem, concern or strength Exist?; What can

we Do about it?

During the SHOWeD technique, the caregivers talked about each of their selected

pictures and the researcher asked questions if more explanation was needed. In addition to the

selected pictures from the caregivers, the researcher selected an additional seven different

pictures to discuss diverse types of photos during the interview if there were enough photos. All

the participants gave consent to be audio-recorded during the interview.

Participants were trained in using disposable cameras and ethical aspects of taking pictures

(Bugos et al., 2014). All procedures were conducted individually in a private place selected by

the participants, in childcare settings or in homes of the participants.

The script and question guide (see Appendix A) was based on the adapted protocol

interview by Dev, (2013) and the interview guide by Sherry et al. (2004). In addition, photo-

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elicitation produced detailed data about eating behaviors and family interactions, and the

participants considered the assignment associated with taking pictures as easy (Galvez et al.,

2017).

Multiple demographic and health status factors were collected to characterize the sample

since contextual and demographics that may be a relevant influence on feeding practices or styles

(Vaughn et al., 2016). These included education level, family size, marital status, employment

status, parent age, age, and sex of the child (De Vriendt, Matthys, Verbeke, Pynaert, & De

Henauw, 2009; Greaney, Lees, Lynch, Sebelia, & Greene, 2012; Patrick & Nicklas, 2005). In

addition, parents reported types of health insurance (private, public, or both). Data saturation

occurred in interview 22.

Data Analysis

Thematic analysis of the influences on parental feeding behaviors. Thematic analysis

refers to the process of identifying repeated pattern of meaning across a data set such as

interviews (Braun & Clarke, 2006). The approach of Braun & Clarke (2006) was utilized to

explore the influences on feeding practices and styles parents apply with their children between

three and five years old.

All interviews were transcribed verbatim by native Spanish speakers from Chile and the

main researcher revised for accuracy. Then, four dietitians conducted the coding of the narratives

obtained from the photo-elicitations. A preliminary step consisted of the independent exploration

of a subsample of three randomly selected interviews by each of the four researchers who were

involved in the analysis, to familiarize themselves with the data and find preliminary codes

(Saldana, 2013; Vaismoradi, Turunen, & Bondas, 2013). Each code was considered as a concept

or idea the participant had conveyed during the interview and captured the richness of the

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phenomenon (Fereday & Muir-Cochrane, 2006).

The final codebook was consolidated by the lead researcher after other researchers

compared and discussed the codes, keeping those that were agreed to by the majority of the

researchers (Galvez, 2017). The codes were collapsed into themes (Braun & Clarke, 2006).

Four Chilean nutritionists/dietitians, with experience in the community field and qualitative

research, conducted the coding process independently to compare their results at the end of the

process. The comparison of the codes by four different researchers reduced bias obtained by only

one researcher coding the data. Given that in the qualitative inquiry “the researcher is the

instrument of the research” (Patton, 1999, p.1198), the background information about the

researchers vital. In this study, four researchers had experience in coding data as part of the

analysis, while I as the main researcher am a dietitian with experience in coding, and analyzing

the data of previous studies as part of my graduate studies. Also, all the researchers have

previously worked with low-income communities in Chile.

In this study, the themes were considered when they appeared in the majority of the

participants. ATLAS.ti 8 Mac and Window, version 8.0.43 (Scietific Software Development

GmbH), was used to conduct the analysis.

This study used qualitative data to expand the findings of a previous quantitative study with

the aim of better understand parental feeding practices in Chile. To address trustworthiness in

this study, three techniques according to Patton (1999) were considered: negative examples,

triangulation, and credibility of the researcher. Negative examples consisted in exceptions that do

not follow the general pattern, while triangulation of coding was achieved at the analysis level.

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 Findings

Participants’ sociodemographic, health and nutritional characteristics are shown in Table

5.1. Parents average age was 32.1 years (SD = 7.6). Most parents were mothers (96%), 52%

completed high school, and 36% had vocational or had some or completed higher education.

Most of them were employed in sporadic, part time or full-time job (80%). Most participants had

public health care. The parent weight status was predominantly overweight or obese (84%).

Feeding styles among parents were 20% classified as high demanding/high responsive, 24% high

demanding/low responsive, 36% low demanding/high responsive, and 20% were low

demanding/low responsive. Child average age was 3.8 years old and 60% of the children were

boys. The child weight status was 60% in the overweight and obesity categories, while the rest

were in normal weight category.

The exploratory nature of this research seeks to better understand influences on parental

feeding of children between three and five years old. Findings from the participants’ interviews

underscored personal, interpersonal and environment factors that converge at the family level to

determine parent feeding practices. Three major themes were obtained from the thematic

analysis reflecting the parents’ perspectives to feed their child: Parent and child characteristics

and the feeding dynamics, family complexity and challenges, and parents’ health knowledge

These themes and subthemes are summarized in Table 5.2.

Parent and Child Characteristics and the Feeding Dynamics

Perspectives from the parents emphasized their life experiences, their beliefs, and the

goals regarding feeding their young child. Meanwhile, the child’s characteristics were perceived

as a relevant aspect to influence whether or not parents offered/allow the child to eat. Given that

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parents respond to the child’s characteristics and behaviors and vice versa, it creates a dynamic

relationship between the parent and the child in multiple situations involving foods.

Parents’ previous experiences and feeding goals. Parents’ personal and interpersonal

experiences in the past, mainly at the family level (16 out of 25, 64%). These experiences were

acquired while interacting with their parents or grandparents and influenced their beliefs that

they have replicated (e.g., children should eat a variety of food) or have intentionally modified to

feed their child (e.g., a young child should eat all the food in the plate). The experiences

described by the parents were based on their own experiences as a child, those related to when

they became parents and were health-related of other family members.

Some parents described similarities to their experiences as a child to how they fed their

children (13 out of 25, 52%), such as encouraging the child to eat foods they liked when they

were children. Particularly the foods/meals that parents related to happy and meaningful

memories with their main caregivers when they were children (who sometimes also were their

grandparents also). For example, one parent mentioned:

. . . I remember my snacks were fruits that my grandma took from their house [where
they cultivated], I always took fruits as a snack [to bring to school] . . . I think this is why
this way of feeding my family made sense to me. (Interview JO)

Parents indicated that meals and foods represented giving love and happiness within their

families. Thus, parents fed their children or ate together with the idea of sharing good moments

together. For instance, one parent said:

All of us like eating ice cream. Then, I believe it’s “our moment” . . . at the corner shop, a
weekday or at any time it’s open we’ll have an ice cream together. It’s like it unites us,
even the cat eats ice cream. (Interview SU)

On the other hand, some parents who had negative feeding experiences with their

caregivers as a child (11 out of 25, 44%), intentionally avoided these type of feeding practices

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with their own children. For example, a few parents described not preparing meals they disliked

as a child or avoided pressuring their child to eat all the food on the plate or giving them large

serving sizes like in the past. For example, one parent mentioned her negative experience with

her grandmother, who cared for her when she was child, as an example of what older generations

thought about feeding children until finished their plates: “If I didn’t eat the [whole] meal, she

[my grandmother] put more in my plate.” (Interview NC)

Similarly, another parent explained that rearing values nowadays have changed compared

to those in the past:

. . . He [the child] is a human being and we have to respect him, his opinions, not that
because he is little, one is going to roll all over him. One is not going to be like in the past,
when we were slapped [to make us eat]. They [her parents] left me eating until 3 or 4 in
the afternoon [to finish my meal]. (Interview RB)

A few participants described their own process of learning to eat foods they did not like

as a young child, but they could eat when they grew up. They believed the child would learn to

eat foods later instead of pressuring the child to eat rejected foods.

Some parents with overweight problems in their childhood tried to promote a healthy diet

in their child to prevent a poor health condition on them. One parent described her experience of

being overweight: “. . . I try to give less of sweets, if possible, because I have suffered so much

from being fat, I have always been fat, so I don’t want my children go through the same

(Interview AG)”. Some diseases were mentioned by parents in relation to their own diet or (e.g.,

diabetes mellitus during pregnancy) in older siblings or their child. These experiences regarding

health conditions led them to learn healthier ways to feed their children. For example, based on

the experience with the hypercholesterolemia of one older sibling of the child, one parent

mentioned: “. . . I learned that one has to give more salads to the children because this way they

won’t have high cholesterol, because cholesterol has much health risks” (Interview SR).

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 The main goals parents described when feeding their child were that the child had a

varied diet and the child learned to eat sufficiently in the absence of their parents. Parents wanted

their child to stay healthy, indicating that they were receiving all the nutrients they needed, were

not getting fat, were growing appropriately, and were avoiding getting sick from nutrient-related

aspects. Some parents mentioned these goals in order to prepare their child to eat in primary

school, a context where their child needed to be more autonomous in eating, and where the

schedule of meals was different than the one in the childcare center.

. . . I want the child eats good foods, without insisting too much, “son stop eating too
much”, or “you have to eat more”… or “come in, son, eat this because it’s good for you”.
I need him to learn because in school I’m not going to be there telling him “son, eat your
meal because in the afternoon you’ll be hungry”. (Interview DC)

Child characteristics. Parent feeding practices were also influenced by the unique

characteristics and behaviors of their child such as food preferences, appetite traits, and

emotional reactions, among others. All interviewed parents were aware of their child’s food likes

and dislikes. Child food preferences and interests influenced the preparation, cooking, and

buying of food, the manner that parents served the foods (e.g., order of the child eating foods

within a meal and arrangements of the foods), availability of foods, and allowing food selection

from already prepared meals.

