Appetite 160 (2021) 105068

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Appetite
journal homepage: www.elsevier.com/locate/appet

Associations between parental perception of- and concern about-child

weight and use of specific food-related parenting practices☆
Katie A. Loth a, *, Nabila Mohamed a, Amanda Trofholz a, Allan Tate b, Jerica M. Berge a
a
Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
b
Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Little is known about the association between parental perception of their child’s weight as well as parent’s
Restriction current and future concerns regarding their child’s weight and a broad range of food-related parenting practices.
Pressure-to-eat This study used the first wave of cross-sectional data from the longitudinal Family Matters study to examine the
Modeling
relationships between parental perception of child weight status, parent concern for child’s current and future
Child food control
BMI
weight and parent use of different types of food-related practices. Parent/child dyads (n = 150) were recruited
Weight status from primary care clinics. Multiple regression models were fit to examine cross-sectional relationships between
Overweight parental perception and concern for their child’s weight and food-related parenting practices (food restriction,
Childhood obesity pressure-to-eat, food control, food monitoring, nutrition education, and parent modeling). Parents who perceived
Parent feeding behaviors their child to be underweight had lower scores for food restriction than parents who perceived their child to be
overweight. Parents who reported concern about their child’s current weight reported higher scores for food
restriction and monitoring than parents who were not currently concerned. Parents who reported concern about
their child’s future weight status reported higher scores for pressure-to-eat and monitoring than parents who
were not at all concerned about their child’s future weight status. The relationship between parental perception
of child’s current weight status and parent use of food restriction, pressure-to-eat, and overall food control was
modified by child sex. Overall, results suggest that parent’s perceptions of and concerns about their child’s
current and future weight status were correlated with their feeding approaches. Health care providers may want
to consider providing anticipatory guidance for parents that have concerns about their child’s weight by teaching
them about positive, evidence-based ways they can engage in healthy food-related parenting practices.

1. Introduction
There is a growing body of evidence that the family environment
plays an integral role in child dietary intake and weight status (Berge
et al., 2012; Berge et al., 2013; Birch & Davison, 2001; Burges­
s-Champoux et al., 2009; Cromley et al., 2010; Cullen et al., 2001; Gable
& Lutz, 2000; Kitzman-Ulrich et al., 2010; Kral & Rauh, 2010; Loth et al.,
2016a). Parents have the opportunity to positively influence their chil­
dren’s weight status and dietary intake by providing healthful foods at
home, teaching their children about nutrition, and modeling healthful
food choices (Arcan et al., 2007; Birch; Birch & Fisher, 1998; Cromley
et al., 2010; Cullen et al., 2000; Davison & Birch, 2001; O’Connor et al.,
2010). Food-related parenting practices, including encouraging children
to eat healthful foods and restricting intake of palatable snack foods,
have also been identified as potentially significant determinants of
children’s dietary intake and weight status (Ek et al., 2016; Faith et al.,
2004; Loth et al., 2014; Rollins et al., 2016). Research has shown that
parents often adopt controlling feeding practices (e.g., food-restriction
and pressure-to-eat) in response to concerns about their child’s
weight. For example, parents who are worried about their child gaining
weight might place restrictions on the amount of sweets consumed by
that child, and parents concerned that their children’s picky eating
patterns will result in them being underweight, might respond by
requiring them to eat all of the food on their plate during mealtime.
Unfortunately, while parents likely engage in these controlling behav­
iors in an effort to improve their children’s dietary intake or weight

Study data was presented as a poster at the Annual Medical Education Conference in Philadelphia, PA, April 19, 2019; and 14th Annual Women’s Health
☆

Conference in Minneapolis, MN, October 7, 2019.

* Corresponding author.
E-mail address: kloth@umn.edu (K.A. Loth).

