Hydrolysed proteins in infant formula and child neurodevelopment up to the age of 3·5 years: the nationwide Étude Longitudinale Française depuis l'Enfance (ELFE) birth cohort.

While breast-feeding is the recommended feeding mode in infancy, rates are low in some Western societies, and infants are widely fed formula. France, in particular, shows high rates of infant formula use, including formulas with protein hydrolysates. The degree of protein hydrolysis has previously been associated with neurodevelopmental outcomes. The present study examines the associations between the protein's hydrolysis degree in infant formula and child neurodevelopment up to 3·5 years of age in the French nationwide Étude Longitudinale Française depuis l'Enfance (ELFE study). Parents reported on brand and name of the formula used at 2 months, and protein hydrolysis degree was derived from the ingredient list. Analyses were based on 6979 infants (92·2, 6·8 and 1 % consuming non-hydrolysed, partially and extensively hydrolysed formulas, respectively). Neurodevelopment was assessed at age 1 and 3·5 years with the Child Development Inventory (CDI), at age 2 years with the MacArthur-Bates Communicative Development Inventories and at age 3·5 years with the Picture Similarities sub-scale (British Ability Scales). Associations between protein hydrolysis degree and child neurodevelopment were assessed using linear and logistic regression for overall scores and poor CDI sub-domain scores (<25th centile), respectively. Among formula-fed infants, protein hydrolysis degree in infant formula was not associated with overall neurodevelopmental scores up to 3·5 years. Some associations were found with the motor skills CDI sub-domain, but they were not consistent at 1 and 3·5 years as well as across sensitivity analyses. The use of hydrolysed formula appears safe in terms of overall neurodevelopment, and research should further investigate specific neurodevelopmental domains.

Associations of preschoolers' dietary patterns with eating behaviors and parental feeding practices at a 12-month follow-up of obesity treatment.

Although dietary patterns are key to the management of childhood obesity, they are rarely assessed and thus poorly understood. This study examines preschoolers' dietary patterns and correlates 12 months after the start of obesity treatment (n = 99, mean age 5.2 years, 52% girls). A food frequency questionnaire (FFQ), the Child Eating Behavior Questionnaire (CEBQ), Child Feeding Questionnaire (CFQ) and Lifestyle Behavior Checklist (LBC) were answered by parents to assess children's food intake, eating behaviors, parental feeding practices, and obesity-related behaviors, respectively. Principal component analysis identified dietary patterns based on FFQ data. Through multiple linear regressions we examined correlations between a healthy (HD) and a less healthy (LHD) dietary pattern and mean scores of the CEBQ, CFQ, LBC scales as well as BMI z-scores. The reported intake of items in the LHD decreased after treatment while no differences were found for the HD. Children's eating behaviors, in particular food fussiness, showed consistent associations with diet (b = -0.39, 95% CI -0.63, -0.14 for HD and b = 0.41, 95% CI 0.15, 0.66 for LHD). Feeding practices and obesity-related behaviours were weakly associated with the dietary patterns (HD and Monitoring: b = 0.36, 95% CI 0.09, 0.62; LHD and Screen time b = 0.08, 95% CI 0.01, 0.15). Among the measured variables, eating behaviors had the largest impact on children's dietary patterns. The LHD was associated with a higher BMI z-score but no associations were found between changes in LHD intake and changes in BMI z-scores. Our findings suggest that decreasing food fussiness in children with obesity is key to positive dietary changes. Assessment of children's eating behaviors can help tailor dietary advice and provide support for families of children with obesity.

Parenting and childhood obesity: Validation of a new questionnaire and evaluation of treatment effects during the preschool years.