Parents described that to a certain extent they took their child’s food preferences into

consideration in food-related decisions. Most parents (20 out of 25, 80%) offered, prepared or

cooked meals or foods they knew their child liked. For example, some parents offered fruits and

vegetables children preferred the most (17 out of 25, 68%) and asked their children what they

wanted to eat to please them especially in weekends or special occasions. For example, one

parent described a food prepared because the child asked for it: “I was preparing mashed banana

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and yogurt. We were going to give this [mashed banana mixed with yogurt] as a dinner to vary

his meal in dinnertime . . . he loves this . . . he asked for it (Interview RB)”.

Another parent described her positive reactions when the child demanded food given in

specific ways:

We are very traditional to eat lentils with chilena typical salad of tomato with onion and
sausage (for the lentils). When there is no sausage [in large pieces], he demands it
[sausage in larger pieces], he also complains [about too little pieces of sausage]. We my
mom and I laugh at him and we give him bigger pieces of sausage, so he can see it, and
then we cut it in smaller pieces. (Interview AS)

Some parents described buying foods when their child demanded or asked (12 out of 25,

48%). Most of the food that parents described here were fruits, cereals, yogurt, snacks, sweets, or

ice cream. Some children asked for specific fruit for their parents to bring it home or when the

child joined to buy foods, particularly fruits. One parent indicated that she buys fruit the child

likes even when it was more expensive than usual: “They her children go with me sometimes

to the open-air market… they ask for bananas. . . . He asks for banana . . . I buy them. Now,

it’s a bit expensive, but it doesn’t matter” (Interview LP).

Another relevant aspect parents described was regarding their child’s appetite in terms of

how much the child usually ate, the selection/rejection of foods and how fast or slow the child

ate. Most parents referred to their child as “good at eating” because the child usually eats

everything in the plate (20 out of 25, 80%). They indicated not being concerned when the child

sporadically did not want to eat the full meal. However, some parents who perceived their child

to eat moderately (4 out of 25, 16%) indicated that they included foods that the child dislikes less

frequently and prepared more often the meals their child enjoyed. Some parents also tried to

reason with the child or to explain nutritional properties in simple terms to promote the child’s

eating.

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 Parents who perceived their child’s appetite to be good or “extremely good” used

strategies to limit excessive eating or to avoid them eating too often.

He [the child] is good at eating, we have to hide the food . . . For example, he just had
eaten and 15 minutes later “mom, can you give me bread?” “Mom, can I have a banana?”
. . . “No son, you already ate, wait a little bit more, you’ll have your milk later”.
(Interview RB)

Some parents were aware their child could be hungry. Thus, they gave the child the

freedom to have some foods in a reachable manner for them to eat when the child was hungry.

Some common foods available for their child were fruits, yogurt, milk or cereal. One parent

described: “We leave the fruit that is reachable for him to take it . . .[although] yogurt or

Chamyto [a small bottle of probiotics that is sweet] is reachable in the fridge, but he has to ask

for it” (Interview SH)

Some parents also use feeding practices in response to their child’s emotional reactions.

Some parents indicated their children have tantrums because they want a food or the parent used

food to soothe the child’s tantrum (10 out of 25, 40%). For example, one parent said: “. . . When

I take him to the childcare center, he eats two Bonobons [cream covered by a biscuit and

chocolate] and it’s not healthy at all. But, he has a tantrum in the mornings “I don’t want to go, I

don’t want to go” (Interview AG).

In order to avoid tantrums, parents avoided triggering situations such as places offering

foods the child likes or hiding favorite foods without the child’s knowledge. Also, a few parents

negotiated or explained how much the child was allowed to eat of certain foods. In unavoidable

situations such as when other children were eating around after the childcare hours finished, the

parent would offer similar or alternative foods that the child wanted. The parents usually

prepared these foods at home and brought them for after childcare hours. For example a parent

described:

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 . . . This preparing popsicles at home avoids buying something outside the childcare
setting for the child and I save this expense because she eats it at home. This is why I
leave on the other side of the street where it’s not the girl who sells sweets, snacks, ice
cream . . . I prefer she eats a fruit instead of eating a Chester or potato chips. (Interview
MP)

Family Complexity and Challenges to Feed the Child

Participants described multiple aspects in which family members were part of to feed

their children. Grandparents and fathers applied feeding practices, such as maintaining the child-

eating routine, encouraging to eat specific foods, limiting the consumption of unhealthy foods,

and encouraging to eat varied meals in the child, among others. These family members interacted

directly with the child or between them (father-mother, grandparent-mother) to influence child

eating behaviors. Meanwhile, participants mentioned learning from grandparent-child

interactions and were aware of those feeding practices they were willing to learn and appreciated

or disagreed. Similarly, mothers and fathers discussed feeding practices for the child, while there

were also differences. These dynamics were contextualized in a physical setting, financial

limitations, and lack of time creating potential challenging situations for the participants and

their families.

Grandmothers and grandfather’s role was one of the most important influences from

parent’s perspectives on feeding their children. Grandparents’ directly and indirectly influence

the manner parent feed their children. Parents described grandparents as supportive in feeding

their children when they were away, to keeping a routine for the child and providing guidance to

parents regarding challenges to feeding their children (22 out of 25, 88%). Parents learned from

grandparents about how to prepare homemade foods and how to diversify their child’s diet.

Parents also described that grandparents showed their affection by the foods they prepared or

offered the child.

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 Some ways grandparents diversified the child’s diet was by preparing typical homemade

meals or through multiple preparations of healthy foods to increase the child’s food intake (e.g.,

fruits and vegetables). Some examples of meals that grandparents prepared were soups such as

“cazuela” (Chilean soup with a whole potato, piece of corn, meat/chicken, vegetables, and rice),

“charquican” (Chilean beef stew), “pantrucas” (Chilean soup with a dough made of flour, water

and oil cooked in this soup, veggies and meat can be added). For instance, one parent described

her appreciation of the grandmother’s preparation of homemade food and diversifying the diet of

their children:

I love when she my mom cooks because they grandmothers cook with a different
flavor. Grandparents, I don’t know what they put on it, they include their magic touch
that everything is more tasty . . . she [grandmother] prepared mushed-up food for meals,
the another day, she gave them rice and broad beans, I thought they won’t like it because
they say that broad beans are gross and look like nail and they liked it!. (Interview AG)

One parent explained the role of the great-grandmother’s role in maintaining a routine

and providing guidance to the parent about the child’s diet:

My grandmother has the schedule of mealtimes of the child, as she is the one who gives
him lunch during the weekend or he [the child] is with her in the evenings before I arrive
from work . . . some decisions regarding feeding, I prefer to ask her, I tell her “Is it fine if
I give him this food?” she tells me, “he has to eat everything [varied foods]. . . She
prefers giving him fruits and veggies he likes [that is healthy] instead of he ate a package
of cookies or a piece of chocolate. (Interview DC)

Also parents described that grandparents involved the children in preparing foods (e.g.,

homemade bread, crepes). One parent described how the grandmother involved the child in

preparing dough at her home:

My mom has a table to knead, and she makes homemade bread, and she asked my dad to
have a little table for the child to knead, so he has his own table because I like
it a lot when my mom makes bread, he [the child] shares this experience with her
[grandmother] . . . So, he participates in the whole process. (Interview JO)

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 Most parents mentioned that grandparents showed affection toward children through

sending foods the child likes, preparing meals or letting the child eat foods she/he prefers (20 out

of 25, 80%), also grandparents knew about the child’s favorite meals by asking the parents or

directly asking the child about what they preferred to eat. One parent described that the

grandparent allowed the child to choose what to eat in the weekend:

. . . Sometimes he says, “Ok, what do you want to eat today?”, because he cooks
Saturdays and Sundays, so he grandfather asks her [the child] what wants for lunch . . .
“I will have pasta, I will have mashed potatoes” . . . he knows that she [the child] is
always going to choose mashed potatoes [because she likes it]. (Interview MT)

While some parents pointed out that grandparents offered homemade foods and

unhealthy snacks (13 out 25, 52%), most of them were unconcerned with grandparents giving

unhealthy foods because it only occurred on weekends when grandparents visited them or in

special occasions. Unhealthy foods offered by grandparents included soft drinks, sweets, ice

cream, chocolate, cakes, empanadas filled sweet doughs, fried sweet doughs, among others. For

instance, one parent mentioned: “. . . We don’t go often to see the grandfather; we go once a

month or less often. When we go [to visit grandparents], she can do anything she wants there

[laughs]. Her grandfather pleases her about everything, as she is spoiled”. (Interview MG)

Some parents did not like that grandparents show affection to their children with

unhealthy foods (8 out of 25, 32%). For instance, one parent reflected on how she would prefer

them to show affection to their child: “My mother-in-law tries to make the children happy with

sweets, like everything is paid off, it bothers me. It should be different. We go rarely to my

mother-in-law’s home”. (Interview LI). When parents wanted to address the disagreement of the

parents’ rules about unhealthy foods, they asked grandparents to replace unhealthy foods with

foods they approved for their child, such as yogurt, fruits or probiotics.

