Improving healthy eating in families with a toddler at risk for overweight: A cluster randomized controlled trial

The increase in US childhood overweight/obesity over the past 20-years across all income and ethnic groups in the USA 1,2 underlines the need for early prevention programs to reduce the increasingly prevalent and costly medical comorbidities associated with overweight.3 To date, however, prevention programs which are often implemented in school settings have met with only moderate success 4 perhaps because the family environment continues to reinforce maladaptive behaviors. At the family level parent feeding practices, such as taking excessive control over their child’s eating, appear to contribute to childhood overweight. 5,6 It is hypothesized that these parental behaviors interfere with the child’s perception of hunger and satiety leading to loss of control over eating and eventually to overweight. Family studies suggest that restrictive feeding by the parent is related to childhood overweight although the majority of these studies are cross-sectional.6,7 Laboratory studies also suggest that restrictive feeding is associated with childhood overweight. For example, when children have restricted access to a specific food they tend to eat more of that food in a later test, although this finding was for girls but not boys.8 On the other hand if children are pressured to eat a healthy food, in this case by making play contingent on consuming a particular food, their preference for that food will diminish in subsequent tests.9 Observational studies also demonstrate the importance of parental behavior on children’s feeding. For example, higher rates of parent food offers, presentations, and prompts, all measures of pressure to eat, were associated with higher caloric intake in young children in a laboratory setting.10 Another study found that higher rates of parental prompts to eat and food offers were associated with higher child relative weights.11 It can be argued that parental control over their child’s eating is simply a reaction to their child’s feeding problems. However, a prospective study from birth to 7 years of age found that parental attributes at infancy predicted over-control at 7-years.12 Such attributes included: Parental body dissatisfaction, parental eating disorders, minority status and parents being born outside the United States. This study indicates that parental over-control of their child’s feeding is not simply a reaction to an existing feeding problem. Thus parent behaviors particularly restricting food choices are risk factors for overweight. However, to determine whether changing these behaviors affect weight gain in young children, i.e. are causal risk factors, an evidence-based intervention to reduce parental over-control during mealtimes is first needed. A child development-based feeding relationship model, Division of Responsibility, formalized by Satter 13,14 has been used to foster optimal feeding practices. The American Academy of Pediatrics recommends the model during child health supervision visits 15 However, this model has not been tested in a controlled trial, hence it is unclear whether it actually reduces parent attempts to control their child’s eating. The aim of this study was to compare, in a randomized trial, an intervention based on the Satter model which is aimed at reducing parental interference during feeding, to a control group adapted from the “We Can” program developed by the National Institutes of Health which is aimed at enhancing family nutrition and activity levels.16 The children involved in the study were at risk for overweight or obesity because at least one parent was overweight or obese.