https://doi.org/10.1016/j.appet.2020.105068
Received 22 March 2020; Received in revised form 23 November 2020; Accepted 7 December 2020
Available online 24 December 2020
0195-6663/© 2020 Elsevier Ltd. All rights reserved.
K.A. Loth et al.
status, the results associated with these behaviors on child outcomes are
mixed.
Laboratory, cross-sectional and prospective research suggests chil­
dren exposed to higher levels of controlling food-related parenting
practices (e.g. high food restriction, high pressure-to-eat) are more likely
to engage in unhealthful eating behaviors (e.g. emotional eating, eating
in the absence of hunger) (Birch & Fisher, 1998; Fisher & Birch, 1999;
Loth et al., 2014), and have overall less healthful dietary intake (e.g.
more frequent consumption of palatable snack foods, less frequent
consumption of fruits and vegetables) (Fisher & Birch, 1999; Loth et al.,
2016a). Further, studies have revealed controlling food-related
parenting practices to be significantly and positively associated with
child weight status (Birch & Fisher, 2000; Costanzo & Woody, 1985;
Fisher & Birch, 2002; Joyce & Zimmer-Gembeck, 2009; Loth et al.,
2013; Loth et al., 2014). Based on these study findings, it would seem
that controlling food-related parenting practices have a detrimental ef­
fect on child weight and dietary intake patterns (Birch; Faith et al., 2004;
Loth et al., 2014; Vaughn et al., 2016; Loth, 2016). However, several
studies have suggested parental control might actually lead to improved
dietary intake and reduce unhealthy weight gain over time (Campbell
et al., 2010; Faith et al., 2004; Farrow & Blissett, 2008), while other
studies have found no significant associations between food-related
parenting practices and child weight and dietary intake outcomes
(Campbell et al., 2010; Faith et al., 2004; Spruijt-Metz et al., 2002;
Spruijt-Metz et al., 2006).
More recently, researchers have been encouraged to expand their
conceptualization of food-related parenting practices to include less
controlling food-related parenting practices, such as parent modeling of
healthful food intake, teaching children about nutrition, and monitoring
their dietary intake (Vaughn et al., 2016). While the individual impact of
these different parenting practices has been researched separately, a
recent article by Vaughn and colleagues encouraged researchers to
explore how this broad range of food-related parenting practices might
work together to impact child dietary intake and weight-related out­
comes (Vaughn et al., 2016). Specifically, Vaughn posits that a parent
has the potential to impact their child’s food environment in a wide
variety of ways, both highly controlling and less controlling (Vaughn
et al., 2016); research that accounts for a broader array of parental in­
fluences that occur within the same household is needed, as it might help
to explain some of the inconsistencies in the literature to date.
Food-related parenting practices are thought to be goal-oriented
behaviors, meaning that parents engage in specific food-related
parenting practices with a goal outcome in mind (Birch et al., 2001;
Costanzo & Woody, 1985; Faith et al., 2004). Indeed, prior research
suggests that parents who perceive their child to be overweight and/or
are concerned about their child’s weight, are more likely to engage in
controlling food-related parenting practices; further, parents who are
concerned that their child is underweight or might not be getting all of
the nutrients they need, are more likely to engage in pressure-to-eat
feeding practices (Crawford et al., 2006; Ek et al., 2016; Robinson &
Sutin, 2017; Webber et al., 2010). However, little is known about the
relationship between parental concern about their child’s weight and
use of less controlling food-related parenting practices, such as parental
modeling or education about nutrition. Further, the bulk of research
exploring parental motivation to use specific food-related parenting
practices has been conducted within white, high-income, mother-­
daughter dyads (Faith et al., 2004), calling into question if parental
motivation for the use of specific parenting practices might be different
in more diverse populations or if there might be differences in parental
motivation by child sex.
