Parenting to prevent body dissatisfaction and unhealthy eating patterns in preschool children: A Delphi consensus study
Introduction
As the foundations for body image and eating patterns appear to be laid in early childhood, it is important that prevention efforts in body dissatisfaction and unhealthy eating, target preschool children. By the end of the preschool years, at age 6, children have started to develop their body image; that is, their subjective evaluation of their physical body and appearance (Smolak and Thompson, 2009a, Smolak and Thompson, 2009b). Research suggests that three- to five-year-old children internalize body size stereotypes, associating positive characteristics with thin body figures and negative characteristics with fatter figures (Holub, 2008, Spiel et al., 2012). Young children have also been found to show behaviors consistent with body dissatisfaction, such as body checking and negative comments about their appearance (Tremblay & Limbos, 2009). In adolescence, body dissatisfaction has been linked to the development of a range of poor health outcomes, including higher depressive symptoms, lower self-esteem, lower physical activity, and greater risk of disordered eating and clinical eating disorders (Neumark-Sztainer et al., 2006, Paxton et al., 2006, Stice and Shaw, 2002).
By age 6, children have also developed consistent eating patterns. Eating patterns may be defined as the broad contexts and components of food consumption, including: meal timing, frequency, and environment (e.g., family, school, restaurant or take-away meals), as well as portion sizes and dietary quality (e.g., intake of fruit, vegetables and energy density) (Nicklas, Baranowski, Cullen, & Berenson, 2001). However, a more inclusive definition also involves attitudes toward food and nutrition (Margetts, Thompson, Speller, & McVey, 1998). Eating patterns can therefore be thought of as eating behaviors, such as portion size and dietary quality, but also eating attitudes that influence what, when, and how much is eaten. We use the term unhealthy eating patterns to refer to eating behaviors and attitudes in children that have been associated with poor health outcomes. These include, for example, emotional eating to soothe negative affect, disordered eating including binge eating or dieting for weight loss, and negative attitudes to food, such as fear of fatty or ‘unhealthy foods’. Research suggests that unhealthy eating patterns occur from early childhood; an American study found 14% of five-year-olds reported dieting behaviors (Holub et al., 2005), and in Australia, clinical eating disorders, such as anorexia nervosa, have been found in children as young as five (Madden, Morris, Zurynski, Kohn, & Elliot, 2009). Importantly, unhealthy eating patterns not only impact on child health, they are also important determinants of adult health outcomes over the longer term (Dietz, 1998, Kotler et al., 2001).
As body image and unhealthy eating patterns have their foundations in the early childhood years, prevention work needs to target this formative developmental period. In recent years there has been an increase in nutrition-based prevention programs for children to arrest unhealthy weight gain (Waters et al., 2011). However, there has also been a concomitant increase in concern about the iatrogenic effects of anti-obesity programs. Anti-obesity programs often narrowly focus on Body Mass Index as a primary outcome, without consideration of the impact on child body image or eating attitudes (Ikeda et al., 2006, O’Dea, 2005). Importantly, there is a promising and emerging literature focusing on the prevention of eating problems at both ends of the weight spectrum, through the reduction of shared risk factors for bulimia nervosa and obesity (Austin et al., 2005, Haines et al., 2012, Neumark-Sztainer, 2005). In addition, the role of body satisfaction in the maintenance of healthy weight is also increasingly noted and targeted in prevention programs (e.g., Stice et al., 2003, Wilksch and Wade, 2013).
