Mothers’ Perceptions as Predictors of Toddler Fruit and Vegetable Consumption

1. Mothers’ Perceptions as Predictors of Toddler Fruit and Vegetable Consumption Presented at the Council for the Advancement of Nursing Science 2012 National State of the Science Congress in Nursing Research Washington, DC, September 15, 2012 Mildred A. Horodynski, PhD, RN, FAAN1; Manfred Stommel, PhD1; Holly Brophy-Herb, PhD2; Lorraine Weatherspoon, PhD, RD3 1Michigan State University (MSU) College of Nursing; 2 MSU Department of Human Development and Family Studies; 3 MSU Department of Food Science and Human Nutrition Funded By: the Office of Planning, Research and Evaluation of the Administration of Children and Families (OPRE/ACF). Grant Number: 90-YF0046

2. Background • Since the 1970s, the prevalence of childhood obesity has more than doubled for children, 2 to 5 years of age. • Approximately ten million American children over the age of six are already “obese”.1 • 1Ogden et al, 2010.

3. Background • Recent estimates state: • 37% African American (AA) children are at risk of being overweight.2 • 35% Non-Hispanic White children are at risk of being overweight.2 2Odgen, 2006.

4. Background • Many children living in the US consume diets that do not meet national dietary recommendations. • Data from the most recent NHANES show that diets of children as young as 2 years old include too much saturated fat, sodium, and calories from nutrient-poor and calorie dense foods and lack adequate vegetables and fruits. • Toddlerhood is recognized as a • critical period for the acquisition of appropriate healthy eating behaviors.3 • 3Duke et al, 2004.

5. Background • Fruit and vegetable consumption for children is important for healthy growth and development. • Diets low in fruits and vegetables can increase the risk of cardiovascular disease4, diabetes5 and other chronic diseases later in life6. • 4Joshipura, et al., 2001; 5Ford & Mordad, 2000; 6Cooke, et al., 2003.

6. Background • Several socio-demographic characteristics are associated with the consumption of fruits and vegetables in families: • Lower SES and educational level6 • Race7 • Gender8 • 6Cooke, et al, 2003; 7Irala-Estever, et at, 2000; 8Gibson, et al, 1998.

7. Background • Other factors influence toddlers’ fruit and vegetable intake: • Mother’s diet quality9 • Maternal self-efficacy10 • Perception of child as “picky eater”11 • 9Hoerr, et al, 2006; 10Carruth, Ziegler, Gordon, & Hendricks, 2004; 11Carruth, Ziegler, Gordon, & Barr, 2004.

8. Background • Home environments that support healthy eating for toddlers are important in establishing healthy future food choices and diet-related health outcomes in children. • Parents play an important role in determining food choices and feeding behaviors of toddlers, based on the theory that the parent determines what food the toddler is offered.12 • Parental practices/styles and pressure to eat are interrelated with picky eating. • 12Satter, 1990.

9. Picky Eater • A child can communicate his/her food likes and dislikes at a very young age, first through body language (moving away from food offered) and later through verbalizing his/her food likes and dislikes. • Preliminary evidence suggests that parents’ perceptions of their child’s “pickiness” increase as they get older from: • 25% at 7-8 months • 35% at 12-14 months • 50% at 19-24 months11 • 11Carruth, Ziegler, Gordon, & Barr, 2004.

10. Picky Eater • Picky Eaters are defined as children who consume an inadequate variety of foods because they reject other foods.13 • Picky Eaters require many more exposures in order to accept a new/novel food.15 • Studies exploring ‘Picky Eaters’ are relatively recent and few in number.14 • 13Galloway et al, 2005; 14Dovey et al, 2008

11. Picky Eater First taste of the novel food Refusal of Food After 15 Exposures Exposure Figure: Likelihood for acceptance of fruits and vegetables in Picky/Fussy eating children.14 14Dovey et al, 2008, p. 188

12. Purpose • To examine whether and how toddlers’ vegetable and fruit (V&F) consumption is associated with maternal V&F consumption, maternal efficacy, mothers’ perceptions of toddlers are “picky eaters”, and sociodemographic characteristics of the mothers.