The current study used a racially/ethnically diverse sample to
examine the association between parental perception of their child’s
weight as well as parent’s current and future concerns regarding their
child’s weight and a broad range of food-related parenting practices,
including controlling food-related parenting practices (e.g., food re­
striction, pressure-to-eat, and food control) and less controlling food-
2
Appetite 160 (2021) 105068
related parenting practices (teaching about nutrition and parent
modeling) (Vaughn et al., 2016). Sex differences in observed associa­
tions were explored. We hypothesized that parents who perceive their
children to be overweight or underweight and parents with greater
concern about their child’s weight (current and future) will engage in
more controlling food-related parenting practices, as compared to par­
ents who perceive their child to be normal weight and parents who are
not concerned about their child’s weight (current or future). No hy­
potheses were made regarding potential sex differences, given the
paucity of previous research. The results of this study will help to
identify factors that influence a parent’s decisions to use certain
food-related parenting practices. A deepened understanding of parental
motivations behind a broad range of food-related practices will enable
public health practitioners and primary care providers to better design
interventions aimed at interrupting the use of food-related parenting
practices thought to lead to potentially unintended consequences.
2. Methods
Data for the current study are from Family Matters, a 5-year mixed-
methods incremental study; data was collected from 2014 to 2016
(Berge et al., 2017). The Family Matters study focuses on identifying
protective factors and novel risk and protective factors for childhood
obesity in a sample of racially/ethnically and socioeconomically diverse
families (Berge et al., 2017). The current study uses data from Phase I of
the Family Matters study; Phase I included an in-depth, mixed-methods,
cross-sectional examination of the family home environment of a diverse
population of families in the Minneapolis-Saint Paul metropolitan area
(n = 150). All protocols used were approved by the University of Min­
nesota’s Institutional Review Board Human Subjects Committee and are
published elsewhere (Berge et al., 2017).
Eligible participants were identified through primary care clinics in
the Twin Cities area between 2015 and 2016; eligible families were sent
a letter by their primary care provider inviting them to participate in the
Family Matters study. Families were eligible if they had a 5-7 year-old
child, at least one additional sibling living in the home full-time, and
the primary parent had to share at least one meal per day with the study
child. The child also needed to be > 5th BMI percentile. Recruitment was
stratified by race/ethnicity so there was an equal distribution (n = 25
per group) of African American, White, Asian/Southeast Asian, His­
panic, Somali, and Native American children. Each racial/ethnic group
was also stratified to ensure there was an equal distribution of weight
status for non-overweight (51%) and overweight/obese (49%) children.
Of note, given this study includes all family types, the primary care­
giver’s race/ethnicity and overweight status did not always match that
of the target child. Additional details on the study child and primary
caregiver, as well as household level characteristics, are included in
Table 1.
2.1. Procedures
Participants participated in a ten-day in-home observation that
consisted of two in-home visits and an eight-day direct observational
period (Berge et al., 2017). The current study regarding child weight and
parent feeding practices used data from Family Matters survey responses,
which consisted of the primary parent filling out an online survey
created by the Family Matters team, as well as the height and weight of
the child, which was collected by trained research staff using stan­
dardized protocols (Lohman et al., 1992). Body mass index (BMI)
percentile values for the 5–7 year old child were calculated using the
Centers for Disease Control calculator (Growth Chart Training Mod,
2011).
K.A. Loth et al. Appetite 160 (2021) 105068