OBJECTIVES: Parenting is an integral component of obesity treatment in early childhood. However, the link between specific parenting practices and treatment effectiveness remains unclear. This paper introduces and validates a new parenting questionnaire and evaluates mothers' and fathers' parenting practices in relation to child weight status during a 12-month childhood obesity treatment trial. METHODS: First, a merged school/clinical sample (n = 558, 82% mothers) was used for the factorial and construct validation of the new parenting questionnaire. Second, changes in parenting were evaluated using clinical data from the More and Less Study, a randomized controlled trial (RCT) with 174 children (mean age = 5 years, mean Body Mass Index Standard Deviation Score (BMI SDS) = 3.0) comparing a parent support program (with and without booster sessions) and standard treatment. Data were collected at four time points over 12 months. We used linear mixed models and mediation models to investigate associations between changes in parenting practices and treatment effects. FINDINGS: The validation of the questionnaire (9 items; responses on a 5-point Likert scale) revealed two dimensions of parenting (Cronbach's alpha ≥0.7): setting limits to the child and regulating one's own emotions when interacting with the child, both of which correlated with feeding practices and parental self-efficacy. We administered the questionnaire to the RCT participants. Fathers in standard treatment increased their emotional regulation compared to fathers in the parenting program (p = 0.03). Mothers increased their limit-setting regardless of treatment allocation (p = 0.01). No treatment effect was found on child weight status through changes in parenting practices. CONCLUSION: Taken together, the findings demonstrate that the new questionnaire assessing parenting practices proved valid in a 12-month childhood obesity trial. During treatment, paternal and maternal parenting practices followed different trajectories, though they did not mediate treatment effects on child weight status. Future research should address the pathways whereby maternal and paternal parenting practices affect treatment outcomes, such as child eating behaviors and weight status.

The role of parental depression during early childhood obesity treatment-Secondary findings from a randomized controlled trial.

BACKGROUND: Parental depression is a risk factor for childhood obesity. OBJECTIVES: To examine the influence of parental depression on child weight status, eating behaviours, and parental feeding practices during childhood obesity treatment. METHODS: Hundred and twenty eight children with obesity aged 4 to 6 years and their parents were randomized to a parent support program or to standard treatment. At baseline and after 12 months, children's heights and weights were measured. Parents reported levels of depression (Beck's Depression Inventory-II), feeding practices (Child Feeding Questionnaire), and children's eating behaviors (Child Eating Behavior Questionnaire). Independent and dependent paired sample t-tests and linear regressions were used to analyze data. RESULTS: After obesity treatment, mothers reported lower levels of depression, whereas fathers did not. No associations were found between parental level of depression and child weight status, or between baseline level of parental depression and feeding practices. Associations were found between baseline parental depression and children's food responsiveness (ß = .03; P = .01; 95% CI [0.01, 0.05]), emotional overeating (ß = .02; P = .02; 95% CI [0.004, 0.04]), and desire to drink (ß = .02; P = .03; 95% CI [0.002, 0.04]) (adjusted for background variables). CONCLUSIONS: Parental depression did not influence child weight status or parental feeding practices but was associated with obesity-related child eating behaviors.

Changes in parental feeding practices and preschoolers' food intake following a randomized controlled childhood obesity trial.

Childhood obesity treatment involving parents is most effective during the preschool age. However, the mechanisms of change are not known. The present study reports on secondary outcomes (changes in parental feeding practices and child food intake) of early obesity treatment. The More and Less study is a randomized controlled trial conducted in Stockholm County, Sweden. Children with obesity (n = 174, mean BMI SDS 3.0, mean age 5 years, 56% girls) and their parents (60% with foreign background, 40% with a university degree) were randomized to: 1) standard treatment focusing on lifestyle recommendations (ST), 2) a parent support program with boosters (PGB), and 3) a parent support program without boosters (PGNB). The Child Feeding Questionnaire (CFQ) was used to measure parental feeding practices. Child food intake was assessed with a Food Frequency Questionnaire (FFQ). We calculated the monthly changes in CFQ practices and FFQ items based on four measurements. We did not find any significant between-group differences in parental feeding practices and child food intake over time. However, general linear models showed that changes in certain feeding practices predicted changes in child food intake. When ST was compared to the parent support groups, some associations moved in opposite directions. For example, increasing maternal restriction predicted increased consumption of cookies/buns in PGNB (b = 2.3, p < 0.05) and decreased consumption of cookies/buns in ST (b = -2.1, p < 0.05). This is among the few studies to examine the effect of parental feeding practices on child food intake and weight status after obesity treatment among preschoolers. We found no evidence that changes in feeding practices or changes in child food intake mediated child weight loss. Future studies should consider other intermediary processes related to general parenting practices and parent-child interactions.