13. Methods - Study Design • Cross-sectional survey design with 199 low-income African American (AA) & 200 non-Hispanic White mother-toddler dyads.

14. Data Collection Procedure • Trained Data Collectors • Made home visits • Maternal and child height and weight measurements • Mealtime feeding observation with toddler • Questionnaire packet

15. Self-Report Measures • Toddler/Parent Mealtime Behavior Questionnaire: Picky Eater Subscale (r=.73) • Food Frequency Questionnaire (child and adult) • Feeding Self-Efficacy Questionnaire (r=.83) • Demographic Survey

16. Food Frequency Questionnaire • Assessed usual weekly food intake of fruits and vegetables on a 3-point scale: • Rarely/never • 3 or fewer times a week • 4 or more times a week

17. ‘Picky Eater’ Subscale of TPMBQ • 5 items • 5-point Likert response scale • 1 = “never” and 5 = “always” • Sample item: My child is a picky eater

18. Feeding Self-Efficacy Questionnaire • 8 items • 5-point Likert response scale • 1 = “not confident at all” to 5 = “always” • Sample item: I can get my child to try veggies.

19. Data Analysis • Frequency distributions, measures of central tendency and variability • Linear regression models with picky eater scale scores as outcome • Logistic regression models for dichotomous outcomes measuring toddlers’ vegetable and fruit consumption

20. Characteristics of Study Participants (* p<0.05)

21. Fruit and Vegetable Consumption

22. Predictors of Maternal Perceptions of their Toddlers as ‘Picky Eaters’

23. Results: Sociodemographics and Maternal Characteristics Predict “Picky Eater” Perception • Race, education, self-efficacy, and toddler age predicted “picky eater” perception (37% of the variance). • African American. • Mothers with less education. • Lower maternal self-efficacy • Older toddlers

24. Results of Logistic Regression Analysis for Associations of Toddler Vegetable Consumption *Four times or more a week versus ≤3 times a week.

25. Results of Logistic Regression Analysis for Associations of Toddler Fruit Consumption *Four times or more a week versus ≤3 times a week.

26. Results: Maternal perception of “picky eater”, mothers’ fruit and vegetable intake & sociodemographics predict toddler vegetable intake • Toddlers were more likely to consume vegetables 4 or more times/week when mothers: • Did NOT view their toddler as “picky eater” (OR 2.5; 95% CI: 1.7-3.7) • Consumed more vegetables themselves (OR: 10.1; 95% CI: 5.7-18.0) • Non-Hispanic White (OR:2.2; 95% CI: 1.3-3.8)

27. Results: Toddler Fruit Consumption Toddlers were more likely to consume fruit if mothers: • Did NOT view toddler as “picky eater” (OR: 1.6; 95% CI: 1.1-2.2) • Consumed more fruit themselves (OR: 9.9; 95% CI: 5.7-17.2)

28. Final Model Maternal Vegetable Intake + - Maternal Race (AA) + Toddler Vegetable Intake - Maternal Education (-) Maternal Self-Efficacy (-) Toddler Age (+) “Picky Eater” Perception - Toddler Fruit Intake + Maternal Fruit Intake

29. Conclusions • Mothers’ intake of fruits and vegetables has a strong influence on toddler fruit and vegetable intake. • Mothers’ own dislike of certain fruits and vegetables may limit introduction of certain fruits and vegetables to toddlers. • Mothers are their toddlers’ greatest role models.

30. Conclusions • Self-efficacy has been identified as a key factor in determining F&V intake.15 • AA mothers who are ambivalent about being a positive role model relative to eating F&V, made less of an effort in ensuring that their children are eating enough F&V.16 • In our study, mothers’ feelings of low feeding self-efficacy were associated with viewing their toddlers as “picky eaters”. • Increasing feeding self-efficacy among mothers could lead to increased F&V consumption among toddlers. 15Granner, 2004; 16Reimer, 2007.