Table 1 original pressure-to-eat and monitoring subscales (Birch et al., 2001).

Family Matters phase I study demographics (N = 150). Parents responded to questions on restriction, pressure-to-eat and
Participant Characteristics Primary Caregiver Study Child (n monitoring using a five point Likert scale ranging from 1 (never) to 5
(n = 150) = 150) (always). Restriction (5 items; Cronbach’s Alpha: 0.86)): I have to watch
N (%) N (%) out that [childs_name] does not eat too many sweets (candy, ice cream,
cake, or pastries); I have to watch out that [childs_name] does not eat too
Female 137 (91%) 71 (47%)
Age in years (sd) 34.5 (7.1) 6.4 (0.8)
many high-fat foods; I have to watch out that [childs_name] does not eat
Weight Status too much of his or her favorite foods; I intentionally keep some foods out
Nonoverweight 35 (23%) 77 (51%) of [childs_name]’s reach; If I did not guide or regulate [childs_name]’s
Overweight/Obese 115 (77%) 73 (49%) eating, he/she would eat too many junk foods; If I did not guide or
Race/Ethnicity
regulate [childs_name]’s eating, he/she would eat too much of his or her
Native American or Alaskan Native 21 (14%) 25 (17%)
Asian/Southeast Asian 25 (17%) 25 (17%) favorite foods. Pressure-to-eat (4 items; Cronbach’s Alpha: 0.64):
Black or African American 22 (15%) 25 (17%) [childs_name] should always eat all of the food on his/her plate; I have
White 27 (18%) 25 (17%) to be especially careful to make sure [childs_name] eats enough; If
Somali 25 (17%) 25 (17%) [childs_name] says “I’m not hungry,” I try to get him/her to eat anyway;
Hispanic 23 (15%) 25 (17%)
Mixed/Other 7 (5%) –
If I did not guide or regulate [childs_name]’s eating, he/she would eat
Household Characteristics much less than he/she should. Monitoring (3 items; Cronbach’s Alpha:
Primary Caregiver Marital Status 0.87): How much do you keep track of the sweets (candy, ice cream,
Married 78 (51%) cake, pies, pastries) that [childs_name] eats? How much do you keep
Committed dating relationship or engaged 31 (21%)
track of the snack food (potato chips, Doritos, cheese puffs) that
Casually dating 2 (1%)
Single (Separated/Divorced, Widowed, 38 (25.3%) [childs_name] eats? How much do you keep track of the high-fat foods
Never Married) that [childs_name] eats?
Educational Attainment Modeling, teaching about nutrition, and child food control feeding
Did not complete high school 32 (21%) practices were measured using abridged versions of the modeling and
High school or GED 60 (40%)
Vocational, technical, trade certificate 28 (18%)
teaching about nutrition, included in the validated Comprehensive
program, or associate degree Feeding Practices Questionnaire (CFPQ) (Musher-Eizenman & Holub,
College degree (e.g., bachelor, masters, or 25 (16%) 2007). Parents responded to these questions using a 5-point Likert scale
doctorate) ranging from 1 (disagree) to 5 (agree). Modeling (3 items; Cronbach’s
Other 4 (3%)
Alpha: 0.72): I model healthy eating for [childs_name] by eating healthy
Household Income
Less than $20,000 50 (33%) foods myself; I try to eat healthy foods in front of [childs_name], even if
$20,000 - $34,999 55 (37%) they are not my favorite; I show [childs_name] how much I enjoy eating
$35,000 - $49,999 16 (11%) healthy foods. Teaching about nutrition (3 items; Cronbach’s Alpha:
$50,000 or more 28 (19%) 0.49): I discuss with [childs_name] why it’s important to eat healthy
$100,000 or more 9 (6%)
foods; I discuss with [childs_name] the nutritional value of foods; I tell
Note: Percentages may not sum to exactly 100% due to rounding. [childs_name] what to eat and what not to eat without explanation.
Parents also responded to a one question regarding food control using a
2.2. Measures 5-point Likert scale ranging from 1 (never) to 5 (always): At dinner, do
you let [childs_name] choose the food she/he wants from what is
2.2.1. Parental perception of child weight status served?
Parental perception of child’s weight was measured through a survey
question adapted from a prior study (Webber et al., 2010), “How would 2.2.4. Statistical analysis
you best describe [child’s]’s weight now?” Responses were on a 6-point Multiple regression models were used to examine the relationship
scale (1–Very underweight, 2–Somewhat underweight, 3–About right, between each of the three categorical predictor variables (perception of
4–Somewhat overweight, 5–Very overweight, 6–Don’t know). Re­ child weight, concern of child weight, and concern for child’s adult
sponses were re-coded to create the following four categories: weight status) and each continuous outcome variable (restriction,
Very-Somewhat Underweight; About Right; Somewhat-Very Over­ pressure to eat, monitoring, teaching about nutrition, and parent
weight; Don’t Know. modeling scales). Categorical predictor variables were used to charac­
terize non-linear relationships with feeding practices including U-sha­
2.2.2. Parental concern ped relationships where extreme values were hypothesized to exhibit
Parental concern about child’s weight was measured with the similar levels of control that were different relative to neutral values of
following two questions: “How concerned are you about [child’s]’s the predictor. Huber-White robust standard errors were computed to
weight now?” and “How concerned are you that [child] will be over­ address misspecification of the error term, and pairwise group differ­
weight as an adult?“ (Campbell et al., 2007). Responses were measured ences between levels of the predictor variables were calculated at the
using a 4-point Likert scale ranging from 1 (not at all concerned) to 4 99% confidence level to deal with multiplicity, and marginal mean re­
(very concerned). sponses at the categorical predictor level was reported. Statistical sig­
nificance for the overall measure of association (e.g., 2df test for a three-
2.2.3. Food-related parenting practices level predictor variable) was set to the 95% confidence level. Each
A broad range of food-related parenting practices were assessed via parent perception and concern predictor and each outcome variable
survey-based instruments; decisions regarding what constructs to assess were modeled with separate adjusted regressions. To supplement
via survey were made with guidance from the literature and specific interpretation, adjusted r (Berge et al., 2012) is reported to describe the
items were selected to fill identified gaps within existing literature (Faith predictive value of the model and its fit characteristics given the model
et al., 2004; Loth, 2016; Loth et al., 2014; Vaughn et al., 2016). Parent covariates. Covariates were included in all analyses adjusting for child
restriction, pressure-to-eat, and monitoring feeding practices were sex, age, race, parent weight and education status, and household in­
measured using the validated Child Feeding Questionnaire CFQ; par­ come status. Separate interaction models were fitted to evaluate if the
ticipants responded to an abridged version of CFQ restriction subscale adjusted associations examined by multiple regression depended on the
(e.g., 5 of 8 items from the original CFQ) and all of the items in the sex of the participant child. In the case of a non-significant