Picky eating in an obesity intervention for preschool-aged children - what role does it play, and does the measurement instrument matter?

INTRODUCTION: Research on picky eating in childhood obesity treatment is limited and inconsistent, with various instruments and questions used. This study examines the role of picky eating in a randomized controlled obesity intervention for preschoolers using subscales from two instruments: The Child Eating Behavior Questionnaire (CEBQ) and the Lifestyle Behavior Checklist (LBC). METHOD: The study includes 130 children (mean age 5.2 years (SD 0.7), 54% girls, mean Body Mass Index (BMI) z-score 2.9 (SD 0.6)) and their parents (nearly 60% of non-Swedish background, 40% with university degree). Families were randomized to a parent-group treatment focusing on evidence-based parenting practices or to standard treatment focusing on lifestyle changes. The children's heights and weights (BMI z-score) were measured at baseline, and at 3, 6 and 12 months post baseline. At these time-points, picky eating was reported by parents using the CEBQ (Food Fussiness scale, 6 items) and 5 items from the LBC. Child food intake was reported with a Food Frequency Questionnaire (FFQ). Pearson correlation was used to study associations between baseline picky eating and baseline BMI z-scores and food intake. Mixed effects models were used to study associations between the two measurements of picky eating and changes in picky eating, to assess the effects of changes in picky eating on BMI z-scores, and to evaluate baseline picky eating as a predictor of changes in BMI z-scores. RESULTS: Neither the standard treatment nor the parent-group treatment reduced the degree of picky eating (measured with CEBQ or LBC). Baseline picky eating measured with the CEBQ was associated with a lower BMI z-score and lower intake of vegetables. Children with a higher degree of picky eating at baseline (measured with the CEBQ) displayed a lower degree of weight loss. When degree of picky eating was examined, for 25% of the children, the CEBQ and the LBC yielded diverging results. CONCLUSIONS: Baseline picky eating may weaken the effectiveness of obesity treatment, and assessments should be conducted before treatment to adjust the treatment approach. Different measurements of picky eating may lead to different results. The CEBQ seems more robust than the LBC in measuring picky eating. TRIAL REGISTRATION: Clinicaltrials.gov , NCT01792531. Registered 15 February 2013 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01792531.

The influence of preschoolers' emotional and behavioural problems on obesity treatment outcomes: Secondary findings from a randomized controlled trial.

BACKGROUND: Few studies have explored the influence of preschoolers' behavioural problems on obesity treatment. OBJECTIVES: To assess emotional and behavioural problems before and after an obesity intervention and examine relationships between changes in child behaviour and changes in weight status. METHOD: The study included 77 children (4-6 years old, 53% girls, mean body mass index [BMI] z-score of 3.0 [SD 0.6]) who participated in the More and Less Study, a randomized controlled trial. Families were randomized to a parenting program or to standard treatment. The children's heights and weights (BMI z-score, primary outcome) were measured at baseline and 12 months post baseline. Parents rated their children's behaviours (secondary outcome) on the Child Behavior Checklist (CBCL) for ages 1.5 to 5 years, a questionnaire that measures psychosocial health and functioning, encompassing emotional and behavioural problems. Changes in child behaviour during treatment were examined through paired samples t tests; the influence of child behaviour on treatment effects was examined through linear regressions. RESULTS: Child emotional and behavioural problems significantly improved after obesity treatment. Lower scores were found for Emotional Reactivity, Sleep Problems, Affective Problems, Aggressive Behaviour, Externalizing Behaviours, Oppositional Defiant Problems, and Total Problems. Child behaviour significantly affected obesity treatment results: Attention Problems and attention deficit hyperactivity disorder (ADHD) at baseline contributed to increasing BMI z-scores, whereas Oppositional Defiant Problems, Externalizing Behaviours, and a higher number of behavioural problems predicted decreasing BMI z-scores. CONCLUSIONS: Child behaviours at baseline influenced treatment results. Child emotional and behavioural problems improved post treatment. The results suggest that obesity treatment may help in reducing emotional distress among preschoolers.