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 He [my father in law] tried to overrule me, he got to my house and [immediately] said
“Take this Super 8 [chocolate covered cookie], take this Chocman [caramel biscuit
covered in chocolate]” for my girls.” [I replied to him] “I am going to ask you something,
if you want to bring something that does not cause them damage, because this causes
them damage, bring them a Chamyto [little bottle of sweet probiotic], bring them a
yogurt” (MR interview)

Another strategy to limit the consumption of unhealthy foods in their child, some parents

preferred limiting the frequency of visits from the grandparents who were resistant to the

parents’ rules. Although some parents limited visits according to what and how much unhealthy

foods their child ate when visiting grandparents, some parents described not being able to do it

because they lived with them. Those parents who were living with grandparents or close to them

made it difficult to keep the grandparents from giving unhealthy foods to their child. Besides,

participants indicated that grandparents in the same household prepared adequate homemade

meals, while other grandparents gave them unhealthy foods. One participants indicated

differences between grandmother and grandparent in feeding their child:

. . . “Dad, how many times do I have to tell you?”, “Ay” he tells me, “it’s only one, no
more”. He hides doing it. Then, I try to talk with him and tell him things, but my dad
doesn’t understand, he is going to spoil her [the child] anyway” . . . My mom
[fortunately] likes to prepare her cazuelas Chilean soup including potato, type of meat
and vegetables, because my child likes soups. (Interview MP)

Most grandparents were present in their grandchildren’s lives where demonstrations of

affection included foods. These interactions occurred on an everyday basis when parents lived

with grandparents, when visiting grandparents, or grandparents sent food to their children if they

lived in a different district or region of the country.

Another family member, who had a relevant role in feeding their child were fathers.

Participants, who were mainly mothers, referred to father’s involvement in feeding their child in

multiple ways. In two-parent and single father families (19 out of 22, 86%) or when mothers

were separated, but still in contact with the father (2 out of 25, 8%). One father had the legal

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authorization to look after his child. Therefore, he was the only father participating in the study,

while the rest of the parents were mothers.

The participants described how fathers cooked, prepared or served food or meal as a way

to support mothers when they needed help at home, were working, or not at home. One

participant indicated how her partner learned cooking:

In fact, he [the father] is the one who cooks . . . he is the oldest sibling in his family, so he
had to learn how to cook [mandatorily]. His mom had to go to work, she [the mom] left
early, so he had to be in charge of feeding his four siblings. (Interview NB)

Many participants described how fathers supported the mothers’ efforts to limit unhealthy

food and promoting a healthy and diverse diet for the child (16 out of 22 families where the

parent was present or 73% of families where the father was present). For example, one parent

described:

If G. says, “Dad, I’m hungry”, because he knows there are cookies or snacks like this, the
dad tells him, “I bought you lots of oranges in the free market, so we’ll eat some of
them”, and they eat them and then it is more fun for him to eat them. (Interview SH)

Although some participants indicated that the father directed some discussions about

preparing child meals (e.g., not giving friend foods or many sweets), mothers indicated that the

help from fathers depended on the fathers’ work hours and if the schedules coincided with the

child’s mealtimes. Additionally, while some participants described the support or involvement of

fathers, some of them described differences between mother and father approaches to feed their

child. Some mothers perceived themselves as more permissive or stricter than their

partner/husband. These differences within the couple were evident in discussions about types,

frequency of consumption or food serving sizes for the child. One parent expressed these

differences:

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 “The dad is stricter. I am more kind of a [laughs] spoiler. He [the father] is stricter in
everything, if we should not buy ice cream, we don’t [buy] and all of a sudden, I give in,
but it’s not all the time. But he is stricter in everything”. (Interview MO).

Not only fathers and grandparents have an important role in feeding their children, other

family members also can be part of the influences on parents feeding practices and child eating

behaviors according to the context and family structure. For example, parents described how the

child imitated other family member’s eating preferences or dislikes. Some parents indicated that

the interactions of the child with other family members influenced the challenges of feeding their

child and also their child’s eating behaviors. A parent commented on the effort in limiting the

sibling influence on the preschooler:

Participant: I try to always tell the older sister not to say that she doesn’t like the veggies
in front of her the preschool daughter because she influences her too much . . . She the
oldest daughter says “I don’t like the veggies” and the other one the preschool daughter
says “I don’t like it either”, I know the youngest likes eating the veggies. She listens her
sister and says “I don’t like them either” (Interview NC)

The extent and complexity of the family influences on the parent feeding practices and

child eating behaviors depended on the family context. Economic limitations were part of

the financial context that parents considered relevant to feed their families. Parents indicated that

financial constraints were considered in food-related decisions, such as buying foods or cooking

(15 out of 25, 60%). Preparing foods they had available at home, giving food serving sizes

parents were sure their child eats and preparing meals/foods according to the routine, and special

occasions were declared.

One parent said: “Thanks God we don’t starve, but it is what there is. We don’t have the

conditions of being affluent, if beans were cooked, beans we will have to eat”. (Interview IS)

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 Given the limited incomes, parents preferred to buy and prepare foods the children and

the family were more likely to eat in order to avoid wasting foods, specially fruits and vegetables

(18 out 25, 72%). For example, one parent referred to buying in the markets to avoid wasting:

He [the child] tells me “I want oranges . . . bananas and strawberries” . . . obviously I

buy these fruits. . . I have bought other fruits, but in the end, I don’t like them, the child
doesn’t eat them, the dad eats very little, the fruits get rotten and we have to throw them
away. So, for this not to happen, it’s better that we buy what we will eat. (Interview SH)

Parents indicated that their limited family budget influenced on giving unhealthier foods

or special meals only when money was available biweekly, or at the end of the month when they

received their monthly payment. Parents were interested in providing the basic foods to

appropriately feed their families (17 out of 25, 68%), which restricted the opportunities to eat

special meals to weekends, when participants’ families could share meals together. Special meals

mentioned by parents included such items as pizzas, sushi, hotdogs, hamburgers and fries. One

parent described when and why she bought special meals:

. . . Well, not all Saturdays, when there is money to treat ourselves, otherwise we eat the
bread we normally eat. For example, it could be once a month that we eat hotdogs or
could be hamburger another day, for all of us, but I do it this way. I prefer buying another
type of foods [necessary] than eating so much nonsense. (Interview AS)

Also, parents indicated that children consumed sweets and snacks on weekends, in

special celebrations of extended families or friends (e.g., birthday parties when children had

several sweets), and during holidays or festivities such as Easter or Halloween. Some parents

went to the malls, Happyland or out for not cooking or to entertain their children, where they

bought unhealthy foods such as La cajita feliz [Happy meal from McDonald’s], ice cream,

hotdogs or pizza (10 out of 25, 40%).

Most parents mentioned that they got their food in open-air markets and supermarkets (23

out of 25, 92%). Parents indicated buying groceries in supermarkets, while fresh fruits and

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vegetables were purchased in outdoor markets to diversify the diet for their families by buying

cheap fresh products that were highly available in the season (e.g., there was more diversity of

fruits available in summer). One parent described its strategy to optimize the family income:

I have to search for the cheapest fresh foods in the markets to access what they her
preschool daughter and teenager son need . . . I know I have to search fresh foods on
the season, because fresh foods on the season are the cheapest, you know? Because
there is more access . . . these are economic strategies for surviving, got it? . . . I look at
the prices of all the fruits. If the green apples are cheaper, I buy green apples.
(Interview JO)

Another important family context deals with the use of technology while eating. About

half of the parents indicated that their child was exposed to technological devices while eating

such as TV or smart phones (13 out of 25, 52%). The TV was turned on while the whole family

was eating together or when the child was eating alone. Watching TV was used by some parents

to distract children to eat food they did not like, or initiate the meal. Parents indicated that the TV

or distractions were used if the child was eating fine, but it was avoided if the child did not eat.

One parent explained how they used the TV as a distraction to encourage eating:

The dad tries more than me, to distract him with other things. All of a sudden, we bring
him his toy car “Ok, let’s eat with the cars on the table while we eat” . . . and distracting
him also helps sometimes to hide some veggies he doesn’t want to eat. (Interview JO)

Perceptions of lack of time in some parents (12 out 25, 48%) was determined by the

housework, long-hours shifts, and extracurricular activities with their children. This lack of time

affected by altering the snack and meal schedule, buying delivery foods, or preparing easy to

make meals, and avoided arranging or decorating the foods to make them attractive to the child.

As a result of the lack of time, parents mentioned relying on other family members to feed their

child; or feeling less guilty of not giving the best foods at home to the child because at least their

child received nutritional meals during childcare hours. For instance a parent mentioned:

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 Knowing that the childcare places give balanced meals [to the child], for me it was super
important, and I can say “I can cook something is less elaborated” or “the dad cooks”, he
knows to cook some things, so I can dedicate time to study (Interview JH).

Few parents mentioned strategies due to address the challenge of the lack of time. For example,

one parent cooked meals one day ahead, so when the family needed to eat it was ready, while

another parent encouraged the child to eat independently as the parent also lacked help.