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K.A. Loth et al. Appetite 160 (2021) 105068

sex-interaction (P > 0.05), the original model was retained to charac­
terize the associations between perception and concern and study
continuous outcomes. All statistical analysis and data management was
performed in Stata 15.1 MP (College Station, TX).
3. Results
3.1. Association between parental perception of, and concern about
child’s weight and food-related parenting practices
3.1.1. Controlling food-related parenting practices
Parental perception of their child’s weight and concern about their
child’s current weight were associated with parental report of restrictive
feeding practices (Tables 2 and 3). Specifically, parents who perceived
their child to be somewhat/very overweight reported high scores for use
of restrictive feeding practices than parents who perceived their child to
be very/somewhat underweight or about right (See Table 3 for details,
including interactions by child sex). Similarly, parents who were very
concerned about their child’s current weight had significantly higher
scores for restrictive feeding practices as compared to parents who were
not at all concerned about their child’s current weight (Table 2).
Parent concern about their child’s weight as an adult was signifi­
cantly associated with parental use of pressure-to-eat food-related
parenting practices (p = 0.044). There appears to be a “U”-shaped
pattern in the relationship between the parent concern about their
child’s weight as an adult and parental pressure-to-eat such that parents
who reported no concern about their child’s weight and parents who had
very high concern about their child’s weight reported higher levels of
engagement in pressure-to-eat feeding practices, as compared to par­
ent’s who expressed a little concern about their child’s weight; however,
individual pairwise comparisons between levels of parental concern and
use of food-related parenting practices were not found to reveal

Table 2
Adjusted relationship between parent perceptional of - and concern for child weight status (N = 149) and food-related parenting practices/teaching about nutrition.
Independent Dependent Variables: Food-Related Parent Behaviors Dependent Variables: Teaching about Nutrition, Modeling, and Child Control
Predictor of Food

Restriction P Pressure to P Monitoring P value Teaching P Modeling P Child Food P

Association value Eat value Association about value Association value Control value
(95% CI) Association (95% CI) Nutrition (95% CI) Association
(95% CI) Association (95% CI)
(95% CI)

Parent Sex Interaction Present1 Sex Interaction Present1 0.087 0.334 0.483 Sex Interaction Present1
Perception
of Child
Weight
Very/ 3.2 (2.5, 4)a 3.8 (3.4, 4.1) 4 (3.5, 4.5)a
Somewhat a
Underweight
About Right 3.1 (2.9, 3.3) 3.9 (3.8, 4.1) 4.1 (3.9, 4.2)
a a a
Somewhat/ 3.8 (3.3, 4.3) 4.1 (3.9, 4.4) 4.4 (4, 4.7)a
Very a a
Overweight
Don’t Know 3.8 (3, 4.7)a 4.2 (3.6, 4.9) 4.2 (3.5, 4.8)
a a
Parent 0.009 0.517 0.017 0.691 0.273 0.673
Concern for
Child
Weight
Status
Not at All 3 (2.9, 3.2)a 2.8 (2.6, 3)a 3.1 (2.9, 3.4) 3.9 (3.8, 4.1) 4 (3.9, 4.2)a 3 (2.8, 3.2)a
Concerned a a
A Little 3.5 (3, 4)ab 3 (2.6, 3.4)a 3.4 (2.9, 3.9) 4.1 (3.8, 4.4) 4.4 (4, 4.8)a 2.7 (2.3, 3.2)
Concerned ab a a
Very 3.9 (3.4, 4.5) 3.1 (2.6, 3.5) 4 (3.5, 4.5)b 4 (3.6, 4.5)a 4.2 (3.8, 4.7) 2.9 (2.2, 3.6)
Concerned b a a a
Parent 0.128 0.044 <0.001 0.534 0.231 0.714
Concern for
Child’s
Future Adult
Weight
Status
Not at All 3.1 (2.9, 3.3) 2.9 (2.7, 3.1) 3.1 (2.9, 3.4) 3.9 (3.8, 4.1) 4 (3.9, 4.2)a 3 (2.7, 3.2)a
Concerned a a a a
A Little 3.4 (2.9, 3.9) 2.5 (2.2, 2.9) 3.2 (2.7, 3.6) 4.1 (3.8, 4.4) 4.2 (3.8, 4.6) 2.9 (2.5, 3.4)
Concerned a a a a a a
Very 3.5 (3.1, 4)a 3.2 (2.8, 3.6) 4.1 (3.7, 4.5) 4.1 (3.7, 4.4) 4.4 (4, 4.8)a 2.7 (2.2, 3.3)
Concerned a b a a