A Parent Treatment Program for Preschoolers With Obesity: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Early obesity treatment seems to be the most effective, but few treatments exist. In this study, we examine the effectiveness of a parent-only treatment program with and without booster sessions (Booster or No Booster) focusing on parenting practices and standard treatment (ST). METHODS: Families of children 4 to 6 years of age with obesity were recruited from 68 child care centers in Stockholm County and randomly assigned to a parent-only program (10 weeks) with or without boosters (9 months) or to ST. Treatment effects on primary outcomes (BMI z score) and secondary outcomes (BMI and waist circumference) during a 12-month period were examined with linear mixed models. The influence of sociodemographic factors was examined by 3-way interactions. The clinically significant change in BMI z score (-0.5) was assessed with risk ratios. RESULTS: A total of 174 children (mean age: 5.3 years [SD = 0.8]; BMI z score: 3.0 [SD = 0.6], 56% girls) and their parents (60% foreign background; 39% university degree) were included in the analysis (Booster, n = 44; No Booster, n = 43; ST, n = 87). After 12 months, children in the parent-only treatment had a greater reduction in their BMI z score (0.30; 95% confidence interval [CI]: -0.45 to -0.15) compared with ST (0.07; 95% CI: -0.19 to 0.05). Comparing all 3 groups, improvements in weight status were only seen for the Booster group (-0.54; 95% CI: -0.77 to -0.30). The Booster group was 4.8 times (95% CI: 2.4 to 9.6) more likely to reach a clinically significant reduction of ≥0.5 of the BMI z score compared with ST. CONCLUSION: A parent-only treatment with boosters outperformed standard care for obesity in preschoolers.

Picky eating in Swedish preschoolers of different weight status: application of two new screening cut-offs.

BACKGROUND: Characteristics of picky eaters of different weight status have not been sufficiently investigated. We used two newly developed screening cut-offs for picky eating in the Food fussiness (FF) subscale of the Child Eating Behavior Questionnaire (CEBQ) to investigate the prevalence and characteristics of picky eaters in preschool-aged children with thinness, normal weight, overweight or obesity. METHODS: Data for 1272 preschoolers (mean age 4.9 years) were analyzed. The parent-reported FF subscale ranges from 1 to 5, and two screening cut-offs were applied to classify children as picky eaters (3.0 and 3.33). Structural Equation Modeling was used to study associations with other factors in the CEBQ, the Child Feeding Questionnaire (CFQ) and the Lifestyle Behavior Checklist (LBC). Scores were compared separately for each weight status group. RESULTS: Nearly half of the children were classified as moderate or severe picky eaters (cut-off 3.0) and 30% as severe (cut-off 3.33). For both cut-offs, prevalence was significantly lower in the obesity group. Still, one-third of children with obesity met the cut-off of 3.0 and 17% met the cut-off of 3.33. While picky eaters displayed similar patterns across weight status groups, some differences emerged. Food responsiveness was lower for picky eaters, but the difference was significant only among children with obesity. Slowness in eating was not as pronounced among picky eaters in the obesity group. In the overweight and obesity groups, parents of picky eaters did not report as high pressure to eat, as compared to the thinness or normal weight groups; in the obesity group, parents of picky eaters also perceived their children's weight as lower. In all weight status groups, parents of picky eaters were more likely to report their children had too much screen time, complained about physical activity, and expressed negative affect toward food. CONCLUSIONS: Picky eating was less common but still prevalent among children with obesity. Future studies should investigate the potential influence of picky eating on childhood overweight and obesity. Moreover, as children with picky eating display higher emotional sensitivity, further research is needed to understand how to create positive eating environments particularly for children with picky eating and obesity.