Parents’ Health Knowledge

Most parents described a diverse range of knowledge about food and nutrition (23 out of

25, 92%) that influence parent feeding practices. Also parents receive information form their

environment in which community organizations such as childcare center and primary healthcare

centers are relevant. For example, they described a variety of foods considered as healthy, the

negative components in foods, the alteration of nutritional properties according to preparations,

the relevance of a diverse diet, and consideration of the amount of food. Most parents described

fruits and vegetables, dairy products, water and cereals as healthy foods for their children. Some

participants mentioned components of the foods that were inappropriate for their children such as

sugar, colorants, additives and salt. Some parents made connections between food and health,

including diet-related long-term health conditions such as obesity, hypertension,

hypercholesterolemia and diabetes. One parent commented about essential foods of the child and

prevention of diseases:

The food I find the most important is milk and yogurt. I try that he [the child] always has
them and I learned that we have to give more salad to children so they don’t have high
cholesterol. (Interview SR)

Parents indicated limiting or having rules about the amounts and the types of foods, avoid buying

specific foods, and the occasions children are allowed to eat certain favorite foods (21 out 25,

84%). One parent mentioned rules related to overweight related to his/her child:

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 . . . If we go to the videogames, she wants an ice cream. It’s normal that every child
wants an ice cream, but, I tell her “You buy one thing here or an ice cream in the park
[because of her overweight]. Otherwise you won’t have anything. It’s only one thing”
(Interview MD).

One relevant health topic for parents associated with their feeding practices was

childhood obesity (19 out of 25, 76%). Many parents indicated that obesity was a concern

because of its negative impact on health. Parents mentioned bullying, negative stigma, negative

feelings, and physical limitations as consequences of child obesity. Some parents mentioned

encouraging the child to eat healthy to promote healthy growth, while some parents limited the

amount of sweets, snacks, and other foods to avoid excessive weight gain and obesity-related

conditions. For example, one parent linked obesity and diabetes: “I feel afraid that there are

many young children that have it [diabetes]. A nephew of my husband is 12 years old and he is

only steps away to becoming diabetic”. (Interview DO)

A parental concern was that other children bullied her child: “I don’t want her to be like

me [bullied] . . . other children bullied me [because I was obese] . . . Now, they [people] make a

big deal of it [bullying].” (Interview MP)

Many parents mentioned their concerns about obesity in general terms and they wanted to

appropriately feed their children to avoid it. However, few parents mentioned that their child was

overweight, it seemed that overweight was not a real concern in their child, but it was a real

problem in their surroundings (4 out of 25, 16%). They thought that the child would eventually

lose weight when she/he was sick or the excessive weight would be corrected while they are

growing up. For instance, a parent said:

I don’t care about that extra one kilogram [in my child] because she sometimes gets sick,
generally in winter time, and she loses a lot of weight . . . When they are young children,
I’m not that concerned; when they are adolescents we try . . . my daughter is adolescent,
so I make a diet for her. I insist that she eat more fruits and vegetables, less bread or [I
buy her] whole-wheat bread (Interview MG).

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 Another parent compared her child’s physical characteristics and behaviors to those of

other children with severe overweight:

Interviewer: If you were told your child is overweight, would you make modifications [in
the diet]?
Participant: I would continue the same [diet], because we see children who are obese,
because you can see it in their face. In their way to walk, it’s difficult for them to walk,
they run a little bit and they get tired. My child spends the day climbing around [child in
the overweight category]. Fat children can’t climb. (Interview LI)

Parents indicated that community organizations and the access to information have been

relevant in acquiring knowledge relevant for feeding their families. All participants indicated that

they obtained information about food and nutrition from health care providers and childcare

centers. Some parents (12 out 25, 48%) described television shows, searching in websites (e.g.,

using Google), and social media as sources of information to learn about diet and lifestyle for

their families (e.g., YouTube, Twitter or Instagram).

Parents described receiving information from public primary healthcare centers about

nutrients in foods, the association of obesity and food with diseases (e.g., sugar and tooth decay),

schedules to feed their children, and the weight status and growth of their child. They received

this information mostly from nurses, nutritionists, and physicians. The people described

information for planning meals and what foods give to the child, foods that the child cannot eat

without limits and those that are healthy. For instance, one parent said:

In the healthcare appointments, [the dietitian] gives a lot of information. When one is
going to start feeding [the baby], they give all that strategies, like guidance, if the child
does not want to try, give the child a taste although she does not like it . . . offer foods.
The dietitian gave a list of foods . . . that were preferred to give at the age of my daughter
[for complementary feeding], among them chard, a lot of foods we don’t usually eat
(Interview BS).

Also, parents appreciated when healthcare professional’s listened to parents’ concerns

and efforts in regard of feeding their children, they were open to clarifying questions and parents

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appreciated the suggestion to consider give small amounts of foods rather than limiting the total

child intake of certain foods. In addition, parents appreciated strategies of how to approach

behavioral changes in their children, the foods that were good for them, and the reinforcement of

having a mealtime structure for the child. One parent described how they wanted to feel

supported and listened to in order to promote a healthier weight in her child:

I tried to request appointments with another healthcare professional . . . who listens you. I
think that is good because it helps, because if I am guilty [of feeding my child wrongly],
how can I fix it? It’s not that I want my child to keep getting fatter. But being criticized,
“look how the child is” [as a dietitian said to her] it is sad. How can I help her [the child]
if I’m supposedly feeding her badly? So, I don’t know what to do, if I don’t receive help.
(Interview NC)

While most participants mentioned receiving some helpful information from dietitians

and other healthcare professionals, many parents also indicated that dietitians did not give them

satisfactory recommendations or helpful approaches to feed their children (18 out of 25, 72%).

Many participants indicated that dietitians told them what their children should eat

without considering the parent’s knowledge, expertise or opinion regarding their children, or the

impact of the changes suggested by the health care provider on the parent-child feeding

interactions, or the feasibility of their suggestions in the context of their family. For instance, one

parent said:

They healthcare professionals are rigid, squared [relating to inflexibility of the

recommendations]. If the child is passed 100g, they healthcare professionals complain
about it and blame me . . . if I give her a glass of milk and I don’t give her dinner, they
complain about it . . . I tell them, “If she has a problem of excessive weight, I prefer to
give her one thing and avoiding her to eat double dinner and the bottle milk”, and they
complain . . . it’s like nothing is enough. Then, when I go to the primary healthcare
center, I put like ear plugs [laughs]. I listen to them and I say “yes, yes, yes”. I just don’t
care anymore. (Interview CT)

Another parent described the difficulties of applying extreme food restrictions that a

healthcare professional indicated for her child:

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 For her [the dietitian], the child couldn’t eat anything, because everything is bad for him.
For example, she told me I had to eliminate two extra milks he drank in a day. Now, I am
giving him only one extra at night, but it’s inevitable [not giving him this milk], he can be
awake until 1 or 2 in the night telling me, “Mommy, I want my milk”. So, if I don’t give
him his milk, he doesn’t fall asleep . . . for her, it’s bad that he eats bread, it’s bad if he
eats that, and this it’s like, argh, I am tired of her. (Interview AS).

Also, some parents indicated that the dietary recommendations did not include

suggestions how to approach dietary changes in the child at this age or they felt that the

suggestions were inadequate. Some parents described that they did not know how to encourage

their child to eat healthy foods or discouraging them to eat too much. One parent explained her

conflict on how to address dietary recommendations:

They healthcare professionals have given me good explanations about it what foods to
give to the child. But, the problem is “How do I do it?” . . . I told her that the child is
good at eating fruits, she told me “although he is good at eating fruits and fruits are
healthy, large amounts also affect him. So, what can I give him, then? (Interview IL)

One parent described his interaction with a dietitian after following the nutritional
suggestions for the child to increase weight for a period of time:

[I told the dietitian] “I’m not going to do what you’ve told me about the serving sizes”
because she gave me a thing [a food measure] for servings. She told me “You are strong
willed”. But, it’s because I take care of him. “You see him one, two, three times a year
and for how long? 10 or 15 minutes? “I live with him. (PC interview)

While parents may feel uncomfortable with suggestions to feed their child given by

healthcare professionals, parents had a positive attitude to the information and approach of

childcare centers to work with parents to feed their child. All parents declared that have received

information about healthy eating and food intake from childcare settings. Most information that

parents mentioned as relevant consisted of eating habits specific in their child (22 out of 25,

88%). For example, teachers gave information about types of foods the child rejected, and/or that

the child eats less or more in the meals during the day. Thus, parents could monitor and

understand why the child was hungry or not later at home (e.g., the child did not want to eat or

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drink the milk). Based on the information given by the teachers, parents realized that the child

eats foods they did not know or the child rejected at home. For example, one parent said about

foods the child has been able to eat in the childcare center:

Coming to the childcare center has been good for the child, M. didn’t eat bread before
and they give him wholemeal bread in the childcare . . . he eats healthy foods here
[childcare] that he does not eat at home (Interview MR)

Most parents described being aware of the meal plan and mealtime schedules in the

childcare center. One parent mentioned to try to follow the schedule of the childcare to maintain

congruence at home and at the childcare:

“The teacher told us that after a week full of scheduled activities, we changed it during
the weekend . . . it’s complicated for them [the teachers] because some children arrive [to
the childcare center] without being hungry, or are hungry too early or too late . . . I prefer
to be coordinated with the schedule of activities the teachers have for children in
weekends. So it’s not difficult for the child [to adjust to the schedule of activities of the
childcare]. (Interview DC)

Another parent also mentioned about the schedule of meals and incorporating healthy

foods at home the child was eating in the childcare:

I used to give her the meal and a juice, but they [teachers/teachers aids] usually gave her
dessert and salad here [in childcare]. I began to give her smaller servings because she had
more diversity of food and I got used to feed her this way (Interview CT)

In addition, many parents indicated appreciation related to the opportunities for the child

to eat healthy food through giving them a healthy meal plan for the month, celebrations with

healthy foods, adequate serving sizes for children their age, among others (15 out of 25, 60%).