1. The association between parent perception of child weight and restriction, pressuring, and food control was modified by the sex of the child (P < 0.05). See Table 3
for interaction results.
Models are adjusted for: Child sex, age, race, parent weight and education status, household income status, and receipt of public assistance.
Note: Superscripts indicate that the pairwise comparison was significantly different at the 99% level if the two levels of the predictor do not share a letter. The overall
test of statistical difference is reported at a 95% significance level.
Interpretation Example: Parents reported on their concern of their child’s weight status (i.e., not at all concerned, a little concerned, and very concerned). Parental
concern of child weight was analyzed as an ordinal, categorical variable. The association between maternal concern of child weight was overall statistically related to
parent restriction of foods (P = 0.009). Parents who reported “very concerned” about child weight were more likely to practice restriction compared to parents who
were not at all concerned about the child’s weight status (P < 0.01).

4
K.A. Loth et al. Appetite 160 (2021) 105068

Table 3
Interaction of child sex on the adjusted relationship between parent perception of child weight status (N = 149) and food restriction, pressuring, and child food control.
Independent Predictor Restriction Association (95% Interaction P Pressure to Eat Association Interaction P Food Control Association Interaction
CI) value (R2) (95% CI) value (R2) (95% CI) P value
(R2)

Parent Perception of Child SONS DAUGHTERS <0.001 (0.33) SONS DAUGHTERS 0.017 (0.35) SONS DAUGHTERS 0.046
Weight Status (0.26)

Very/Somewhat 3.2 (2.6, 2.3 (1.7, 2.8)a 3.1 (2.5, 3 (2.3, 3.7)ab 3.5 (2.7, 1.7 (0.8, 2.6)a
Underweight 3.8)abc 3.8)ab 4.3)b
About Right 3 (2.7, 3.2 (2.9, 3.5) 2.8 (2.5, 3 (2.8, 3.3)ab 2.9 (2.6, 3.1 (2.7, 3.4)b
3.3)ab bc 3.1)ab 3.2)ab
Somewhat/Very 4.1 (3.5, 3.5 (3, 4.1)bc 2.4 (1.9, 3.1 (2.7, 3.5) 2.6 (1.8, 2.7 (2.2, 3.3)
Overweight 4.7)c 2.9)a ab 3.3)ab ab
Don’t Know 3.9 (3.4, 2.2 (1.4, 3)ab 3.3 (2.9, 2.1 (1.3, 3)ab 3.4 (1.1, 3 (1.5, 4.4)ab
4.4)c 3.7)b 5.7)ab

Models are adjusted for: Child sex, age, race, parent weight and education status, household income status, and public assistance.
Note: Superscripts indicate that the pairwise comparison was significantly different at the 99% level if the two levels of the predictor do not share a letter. The overall
test of statistical difference is reported at a 95% significance level.
Interpretation Example: The association between parental perception of child weight and food control was modified by the sex of the child (P = 0.046). The magnitude
of the modified relationship indicates that parents were more likely to allow boys to choose foods who they perceived to be somewhat/very overweight compared to
girls of the same perceived weight status.