Although these prevention interventions have been developed to improve positive body image and healthy eating attitudes, they have largely focused on the school setting (Hart et al., in press, Waters et al., 2011), or older adolescents and young adults (e.g., Becker et al., 2010, Stice et al., 2006). Parents are also known to strongly influence the development of a wide range of risk and protective factors for body image and eating problems in their children (Fisher et al., 2009, Rodgers and Chabrol, 2009). Parents are salient role models who also communicate attitudes and display behaviors relating to body weight and shape. A review by Rodgers and Chabrol (2009) found that parental focus on the importance of appearance and weight can increase body shape and weight concerns among their children, and that this effect is particularly strong when parents directly criticize their child, or actively encourage them to lose weight. As parents provide both the genes and the environment for their child's eating patterns, parents play a powerful role in shaping their development (Savage, Fisher, & Birch, 2007). Child eating patterns can be influenced in utero through maternal diet, and are shaped in infancy and early childhood through parental modeling (Johannsen et al., 2006, Rodgers and Chabrol, 2009, Savage et al., 2007), parental feeding practices (Birch and Fisher, 2000, Birch et al., 2003, Johannsen et al., 2006), parental comments (Smolak, Levine, & Schermer, 1999) and the family environment in which food is prepared and consumed (Birch, 1999, Wansink, 2004).
While there is an increasingly complex understanding of how parents influence the development of unhealthy body image and eating patterns in their children, there has not yet been a systematic attempt to identify reliable parenting strategies that could be used with young children to help prevent the onset of body dissatisfaction and unhealthy eating patterns. The delineation of safe and effective parenting strategies would create a foundation for prevention programs designed for parents of young children, which could be provided in the family rather than school setting. However, traditional research methods such as longitudinal observation and experimental designs are sparse and difficult to achieve in this area, because of the very large sample sizes needed and the complexity of the multitudinous parenting and environmental variables impacting on child body image and eating patterns (Rodgers & Chabrol, 2009). In addition, although the academic literature provides an understanding of the risk factors associated with the development of body dissatisfaction and unhealthy eating patterns, a systematic review is unlikely to provide guidance for parents, as public health commentators have noted the dearth of experimental data being translated into practical strategies and resources useful for parenting (Hart et al., 2014, Schwartz et al., 2011).
An alternative approach to identifying parenting strategies is to use clinical and research expertise to develop consensus guidelines. The Delphi consensus method is a mixed qualitative and quantitative research framework for gathering expert opinion (Hasson et al., 2000, Linstone and Turoff, 1975), which has been used widely in public mental health over the last decade, and in particular, to develop guidelines for parents on the prevention of alcohol misuse (Ryan et al., 2011), and depression and anxiety disorders (Yap, Pilkington, Ryan, Kelly, & Jorm, 2014). These guidelines have not only been used as an accessible resource for parents, they have also been used as a framework to develop more complex intervention resources for population-level prevention interventions (Jorm and Kitchener, 2011, Yap et al., 2011). The aim of the current study was therefore to develop guidelines for parents to prevent body dissatisfaction and unhealthy eating patterns in preschool children, by using the Delphi method for establishing expert consensus.
Section snippets
Participants
Experts involved in treatment, research, or education in the fields of body image, eating disorders, or parenting were invited to participate on the expert panel. Expertise was determined through authoring relevant books or scientific papers, or membership in key professional or advocacy groups (e.g., member of Academy for Eating Disorders, Body Image and Prevention Special Interest Group). Experts were recruited via an emailed invitation to participate accompanied by an information sheet about
Results
The systematic search revealed that there were numerous publications on parenting strategies addressing the development of body image and healthy eating patterns in children. The major sources of information were websites about child health (e.g., www.kidshealth.org, www.raisehealthyeaters.com, www.raisingchildren.net.au), publications by eating disorder organizations (e.g., Anorexia Nervosa and Related Disorders Inc. and National Eating Disorder Association), and fact-sheets and books written
Discussion
The current study used the Delphi method to develop guidelines for parents to help prevent body dissatisfaction and unhealthy eating patterns from developing in their preschool children. The expert participants were able to reach consensus on a wide range of issues represented by the proposed parenting strategies. Statements that reflected an acceptance of body diversity and appreciation of personal worth, rather than appearance, were highly rated. There was also a high level of agreement on
Acknowledgements
This research was funded by a grant from the Faculty of Science, Technology and Engineering, La Trobe University awarded to Laura Hart and Susan Paxton, and by a grant from the CAGES Foundation awarded to Susan Paxton.
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