For example, one parent indicated that the childcare center had a role in encouraging the child to

eat healthy foods that the parent did not model eating at home: “It was a good idea the children

bring fruits to share, as I told you I am not good at eating fruits [to encourage the child to at

fruits]” (Interview AS).

One parent appreciated the serving sizes of their child during childcare hours:

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 “I only know that here, they [people who work in the childcare center] give the calories
that are appropriate for a child . . . I know that she [my child that has overweight] is going
to eat enough and what she [nutritionally] needs during childcare hours . . . sometime I
give her more [than she needs]. This is why I think here [in the childcare] is better.
(Interview MP)

Parents described feeding practices to explore new foods and promote autonomy. Parents

felt supported in the childcare center because they offered a model of good eating behaviors.

They praised the child for eating their meals, and reasoned with children about eating healthy

foods in order to solicit the child’s involvement (e.g., teachers and children prepare fruits to eat

in the childcare). However, some parents indicated that some teachers fed children by the mouth

or allowed them to eat too little or too much. One parent perceive some issues about feeding

practices affecting children to eat too little or too much in the breakfast:

There are children that don’t have breakfast because the teachers ask [children] “who
wants to have breakfast?” and obviously children are going to say “no, I don’t want I
already had breakfast” . . . there are children who lie [about they had breakfast at home].
S. has said he has had breakfast, but he never has breakfast at home . . . Sometimes the
children drink the milk of children who didn’t drink it. (Interview AG)

From their surroundings, all parents mentioned identifying food labeling, especially a

food warning label. Most parents (20 out of 25, 80%) indicated that these warnings labels were

helpful to identify foods with less of the nutrients that affect negatively the health. Critical

nutritional characteristics were described by parents when saw the food warning labels

describing calories, sodium, sugar and fats. Some parents (5 out of 25, 20%) also indicated that

foods with high number of signs were given in less frequency and amounts if they bought or had

them at home. One parent explained the benefit of having a food warning label on the packaging:

It is good that this [food warning labels] has been implemented because you see
everything that the food actually has . . . It has helped me because I prefer the things with
no food warning labels or less of them. (Interview MP)

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 A few parents (7 out of 25, 28%) described how their child identified these signs, and

this led the parent to pay attention to them or buying foods with less food warning labels. For

instance, a parent commented: “It hasn’t influenced me, but it has influenced the children. The

children say: “It has three food warning labels!” [like it is too much]. So, I tell them “Ok, we are

not going to buy this one (Interview AG).”

Two parents (2 out of 25, 8%) indicated that these food warning labels were not useful to

select foods because all foods said it has some critical nutrient that was high. One of these

parents mentioned:

It hasn’t helped much. I don’t like it [food warning labels] because all of them are high in
something [laughs]. I mean, it’s good because one knows what [nutrients] the foods have .
. . but all foods have them [food warning labels]. We don’t know what to eat anymore
[laughs]. (Interview NC)

While some parents (6 out of 25, 24%) identified food warning labels, they did not consider them

to choose their foods. Few indicated that the price of food items were more relevant than food

labelling (2 out of 25, 8%). One parent mentioned: “We actually buy the yoghurts that are the

cheapest, we don’t pay attention whether it has too much sugar . . . in fact we flip the food

package [so we can’t see the food warning labels]” (NB interview).

Discussion

This study explored factors that influence how parents feed their young children, and

specifically focused on Chilean families residing in low-income neighborhoods in Santiago,

Chile. During the crucial period of preventing childhood obesity, there are three themes that

reflect parents’ reasons to feed their children: 1) parent and child characteristics and the feeding

dynamics; 2) family complexity and challenges; and 3) parents’ health knowledge.

Parents’ childhood experiences, children’s characteristics, and the parent-child interactions

all influenced how parents feed their child. Parents’ experiences while growing up and concerned

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parenting were influential to the development or acquisition of beliefs, goals, and meaning

related to feeding their children. Parents believed that their child should eat healthy, and that

diverse foods were necessary to promote healthy growth. In addition, parents’ goals for feeding

their child involved making the child happy, conveying love, and promoting child’s healthy

growth. These beliefs have been also shared by parents from the United Kingdom (UK) (Carnell,

Cooke, Cheng, Robbins, & Wardle, 2011).

A belief that parents disregarded was forcing the child to eat everything on their plate.

While it was frequent in the past, it is currently perceived as unnecessary. This change of beliefs

suggests a cultural shift to adopt an approach that is responsive to children’s signals related to

food intake. This finding is relevant given that parents can stimulate or interfere with the child’s

capability to self-regulate their appetite (Frankel et al., 2012). Parents in our study did not force

their children to eat. Instead, parents checked whether the child did not want to eat anymore, or if

the child indicated they were hungry, the parent gave them the rest of the meal. Therefore,

disregarding coercive feeding practices, and instead focusing on monitoring the child’s

communications about hunger suggests that parents are applying responsive feeding practices

that are beneficial for their child (Engle & Pelto, 2011). Other aspects of child development also

indicated that parents are responsive to their child’s development and contingent transition from

early education programs in childcare centers to elementary school. Parents were aware that the

child was independently learning to eat appropriate amounts and healthy foods. The awareness of

such learning environments influenced the goals of feeding the child; the parents focused on

developing the child’s independence and competencies to eat in preparation for a new

educational context.

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 One salient aspect related to parents feeding their children was the feeding dynamics. In

that, the child directly influenced parents’ feeding practices. Parents were feeding their child

according to the child’s food preferences, appetite, and temperament, among other dynamics.

Thus, these mutual influences reveal adjustments that are unique to the parent-child dyad. For

instance, parents who perceived their child to be a good eater or to be overweight reacted by

restricting foods, while parents of children who were slow to eat gave more frequent meals that

the child liked to encourage food intake.

Parents’ reactions to their child’s characteristics, such as appetite or temperament, has

been reported in developed countries (Carnell et al., 2011). This dynamic aspect in parent

feeding practices has been previously suggested in association with practices, such as food

restriction and practices based on child BMI z-scores. Parents who have overweight children

may restrict foods to prevent worsening of the child’s condition (Shloim et al., 2015). A

longitudinal study in preschool children has indicated that parent food restriction of energy-dense

foods and beverages has been associated with lower child BMI z-scores after a three-year follow

up (Campbell et al., 2010). Another experimental study indicated that overweight girls ate more

in absence of hunger when parents restricted foods (Leann L. Birch et al., 2003). Thus,

considering individual characteristics of the dyad and their interactions may be helpful to further

explore feeding factors affecting children’s eating behaviors and weight status.

In our study, parent and child feeding dynamics were complex given the large number of

feeding practices and their characteristics being mutually influential, family members added

complexity to the feeding of a child. Grandparents, mothers, fathers, and the child her/himself

are often involved in these interactions. In our study, parents assigned a particular role to

grandparents to follow a meal and snack routine, offering for the child to taste homemade meals,

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and preparing healthy food, such as fruits and vegetables with different recipes to increase the

child’s intake. Based on the advice of grandparents, and/or observing grandparent-child feeding

interactions, parents learned feeding practices to use with their child.

Our findings align with previous studies describing an intergenerational influence in

knowledge related to foods and traditions (Johnson et al., 2010; Moisio, Arnould, & Price, 2004;

Jain et al., 2001). Similar to our study, Johnson et al. (2010) described that mothers in the United

States (US) were influenced by grandmothers when it came to feeding their child, and as a result

of their own rearing experiences. In another study, grandparents were considered to have a key

role in the family as a result of the food environment they created for the child (Speirs, Braun,

Zoumenou, Anderson, & Finkbeiner, 2009); their role has been related to better child growth

outcomes in children under the age of three (Meehan, Helfrecht, & Quinlan, 2014). Also, in a

recent qualitative study in Chile, grandmothers characterized the interaction with the child as

warm and child-centered during the time they cared for them (Ortúzar, 2018).

In other cultures, like in China, grandparents offering foods to children also had a strong

meaning of conveying love (Jingxiong et al., 2007). In our study, preparing and offering foods to

the child was described as a way for parents and grandparents to convey affection. However,

some of the grandparents’ feeding practices were in opposition to parents’ rules and limits.

Similar to our results, Farrow (2014) described that grandparents reported positive and negative

feeding strategies compared to mothers. Some positive feeding strategies were maintaining

healthy foods at home, while negative strategies were discouragement of energy balance and

variety, and more meal restrictions for weight monitoring purposes (Farrow, 2014). In our

findings, most grandparents created opportunities to diversify the diet and expose the child to

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healthy foods. However, they also provided or prepared fried foods, salty snacks, and sweets,

making difficult situations for parents interested in promoting healthy eating for their child.