statistically significant differences at the 99% level. 4. Discussion

Parent concern for child weight now and in the future were both
positively associated with monitoring feeding practices.
3.1.2. Less-controlling food-related parenting practices
There was no statistically significant association between parental
perception, concern for child weight, or concern about child weight as
an adult with teaching about nutrition and modeling. Please see Table 2
for a full report of all associations examined.
3.2. Interactions
Sex differences in observed associations were identified; see Table 3
for a full report of all significant interactions. The relationship between
parent’s perception of child weight and their use of food restriction (p <
0.001), pressure-to-eat (p = 0.017), and child food control (p = 0.046)
were modified by child sex. Specifically, parents that perceived their
sons to be somewhat or very overweight had higher scores for food re­
striction parenting practices, as compared to parents who perceived
their daughters to be somewhat or very overweight. Parents who indi­
cated that they “don’t know” their perception of their child’s weight
status had significantly lower scores for food restriction with daughters
compared to sons.
Furthermore, parents who perceived their sons to be somewhat/very
overweight had lower scores for pressure-to-eat feeding practices as
compared to parents who perceived their daughters to be somewhat/
very overweight. In addition, no association was observed between
parental perception of child’s weight and parent use of pressure-to-eat
with daughters.
The direction of association for perceived weight and food control
was negatively correlated among sons but positively correlated with
food control among daughters. For example, parents who perceived
their son to be underweight reported higher scores in child food control
as compared to parents who was perceived their daughter to be under­
weight. Among children who parents perceived to be somewhat or very
overweight, the level of child food control was similar for sons and
daughters.
Child sex was not found to modify the relationship between parental
perception of their child’s weight monitoring, parent modeling or
teaching about nutrition; further, child sex was not found to modify the
relationship between parent current or future concern about child’s
weight and any of the food-related parenting practices examined.
This study aimed to examine the relationships between parental
perception of child weight status, parental concern for their child’s
current and future weight and use of a broad range of food-related
parenting practices. Further, sex differences in observed associations
were explored. Results revealed a significant association between
parental perceptions and concerns and their use of specific food-related
parenting practices. Further, observed sex differences suggested that
associations between parental perceptions and concerns about their
child’s weight and their use of food-related parenting practices differs by
child sex.
Findings from the current study add to the existing literature that
seeks to challenge the premise that if parents do not know that their
child is overweight (e.g., inaccurate perception) or if they are not con­
cerned about their child who struggles with overweight, then they will
not be as motivated to engage in helping their child to adopt healthy
lifestyle behaviors (Boutelle et al., 2004; Puhl et al., 2013a; Puhl et al.,
2013b; Robinson & Sutin, 2017; Webber et al., 2010). Indeed, the cur­
rent study found that parents who perceived their child to be overweight
reported higher scores for food restriction, a type of food-related
parenting practice that has been shown to lead, in some cases, to the
adoption of maladaptive eating behaviors and unhealthy weight gain
overtime (Faith et al., 2004; Loth, 2016; Loth et al., 2014). Further,
parents who perceived their child to be overweight did not report
engaging in higher levels of feeding behaviors thought to be associated
with healthful weight-related outcomes in children, including parental
modeling of healthy dietary intake and teaching children about nutri­
tion. Overall, data from the current study, in combination with findings
from previous research (Gerards et al., 2014; Neumark-Sztainer et al.,
2008a), suggest that while public health professionals and clinicians
may feel compelled to focus on making parents aware about their child’s
overweight status, a parent having an inaccurate perception of their
child’s weight may not be problematic, and in fact, failure of parent to
perceive their child as overweight might be protective in some ways
(Webber et al., 2010).
Findings revealed potentially important differences in the specific
food-related parenting practices associated with parental concern about
their child’s current weight, as compared to parental concern about their
child’s future weight. Specifically, parents who were concerned about
their child’s current weight reported higher scores for restriction and
monitoring practices, as compared to parents who were not at all con­
cerned. On the other hand, parents who were concerned about their
child’s future weight reported higher scores for pressure-to-eat and
monitoring practices, as compared to parents who were not at all