Perceived child eating behaviours and maternal migrant background.

The Child Eating Behaviour Questionnaire (CEBQ) is a well-established instrument in the study of obesity-related eating behaviours among children. However, research using the CEBQ in multicultural samples is limited. This study aims to identify and examine differences in child eating behaviours as reported by Swedish-born and non-Swedish-born mothers living in Sweden. Mothers (n = 1310, 74 countries of origin, mean age 36.5 years, 63.6% with higher education, 29.2% with overweight or obesity) of children aged 3-8 years (mean age 4.8 years, 18.1% with overweight or obesity) completed the CEBQ. Responses were analysed using CEBQ subscales Food Responsiveness, Emotional Overeating, Enjoyment of Food, and Desire to Drink, clustering into Food Approach, and subscales Satiety Responsiveness, Slowness in Eating, Emotional Undereating, and Food Fussiness, clustering into Food Avoidance. Data were compared across seven regional groups, divided by maternal place of birth: (1) Sweden (n = 941), (2) Nordic and Western Europe (n = 68), (3) Eastern and Southern Europe (n = 97), (4) the Middle East and North Africa (n = 110), (5) East, South and Southeast Asia (n = 52), (6) Sub-Saharan Africa (n = 16), and (7) Central and South America (n = 26). Crude, partly and fully adjusted linear regression models controlled for child's age, gender and weight status, and mother's education, weight status and concern about child weight. The moderation effect of maternal concern about child weight was examined through interaction analyses. Results showed that while Food Approach and Food Avoidance behaviours were associated with maternal migrant background, associations for Food Fussiness were limited. Notably, mothers born in the Middle East and North Africa reported higher frequencies of both Food Approach (except for Enjoyment of Food) and Food Avoidance. The study highlights the importance of examining how regionally-specific maternal migrant background affects mothers' perceptions of child eating behaviours.

Controlling feeding practices and maternal migrant background: an analysis of a multicultural sample.

OBJECTIVE: Parental feeding practices shape children's relationships with food and eating. Feeding is embedded socioculturally in values and attitudes related to food and parenting. However, few studies have examined associations between parental feeding practices and migrant background. DESIGN: Cross-sectional study. Parental feeding practices (restriction, pressure to eat, monitoring) were assessed using the Child Feeding Questionnaire. Differences were explored in four sub-samples grouped by maternal place of birth: Sweden, Nordic/Western Europe, Eastern/Southern Europe and countries outside Europe. Crude, partly and fully adjusted linear regression models were created. Potential confounding variables included child's age, gender and weight status, and mother's age, weight status, education and concern about child weight. SETTING: Malmö and Stockholm, Sweden. SUBJECTS: Mothers (n 1325, representing seventy-three countries; mean age 36·5 years; 28·1 % of non-Swedish background; 30·7 % with overweight/obesity; 62·8 % with university education) of pre-school children (mean age 4·8 years; 50·8 % boys; 18·6 % with overweight/obesity). RESULTS: Non-Swedish-born mothers, whether European-born or non-European-born, were more likely to use restriction. Swedish-born mothers and Nordic/Western European-born mothers reported lower levels of pressure to eat compared with mothers born in Eastern/Southern Europe and mothers born outside Europe. Differences in monitoring were small. Among the potential confounding variables, child weight status and concern about child weight were highly influential. Concern about child weight accounted for some of the effect of maternal origin on restriction. CONCLUSIONS: Non-European-born mothers were more concerned about children being overweight and more likely to report controlling feeding practices. Future research should examine acculturative and structural factors underlying differences in feeding.