The extent to which grandparents affect children’s diet habits and weight status has

become more relevant given the increased time of grandparent care. Grandparents take care of

grandchildren when parents need support (Glaser et al., 2018; He, Li, & Wang, 2018). In Chile,

life expectancy is 80 years for both genders (Departamento de estadísticas e información de

salud, n.d.), and the tendency is that the population is aging. Among older adults, 60% live with

their children and 38% live with grandchildren, while 24% of older adults’ time is dedicated to

taking care of grandchildren (Instituto de Sociología Universidad Catolica, 2017).

Recently, results of a meta-analysis suggested that child BMI z-scores and grandparental

care were not associated (An, Xiang, Xu, & Shen, 2020). Furthermore, the literature about

grandparental care and child eating behaviors is mixed (An et al., 2020). Research suggests a

positive association between grandparental care and unhealthy and sugar-sweetened drinks, a

negative association with irregular mealtimes, or no association was found (An et al., 2020).

However, An et al. (2020) found a 30% increased risk of children to be overweight or obese

when grandparents supervised their grandchildren (An et al., 2020). These mixed results may

indicate a lack of understanding about the potential mechanisms linking grandparent behaviors

and a risk of the child being overweight or obese. Therefore, our study provides valuable

information about grandparents’ feeding behaviors, beliefs, and knowledge in Chile, which can

provide insights on whether the grandparents will have a positive or negative effect on children’s

diets.

In the two-parent families interviewed in our study, the participants described how

fathers held an active role in feeding their child (e.g., cooking, serving meals, and preparing

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foods). Fathers fed their child while mothers were unavailable because of work, studying, or

other tasks at home. Fathers were perceived as cooperative in mother’s decisions about offering

adequate foods for their child and limiting the food consumption of sweets and snacks.

Furthermore, parents did not want to pressure their child to finish their plate. These findings may

indicate generational changes in terms of coercive feeding practices, and cultural changes in the

distribution of parental responsibilities, specifically those related to feeding their children.

Fathers were not merely acknowledged as “providers,” and their father’s role in parenting their

young children is becoming more visible in Chile. It may be relevant in diet and weight-related

outcomes in the child, who is developing eating habits and other lifestyle behaviors; this is

especially important because, currently, more women are working than in the past (Calvo &

Maffei, 2011).

A higher visibility of a father’s role in parenting may also be related to the Chilean

governmental initiatives to boost women’s participation in the job market and entrepreneurship

projects (Calvo & Maffei, 2011). Additionally, mothers are allowed by the Chilean Law 20.545

to transfer post-natal time to fathers for caring for the child after giving birth (BCN, 2016).

Although only a small number of fathers request this benefit, this law is an effort from the

government to support attachment and a loving relationship between fathers and their children

from an early age (Gobierno de Chile, 2019). Thus, fathers’ involvement in parenting may be

greater and more acceptable than in the past.

In line with our results in which Chilean parents are perceived as being involved in

feeding their children, other cultural ethnicities, such as African American fathers, have also

reported being involved in feeding their child by cooking, preparing, or giving meals, and/or

eating with the child. In another study, fathers perceived themselves to be responsible for feeding

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their child and applied more diet restrictions and pressure to eat, and they reported more concern

about their child being overweight (Mallan et al., 2014). Thus, as in our study, literature on

feeding practices and father’s concerns regarding child nutritional issues suggest the fathers’

influence on their child eating behaviors.

Given that fathers were involved in making decisions in feeding the child, mothers

recognized some differences of feeding practices between them and their partners/spouses.

Discordances and agreements between the mother and father may impact eating behaviors in the

child differently (Fraser et al., 2011). In a recent systematic literature review, four studies

reported that when there is agreement on feeding styles and practices between fathers and

mothers, the children chose healthier foods (Litchford, Savoie Roskos, & Wengreen, 2020).

Nevertheless, fathers’ feeding practices and the extent of this influence on the child to eat

has only recently emerged as an area of research. Some research indicates an important

participation of parents in feeding. In the US, for 40% of parents, both parents participated in

feeding their children, and a father’s eating out with the child had been associated with the

child’s intake of sugar-sweetened drinks and fast food (Guerrero, Chu, Franke, & Kuo, 2017). In

Australia, 42% of fathers feed their child half of the time or more. Similar to our results, fathers

also participated in making decisions regarding the right food for their child (Mallan et al.,

2013).

The interpersonal dynamics between the parent and the child and other family members

creates a complex family context for feeding the child. Added to this family complexity, parents

also considered other contexts of the family that affect their feeding practices. For example,

limited income resulted in the development of a feeding structure for their child. More

specifically, parents considered children’s preferences to avoid wasting healthy foods. Also,

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parents provided enough meals for their families by seeking food suppliers, such as those in

open-air markets, to buy enough healthy foods for optimizing the family income. Parents

indicated that constrained family income led them to prioritize their money to buy essential food

for their families, while they limited money to buy more expensive food and meals, considered

mostly unhealthy, reserving those for special occasions and family gatherings. On the other hand,

limited time potentially reduced the quality and scheduling of meals because the parents

prepared easy-to-make meals that were not necessarily healthy. Thus, limited income and limited

time led parents to use feeding strategies contingent to their situations, positively and negatively

affecting the opportunities of the child to eat healthy food.

The financial constraint of lower income families is associated with the high income

inequality in Chile (Paredes et al., 2016). Related to the participants in this study, financial

constraints to buy healthy foods have been previously described in families living in low-income

neighborhoods (Bell et al., 2013). Chilean mothers of children 12 years old and older have

reported lacking money to buy the foods they wanted for themselves (Galvez Espinoza et al.,

2018). Mothers juggled buying food for their children and covering expenses for the household

(Galvez Espinoza et al., 2018). Families residing in low-income neighborhoods in the US have

also pointed out limited access to healthful food options, which was characterized by high prices,

difficult access, and reduced availability of healthy foods to buy (Evans et al., 2015). In Chile,

free markets allow parents to have access to a variety of fresh fruits and vegetables at reasonable

prices (Tonacca & Escobedo Gonzalez, 2013), which is central to having a healthy diet in

families with limited incomes. Therefore, the financial context and perceptions of time also were

relevant for parents to feed their children.

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 Regarding participant’s health knowledge, parents described community resources,

including primary healthcare centers and childcare settings, as information sources. Primary

healthcare centers provided information about food and nutrition. However, parents perceived

the nutritional counseling or overweight treatment for their children as prescriptive, restrictive,

unidirectional, and lacking in consideration of the parents’ needs to feed their children.

In our study, parents described not being receptive to healthcare professional’s

suggestions, because the suggestions did not seem feasible in terms of their beliefs regarding the

best strategies to feed a young child. Specifically, the parents felt the healthcare professionals

were not sensitive to their child’s appetites, characteristics, and her/his reactions when parents

applied restrictions suggested by healthcare professionals. Although healthcare professionals

delivered messages regarding optimal foods, amounts, and mealtimes for children, this

information was ineffective to improve the child’s diet. The child’s characteristics in addition to

a stressful family context are perceived as barriers for parents to modify the child’s eating

behaviors because they perceive they are making efforts to feed their children healthily, just not

at the pace of healthcare professionals.

Primary healthcare professionals are part of the public system for about 75% of the

population in Chile (Ministerio de Salud de Chile, 2016a). In addition, the National Policy of

Food and Nutrition states that the nutritional guidance or counseling given by professionals

should be person-centered and respectful of the person’s expectations and needs (Ministerio de

Salud de Chile, 2017b). This approach suggests the need for building relations between the team

of healthcare professionals and the individual members of families and the broader community.

To achieve this goal, the National Policy of Food and Nutrition proposes humanizing the

interaction between the family and healthcare professionals, which requires building cultural

219
competence and empowering individuals (Ministerio de Salud de Chile, 2017b). However, the

findings from this research regarding the relation between primary healthcare providers and

parents suggests that this relationship is not developing an empowering way yet. In our findings,

a nutritional or health counseling focused on what parents should do and the lack of

consideration of parents’ opinions, values, and beliefs reflects a professional-centered service

toward the community. Therefore, this research suggests that families are not feeling supported

or empowered as required in the National Policy of Food and Nutrition (Ministerio de Salud de

Chile, 2017b).

Limitations of the nutritional counseling or guidance for parents of young children may

relate to the lack of training in cultural competence and child development for healthcare

professionals. This may occur in part because the curriculum of dietitians, nurses, and other

healthcare professionals in college is more focused on healthcare goal–centered services. This

training focus may lead to ignoring the needs, culture, and socio-economic contexts of families.

Cultural competence and child development training for healthcare professionals who are

working in the public health system may be beneficial to better support parents. More research

evaluating the training of dietitians and work-training consistent with family needs and human

development will be helpful to mobilize improvements to nutritional education.

While this kind of training may be helpful, it is also necessary to develop the curricula for

healthcare professionals in parent feeding practices and styles based on evidence (Betancourt,

Green, & Carrillo, 2002). Our study provides an understanding of what influences feeding

practices and child development, which can inform the design of nutritional programs and take

into account parents’ perspectives and their particular challenges for feeding their children, as

has been previously proposed (Bentley et al., 2014). Other studies have also involved a formative

220
research to implement culturally congruent programs. For instance, Valencia et al. (2016)

explored the challenges that healthcare professionals face when talking to parents about infants’

weight status and growth due to low levels of health literacy and understanding of child growth

charts. While parents indicated the challenges of feeding their children and the lack of

understanding of child growth charts as a monitoring mechanism, they were interested in

learning about the charts (Valencia et al., 2016). Our study is a formative research in child

development and nutritional issues that can be considered for developing educational programs.