5
K.A. Loth et al.
concerned. These differences align with the well-accepted theory that
parents engage in food-related parenting practices in a goal-directed
fashion and helps to identify that parent’s current and future concerns
as a potentially important factor in the formation of a parent’s goals for
their child. For example, it is possible that parents who report current
concern are responding to a worry that their child weighs too much or is
gaining weight too rapidly by restriction and monitoring their intake. At
the same time, a parent who is concerned about their child’s weight in
the future might be responding to concerns about pickiness (e.g., they
need to start eating vegetables or they will not be at a healthy weight in
the future) or concerns about failure to grow appropriately (e.g., they
need to eat more now or they will not grow as they should, causing
problems in the future). Interestingly, parents that reported concerns
about their child’s current or future weight did not report higher levels
of engagement in parental modeling of healthful dietary intake or
teaching children about nutrition, two behaviors known to lead to
improved dietary intake and weight-related outcomes over time (Loth
et al., 2016b; Palfreyman et al., 2014; Vaughn et al., 2017). Future
research should explore the association between parental perception of
their child’s weight and use of food-related parenting practices using
longitudinal and intervention-based study designs with the goal of
clarifying best practices for teaching or providing resources to help all
parents use food-related parenting practices known to be associated
with more healthful weight and weight-related outcomes for children.
(e.g., routines and rules (Fiese, 2007; Vaughn et al., 2016), modeling
healthy eating (Draxten et al., 2014; Loth et al., 2016a; Vaughn et al.,
2016), education about nutrition (Vaughn et al., 2016), and having
family meals (Berge et al., 2014; Berge et al., 2015; Larson et al., 2007;
Neumark-Sztainer et al., 2008b)).
Results of the current study also revealed interesting sex differences
in the association between parental perception of their child’s current
weight and their use of specific food-related parenting practices. Over­
all, parents of sons reported using higher levels of controlling food-
related parenting practices (i.e., food restriction and pressure-to-eat) if
they perceived their son’s weight to be over/underweight as compared
to parents of daughters. These findings ran contrary to our hypothesis
that parents of daughters would be more active in responding to their
child being over/underweight than parents of sons and that we would
observe greater use of controlling food-related parenting practices
among those parents of daughters who perceived their daughters to be
under/overweight. To date, the majority of the research exploring food-
related parenting practices has been conducted within samples of
daughters (Birch; Faith et al., 2004), challenging our ability to corrob­
orate or to make sense of these sex differences and highlighting a need
for future quantitative and qualitative research aimed at deepening our
understanding of these observed sex differences.
There are both limitations and strengths of this study. One limitation
is the overall small sample size (n = 150); for example, we were not
adequately powered to explore potential differences in associations
across ethnic groups given that we had only 25 participants per group.
Data collected during Phase II of Family Matters (n = 1307) will allow
our team to examine potential differences in observed associations be­
tween subgroups of participants and this is a direction that should also
be explored further by other research teams. Further, while we captured
data on a broad range of food-related parenting practices (food restric­
tion, pressure-to-eat, monitoring, food control, parent modeling, and
nutrition education), the scales used to measure these constructs were
abbreviated versions of full validated-scales. Changes to the number of
items in the scales may have impacted their validity and challenged our
ability to compare our findings to the broader literature. Further, future
research should seek to include an even wider range of parental in­
fluences, including parental encouragement, and food availability and
accessibility. Finally, we are unable to disentangle parental concern that
their child’s weight is too low versus parental concern that their child’s
weight is too high. Further quantitative and qualitative research is
needed to understand these different facets of concern and explore
6
Appetite 160 (2021) 105068
whether different food-related parenting practices are associated with
these different types of concern. A primary strength of the study is the
racially/ethnically and socioeconomically diverse sample, including a
number of immigrant/refugee households. Further, differentiating be­
tween parent’s concern for their child’s current and future weight rep­
resents a unique addition to the literature and observed differences in
associations between these two distinct variables and parent’s use of
specific food-related parenting practices has potentially important im­
plications for intervention development.
5. Conclusions
The current study sought to understand how parents perception of
their child’s weight, as well as parent’s concern for their child’s weight
currently and in the future, are associated with parent’s use of different
types of food-related parenting practices. Overall, findings suggest that
parent’s respond to their perceptions of and concerns (current and
future) about their child’s weight by changing the way they interact
with their child around food via their parent feeding practices. Public
health practitioners and health care providers working with parents of
young children should aim to identify parents that have concerns about
their child’s weight and work to teach them about positive, evidence-
based ways they can engage in healthy food-related parenting practices.
Ethical statement
All protocols used in both phases of the Family Matters study were
approved by the University of Minnesota’s Institutional Review Board
Human Subjects Committee and are published elsewhere. Adult partic­
ipants gave informed consent and children gave verbal assent before
taking part any parts of the study protocol.
Funding
Research is supported by grant no. R01 HL126171-04 from the Na­
tional Heart, Lung and Blood Institute (PI: Jerica Berge) and the first
authors (KAL) time is supported by grant no. K23-HD090324-01A1 from
the National Institute of Child Health and Human Development (PI:
Katie Loth). Content is solely the responsibility of the authors and does
not necessarily represent the official views of the National Heart, Lung
and Blood Institute, the National Institute of Child Health and Human
Development or the National Institutes of Health.
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