31. Conclusions • “Picky eating” is one aspect of child development. • Perceptions of a toddler as a picky eater may be related to parenting style or culture. • In our study, mothers who viewed their toddlers as a picky eater may be more “Laissez-faire”, where toddlers choose, which, if any, fruits and vegetables to eat.

32. Limitations • Self-Report measures • Measurement issues

33. Implications for Research • Measurement of “Picky Eater” construct: • Studies have attempted to characterize “picky eating” using various measures, such as the Child Feeding Questionnaire17, asking the caregiver if they considered their child a “picky eater”18, or by designing a questionnaire for their own specific study.19 • Differences in measuring the “picky eater” construct requires an applicable, validated measure. • Understanding the concept of “picky eating” is needed to deliver a multi-faceted approach to get children to independently choose and eat fruits and vegetables in their diets. • 17Birch et al, 2001; 18Carruth et al, 2004; 19Smith et al, 2005

34. Implications for Practice • Increase mothers’ own fruit and vegetable intake • Increase maternal self-efficacy • Receive additional education about their own and their toddler’s healthy food intake.

35. Implications for Education • Mothers need knowledge to: • Provide a healthy diet, especially including adequate vegetables and fruits, and life style for their toddler’s growth and to maintain an appropriate weight and ultimate health. • Gain an increased awareness regarding the quality of their own food intake and the influence on the quality of their toddlers’ food intake.

36. The findings from this study: • Provide useful insight on how nurses and other health professionals can maximize F & V intake for vulnerable children. • Identify the need for healthy eating strategies, for addressing for prevention of childhood obesity and other health-related conditions, that are individualized and effective for vulnerable children and their families. • Identify the need for further research in understanding the problem and measuringthe concept of “picky eating”.

37. Thank You Questions?

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39. References Carruth, B.R., Ziegler, P.J., Gordon, A., & Hendricks, K. (2004). Developmental milestones and self-feeding behaviors in infants and toddlers. Journal of the American dietetic Association, 104(1), S51-S56. Carruth, B.R., Ziegler, P.J., Gordon, A., & Barr, S.I. (2004). Prevalence of picky eaters among infants and toddlers and their caregivers’ decisions about offering new food. Journal of the American Dietetic Association, 104(1), S57-S64 Satter, E. (1990). The feeding relationship, problems and interventions. Journal of Pediatrics, 117(2 pt 2),5181-9. Galloway, A.T., Fiorito, L.M., Lee, Y., & Birch, L.L. (2005). Parental pressure, dietary patterns and weight status among girls who are ‘picky/fussy’ eaters. Journal of the American Dietetic Association, 105, 541-548. Dovey, T.M., Staples, P.A., Gibson, E.L., & Halford, J.C. (2008). Food neophobia and ‘picky/fussy’ eating in children: A review. Appetite, 50, 181-193. Granner, M.L., Sargent, R.G., Caalderon, K.S., Hussey, J.R., Evans, A.E., & Watkins, K.W. (2004). Factors of fruit and vegetable intake by race, gender, and age among young adolescents. Journal of Nutrition Education and Behavior, 36, 173-180 Reimer, K., Smith, C., Reicks, M., Henry, H., Thomas, R., & Atwell, J. (2007). Child-feeding strategies of African American women according to stage of change for fruit and vegetable consumption. Public Health Nutrition, 7, 505-512 Birch, L.L., Fisher, J.O., Grimm-Thomas, K., Markey, C.N., Sawyer, R., & Johnson, S.L. (2001). Confirmatory factor analysis of the Child Feeding Questionnaire: A measure of parental attitudes, beliefs, and practices about child feeding and obesity prevention. Appetite, 36, 201-210. Horodynski, M.A., Stommel, M., Brophy-Herb, H., & Weatherspoon, L. (2010). Low-income African American and Non-Hispanic white mothers’ self-efficacy, “picky eater” perception, and toddler fruit and vegetable consumption. Public Health Nursing Journal, 27, 408-417.