Understanding parents’ perspectives to feed their children can help healthcare professionals to

improve interactions with families in topics that are relevant for them.

This research has shown that parents also learn about food, nutrition, and health through

social media and by navigating the internet. A previous study has also described that parents of

young children searched for health information from websites, which may conflict with

messages delivered in healthcare centers (Perkins, Cunningham, & Taveras, 2015). Thus, paying

attention to the health information environment of parents may be necessary given the access that

Chilean families have to information via the internet.

Meanwhile, in our study childcare centers were considered a relevant community

organization for parents to obtain valuable information and to learn about their child’s eating

behaviors in the centers. The creation of a food environment to promote healthy eating during

childcare hours was helpful for many of the families. According to parents, childcare settings

helped children to learn about eating healthy by exposing the child to a more diverse diet, which

is a key element to increase child acceptance of foods (Cooke, 2007). Some parents learned that

their children have a higher acceptability of new foods in the childcare settings than at home.

This difference of children eating more diverse foods in childcare centers has been observed in a

221
previous study (Luchini, Musaad, Lee, & Donovan, 2017). Therefore, childcare centers are an

important organization to help parents work on promoting healthy feeding practices. Childcare

centers practice feeding styles in the categories of structure and autonomy, which are beneficial

for socializing children to develop healthier eating habits (Vaughn et al., 2016).

Childcare settings of the Chilean National Board constitute an important governmental

social program, where around 160,000 children from low-income families receive early

education (Mansilla Bravo, Reveco Vergara, & Mena Tapia, 2015). As the program focuses on

an integrated development in preschoolers, it includes nutritional meals that are developmentally

adequate (Gobierno de Chile, n.d.-b). In addition, teachers are respectful of culture and parents’

decisions in their families, enacting cultural competence, which is a key element to interacting

with families (Anderson et al., 2003; Gobierno de Chile, n.d.). Therefore, childcare centers

managed by the government seem to constitute a bridge between government policies and the

community to promote appropriate feeding practices to help prevent childhood obesity in young

children.

Influences of the broader environment on feeding practices, such as culture and food

marketing regulations, were also mentioned by parents in this study. Among these influences,

parents described knowledge about obesity risks in the child, and they did not intend for their

child to have these issues. However, some parents thought that the overweight status or obesity

of their child was not a concern because they believed that young children would improve their

weight status as a result of natural growth, or the child would eventually lose weight when she/he

get sick. Additionally, parents were not concerned if the child was active or if they were not

developing extreme cases of obesity. Cultural misbeliefs regarding children’s weight status is

highly prevalent across cultures, especially with parents of children under the age of six

222
(Heitzinger et al., 2014; Lundahl et al., 2014). Similar to this study, it has been reported that

parents believe their young children will improve their weight status as they get older, or their

children are not affected by their overweight status because they were physically active

(Chatham & Mixer, 2019).

In relation to Chilean food regulations, it was relevant for some parents to choose foods

after considering food label warnings (e.g., one food label warning that one critical nutrient

exceeded the allowed amounts of sodium), while for other parents, prices were a decisive factor

to select food regardless of these warnings. This structural measure is considered a key to

controlling the urgent obesity problem in Chile (PAHO-FAO, 2017). For some parents in this

study, food marketing regulation enforcement has had a positive effect in creating a better home

food environment. A governmental report has reported that a majority of the population approves

of the policies to use food warning labels (Gobierno de Chile, 2017). It appears that recent food

regulations have raised awareness in the Chilean population. For example, most college students

in Chile were aware of food regulations, but were not prepared to modify their eating habits

(Durán et al., 2020). In our study, some parents indicated they were limiting the consumption of

foods with food label warnings. However, further research regarding food choices is needed to

determine whether the warning labels are more influential compared to other factors, such as

limited incomes.

Strengths and limitations. This study offers insight into the Chilean parents’

perspectives on the influences of their feeding practices with their three to five year old children.

The insights gained from this study may provide directions on how to overcome barriers before

implementing necessary actions to address childhood obesity in the feeding domain. This study

223
has been one of the first attempts to thoroughly examine the factors that parents perceive

influential in the feeding practices during a crucial developmental period of their children in the

context of Chile. Additionally, the use of a photo-elicitation interview is a useful method for

collecting data in that it reduced barriers related to education or literacy during data collection;

therefore, it may be applied to similar research in other contexts (Najib Balbale, Schwingel,

Chodzko-Zajko, & Huhman, 2014; Jenkings, Woodward, & Winter, 2008).

A limitation of this study is that its findings may be applicable in the specific context of

Chilean families of three to five year-old children attending childcare centers. Moreover,

although the sample is small (n = 25) and no new information was identified after interview #22,

the purposive sample involving parents with diverse feeding styles led to diversify the parents’

attitudes in their feeding perspectives. Despite these limitations, the provided description of the

parents’ sample should help other researchers and policymakers to determine the conclusion of

this study may be valid in contexts and samples of similar characteristics.

Conclusions and Implications

This study provides useful information about factors that influence parents regarding the

eating socialization of their child. Parents provide a fundamental role in determining feeding

practices for their young children, and grandparents contribute significantly to the process as

well. Family interactions and the context in which families live also influence how parents

organize the food environment, creating routines and schedules for the child to eat. Parents

applied feeding practices based on: (a) their limited incomes and time; and (b) their child’s

characteristics and family dynamics in a broader context, including culture, information, and

regulations. Also, parents applied knowledge from their own family experiences and acquired

knowledge from community organizations to make decisions regarding how to feed their

224
children. Different influences led to distinctive feeding practices, and most influences provided

structure for child feeding practices; these practices involved autonomy and competence for the

child as they learned eating habits.

More research is needed to determine the unique effects of each of the factors at the

individual, family, community, culture, and country levels, all of which influence parents’

feeding practices. Interactions and paths of associations between the effects in eating behavior

and weight status of the child need to be investigated as well. The information regarding these

diverse and multi-level influences on the parents can help to tailor existing public health

programs to promote a healthy child development to align with the reality in which Chilean

families live.

225
 Tables
Table 5.1

Socio-demographic, nutritional characteristics and feeding styles of the participants

Characteristics Total participants

n = 25
Parents
Age in years (Mean ± SD) 32.1 (7.6)
Educational attainment, n (%)
Elementary 3 (12)
High school 13 (52)
Vocational 3 (12)
Higher education 6 (24)
Work status, N (%)
Unemployed 5 (20)
Currently working n (%) 20 (80)
Housing
Own a house 10 (40)
Rent a house 5 (20)
Live with other family members 10 (40)
Household size mean (range) 5 (2 - 14)
Type of caregiver, n (%)
Mother 24 (96)
Father 1 (4)
Marital status n (%)
Two parent family 20 (80)
One parent family 6 (24)
Type of health insurance
Public 8 (78%)
Private 2 (8%)
Both 5 (20%)
Weight statusa, n (%)
Underweight 1 (4)
Normal 3 (12)
Overweight 8 (32)
Obese 13 (52)
Siblings (mean, range) .8 (0-3)
b 31 (7.1)
BMI (Mean ± SD)
Feeding styles
High demanding/high responsive 5 (20)
High demanding/low responsive 6 (24)
Low demanding/High responsive 9 (36)
Low demanding/Low responsive 5 (20)
Children
Age in years (Mean and range) 3.8 (3 - 5)
Child sex, n (%)
Girls 10 (40)
Boys 15 (60)
c
Categorization weight status
Normal weight 10 (40)
Overweight 5 (20)
Obese 10 (40)
a
Parent weight status for adult population based on Body Mass Index (BMI), underweight (BMI lower than 18.5kg/m2),
normal weight (BMI between 18.5 and 24.9 kg/m2), overweight (BMI between 25 and 29.9 kg/m2), and obese group
(BMI above 30 kg/m2) (WHO, 2018).
b
BMI: Body Mass Index in kg/m2
d
Categorization of weight status according to WHO Growth Standards (2006) for children of five years old or younger,
and WHO Growth Standards (2007) for children between five years and one month and 5 years and 11 months

226
Table 5.2

Summary of study results: Factors influencing parental feeding practices with preschool
children in Chile

Theme Aspects influencing parent feeding practices

(1) Parent and child Life experiences and goals for feeding their children influenced parents to do
characteristics and the following:
the feeding  Perceived the act of feeding their child and sharing family meals and
dynamics foods together based on love and happiness.

 Promoted child independence to eat sufficiently and adequately in the

absence of parents.

 Avoided explanations about food’s benefits to encourage the child to eat.

 Rejected the outdated belief that the child has to “clean the plate” (eat
everything on the plate) and monitor how much the child eats.

 Gave the child homemade meals, a variety of healthy foods/meals, and no

sweets.
 Avoided nutritional-related health issues in the child by giving them
appropriate food because the parents or family members have had them as
well.
Parents reacted to certain child characteristics and exhibited the following
feeding practices:
 When the child ate too little or too slowly, parents prepared the child’s
favorite meals more frequently and encouraged non-coercive eating. In
contrast, children who were extremely good eaters led parents to
implement rules and limits, a meal and snack routine, and to provide
guidance for healthy eating choices.
 Tantrums led parents to bribe the child to do something or to use foods to
soothe the child.
(2) Family  Grandparents supported parents by following the child’s meal schedule,
complexity and involving the child in food preparation, and eating homemade meals and
challenges to feed varied healthy foods.
the child  Parents learned to encourage their child to eat a variety of foods and cook
traditional meals from grandparents.
 Grandparents showed affection by giving the child foods and doing the
cooking. Some parents did not like grandparents giving unhealthy foods to
their child.
 Fathers cooked, prepared or served foods/meals to keep the meal and
snack routines of the child in most two-parent families.
 Fathers generally supported the mother’s rules/limits to feed their child
and discussed them with the mothers.
 There were differences in feeding styles between mothers and fathers.

227
Table 5.2 (Cont.)

Themes
(2) Family  Limited incomes influenced parents’ possibility to bring home necessary and
complexity and healthy foods for the family meals at the lowest price possible.
challenges to feed  As a healthy food choice, parents bought fruits, which were those the child liked
the child to avoid food waste.
 The consumption of special foods or unhealthy meals was limited to family
gatherings during weekends and special occasions.
Lack of time
 The lack of time influenced parents’ food preparation in that it reduced the
quality of meals; there was no decoration or arranging of foods for their child;
the meal and snack schedule was altered. Parents had to rely on other family
members for making more elaborated homemade foods and maintaining the
child’s meal and snack schedule.
The physical environment
 Multiple co-residing families led to more food availability at home for the child
to try and meal and snack routine changes by repeating meals for the child.
 Technology was used to distract the child and make her/him eat what she/he did
not like; electronic devices at meal times is part of the family’s and the child’s
habits, as these make the children eat without difficulties.
(3) Parents’ health  Parents’ knowledge about nutrients, foods and diet-related diseases led them to
knowledge establish rules and limits for favorite foods as well as to encourage the child to
eat beneficial foods.
 Parents knew that obesity impacted their children’s health negatively. However,
parents of overweight children did not modify their children’s diet because they
believe that excessive weight is not a problem in this age, that a child can lose
weight when they get sick, that growing up will correct overweight, and that
their child’s breathing and physical condition are normal compared to severe
overweight children they have seen.
 From childcare centers, parents learned about their child’s eating behaviors,
teacher’s strategies to feed the child, and opportunities for the child to eat
healthy so that parents could monitor child eating.
 From primary healthcare centers, parents learned about healthy eating, meal
schedules, and restrictive dietary recommendations. Parents preferred
establishing rules and limits instead of applying extreme restrictions suggested
by healthcare professionals.
 Participants also needed help to improve their child’s diet while considering
family challenges.
 Warning food labels of critical nutrients such as sodium, sugar, or fats
influenced parents to reduce accessibility of those foods, especially those with
several warning labels. However, some parents were more interested in pleasing
their child or buying food based on low prices rather than in considering the
multiple labels on those foods.

228
 Figures

Figure 5.1

Data collection procedures involving face-to-face interviews. FS: Feeding Styles;

CFSQ: Caregiver’s Feeding Style Questionnaire

229
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 Chapter 6

Integrated Conclusion and Future Directions

Currently, Chile is a country with a high prevalence of obesity in young children. Given

that the prevalence of obesity increases with age, early prevention is crucial. The nature of

parenting in the feeding domain is multifaceted, and coupled with the misperceptions of child

weight status; we can begin to understand how these factors relate to the weight status of young

children in Chile. Parents’ feeding styles, parent feeding practices, and underestimation of child

weight status exemplify family and cultural factors associated with child weight status.

Feeding styles did not moderate the relation of underestimation of child weight status on

child BMI z-scores (Study 1). Underestimation of child weight status and demandingness were

independently associated with child BMI z-scores. The parents who underestimated their child’s

weight status had children with higher BMI z-scores. On the contrary, more demanding parents,

who encouraged their children to eat more, had children with lower BMI z-scores (study 1). The

strong association between underestimation of child weight status and child BMI z-scores is

particularly relevant because this misperception was more than two-thirds in parents of children

categorized as overweight or obese (Study 2). Given the relevance of underestimation of child

weight status, the factors that emerged that would increase the likelihood of underestimating

child weight status were being the parent of a boy, and the increase of a child’s BMI z-scores

(Study 2).

Furthermore, the reasons why parents apply feeding practices were explored from

parents’ perspectives, given the permeation of the context and culture in this topic (Hughes et al.,

2006). Parents, who were mostly mothers, perceived a dynamic interaction between the

individual characteristics of the mother and child to determine unique adjustments to the child in

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the feeding situation and food environment. Added to these parent-child dynamics, fathers and

grandparents had essential roles in feeding the child in contexts characterized by limited incomes

and time. Also, the knowledge that parents had in terms of health and nutrition guided their

feeding practices. Community organizations, such as childcare centers and healthcare centers,

were supportive in promoting healthy eating behaviors in the child. Parents had a particularly

positive attitude toward childcare centers because the parents received information regarding

their child’s eating behaviors and how to approach feeding at home.

This research provides new and valuable insights about parenting in the feeding domain

and misperceptions of child weight status, all of which can influence the approach Chile takes to

combat childhood obesity. Future research should elucidate mechanisms involving

demandingness and misperceptions of child weight status and child BMI z-scores. Interactions

between key family members involved in feeding the child in contexts of limited income and

time should be further explored to promote parent feeding practices that lead to healthy eating

and development for the child.

Future Directions

There are diverse avenues to develop research on the feeding domain in Chilean families,

especially those that may be more affected due to disparities in the quality of the diet. Possible

steps to continue developing this emerging aspect in the context of Chile may be the following:

(1) identifying frequent feeding practices of parents with children in preschool years and the

association with child eating behaviors and other weight-related outcomes in the context of

feeding styles. Identifying these practices would help to assess to what extent these promote

children’s autonomy and improvements in children’s diet quality. Similarly, applying specific

feeding practices may help dis/encourage eating according to parent feeding styles; (2)

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examining the underestimation of child weight status and factors associated with it in a larger

sample of preschool children. Given the frequent underestimation of child weight status in

preschoolers, determining factors that are key for parents to improve perceptions of child weight

status and the risks associated with it may be key to improve the efficacy of programs addressing

childhood obesity. Additionally, future studies could determine potential associations between

feeding practices and underestimation of weight status in Chilean parents of overweight or obese

children specifically; and (3) identifying whether specific feeding practices and perceptions of

child weight status are associated with weight-related outcomes. Differences in feeding practices

according to the underestimation of child weight status in obese or overweight children can help

to differentiate mechanisms related to child overweight and obesity and parent feeding approach

in Chile.

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 Appendix A

Interview Script and Question Guide

Thank you very much for agreeing to participate in this interview with photos. My name

is Marcela Vizcarra and I am student at the University of Illinois at Urbana-Champaign. This

second interview of our study is for understanding how and why parents feed their children the

way they do. The main reason to conduct this study is because parents may use certain feeding

practices to encourage the child to eat, and we want to develop future programs that consider the

perspective of parents to promote interactions to promote a healthy weight for their children.

This interview is a chance to explore the food world in connection with your child. The

interview will be based on the photos you want to talk about, and I will be asking about them

too. I would like to audio record this interview using this digital audio-recorder so I can listen to

it later, when I write down my notes. No one outside our research team will listen to the

recordings. After my notes are finalized, I will erase/destroy the audio-recordings. If you want to

say anything that you don’t to be recorded, please let me know and I will be glad to be pause the

digital recorder. Do you have any question or objection about the recordings discussion? Also,

you can decide not to be recorded. It is fine too.

The discussion will take about one hour and we will not take any formal brakes. But,

please feel free to stop at any time to stretch or going to the restroom.

Once again thank you for participating in this second interview.

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 Interview Guidance

Family/Clan factors

 What is the favorite food of your child? How do you know it?

 What are the foods that s/he does not like or like less? How do you know it? Do you help

him to eat or s/he eats by himself? When a child can start eating by him/herself?

 How do you know she/he is full? How do you know when s/he is hungry?

 Are there things about feeding your child that you find fun or easy?

 Are there things about feeding your child that you find difficult to deal with?

 What goals do you have when you are feeding your child? What happens?

 Think about the times it has been difficult to feed your child. What was happening?

 What strategies do you use for feeding your child?

 Does your family or your husband’s family participate in feeding your child? Do you

think that your family or your husband/partner’s family influence the way your child

eats? When do they participate with your child (e.g., in the week or weekends)?

Culture

 Have you heard about healthy foods and habits? Are they important for you? How

important is for your child? How did you learn to introduce new foods to your child?

 How do you perceive the weight of your child? Why?

Community/Childcare Setting

 Have received education or any type of instruction about how to feed your child (e.g.

 How to respond to your child when he/she does not want to eat)? In the childcare? or in

your health care center where your child is usually attending?

 Do you know how your child is being fed in the childcare setting hours?

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Country

 Have you seen food packages with cartoons that your child like? (e.g., cereal, yoghurt).

 Do you select any food for your child in the last year based on the food labels (notes in a

black sign in the foods)?

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