MANOVA

Research Article

Feeding and Mealtime Correlates of Maternal Concern About Children’s Weight

Jacqueline M. Branch, MD1; Danielle P. Appugliese, MPH2; Katherine L. Rosenblum, PhD3,4; Alison L. Miller, PhD4,5; Julie C. Lumeng, MD1,4,6; Katherine W. Bauer, PhD6

1Departm School, 2 Appugl 3Departm 4Center 5 Departm Public H 6Departm Arbor, M Conflict o with thi Address Develop MI 4810 �2017 S reserved http://dx

490

ABSTRACT

Objective: To examine associations between maternal concern regarding their children becoming overweight and two domains of weight-related parenting; child feeding practices and family meal charac- teristics. Design: Cross-sectional study. Participants: Low-income mothers (n ¼ 264; 67% non-Hispanic white) and their children (51.5% male, aged 4.02–8.06 years). Variables Measured: Maternal concern and feeding practices, using the Child Feeding Questionnaire. Meal characteristics were assessed using video-recorded meals and meal information collected from mothers. Analysis: The authors used MANOVA and logistic regression to identify differences in maternal feeding practices and family meal characteristics across levels of maternal concern (none, some, and high). Results: Approximately half of mothers were not concerned about their child becoming overweight, 28.4% reported some concern, and 19.0% had high concern. Mothers reporting no concern described lower restrictive feeding compared with mothers who reported some or high concern (mean [SE], none ¼ 3.1 [0.1]; some ¼ 3.5 [0.1]; and high ¼ 3.6 [0.1]; P ¼ .004). No differences in other feeding practices or family meal characteristics were observed by level of concern. Conclusions and Implications: Concern regarding children becoming overweight was common. However, concern rarely translated into healthier feeding practices or family meal characteristics. Maternal concern alone may not be sufficient to motivate action to reduce children’s risk of obesity. Key Words: childhood obesity, maternal concern, feeding practices, family meals (J Nutr Educ Behav. 2017;49:490-496.)

Accepted March 16, 2017. Published online April 28, 2017.

INTRODUCTION

Despite the heightened attention to childhood obesity over the pastdecade, several studies documented that only a limited proportion ofparents recognize that their children are overweight, and

ent of Pediatrics and Communicable Ann Arbor, MI iese Professional Advisors, North Easto ent of Psychiatry, University of Mich

for Human Growth and Development ent of Health Behavior and Health Ed ealth, Ann Arbor, MI ent of Nutritional Sciences, University I f Interest Disclosure: The authors’ confli s article on www.jneb.org. for correspondence: Jacqueline M. Bra ment, 300 North Ingalls Bldg, Rm 1024 9; Phone: (716) 785-2244; Fax: (734) 93 ociety for Nutrition Education and Beh . .doi.org/10.1016/j.jneb.2017.03.011

relatively few parents reported concern about their children's current weight or future risk of becoming overweight.1-6

Parents of young children and lower socioeconomic status in particular reported less concern about their children's current or future risk of overweight than did

Diseases, University of Michigan Medical

n, MA igan Medical School, Ann Arbor, MI , University of Michigan, Ann Arbor, MI ucation, University of Michigan School of

of Michigan School of Public Health, Ann

ct of interest disclosures can be found online

nch, MD, Center for Human Growth and NW, University of Michigan, Ann Arbor, 6-6897; E-mail: jmbranch@umich.edu avior. Published by Elsevier, Inc. All rights

Journal of Nutrition Education and Beh

parents of older children or higher socioeconomic status.1,2,4 This limited concern prompted calls for programs and policies to elevate parents' concern about obesity and/or their children's weight.2,3 Initiatives designed to increase parental concern about their children's weight included universal body mass index (BMI) screening during health care visits,7 BMI report cards,8 and me- dia campaigns highlighting the health risks of obesity.9

Interventions to elevate concern about childhood obesity assumed that parents who are concerned about their children'sweightaremorelikely totake actiontoimprovetheirchildren'sbehavior and weight status.8 For such interven- tions to be successful at reducing obesity, it is essential that concern prompts parents to participate in evidence-based approaches to improve children's en- ergy balance, and that actions do not contribute to weight gain or that there be other negative health problems. Ev- idence is mixed as to whether parental

avior � Volume 49, Number 6, 2017

Journal of Nutrition Education and Behavior � Volume 49, Number 6, 2017 Branch et al 491

concern about children's weight is associated with healthy changes in child weight6,10 or parents' participation in behaviors that promote children's healthy weight.1,4,11-14 Some studies found that parents who were concerned about their child's weight were more likely to limit screen time, encourage physical activity, and change the family diet, compared with parents who were not concerned.4,11 These evidence- based actions were recommended to address childhood obesity.7 However, 1 study found that parental concern about children's weight was not associ- ated with healthier food available in the home.1 Furthermore, parents who wereconcernedreportedgreaterencour- agement of skipping meals and diet- ing, as well as higher use of restrictive feeding practices.1,11,12,14 These practices were associated with low body satisfaction, poorself-regulationofeating,increased binge eating, and a greater risk of obesity.15-17 Based on this literature, evidence is insufficient to determine whether promoting concern will prompt engagement in evidence-based parenting practices to improve children's weight status. This lack of evidence is particu- larly true for parents of young chil- dren, because the majority of studies of concern were conducted among parents of older grade school or adolescent-aged children.1,4,11,13

Given the need to understand the association between parental concern about young children's weight and parents' participation in actions that promote healthy behavior and weight, the aim of the current study was to examine differences within 2 domains of weight-related parenting: child feeding practices and family meal characteris- tics, among mothers of young children, by mothers' concern about their chil- dren becoming overweight. This study drew from data from ABC Feeding, which enrolled children eligible for Head Start and their caregivers. This study's population provided a unique perspective on how low-income mothers sought to address their children's risk for overweight and obesity. This insight is important given the increasing burden of childhood obesity among low- income families18 and the need to develop interventions that are effec- tive in this context.19 The authors hy- pothesized that greater concern by mothers that their child would become overweight would be associated with

more restrictive feeding and greater monitoring of child's eating, but less pressuring feeding practices. In addi- tion, the authors hypothesized that concern would be associated with fam- ily meal characteristics that reflected current clinical guidance for child nutri- tion promotion and obesity preven- tion and treatment.7,20

METHODS Study Design

The current cross-sectional study used data from the first measurement of ABC Feeding, a longitudinal study of maternal feeding practices.

Participants and Recruitment

The current study included a sample of 264 low-income female primary care- givers (mean age, 31.0 years; SD, 7.06 years; 67% non-Hispanic white; 45% single parent) and their children (mean age, 5.4 years; SD, 0.75 years; range, 4.0 to 8.1 years; 153 boys). The caregivers were predominantly (95%) biological mothers; therefore, caregivers will be referred to as mothers. These mother–child dyads were originally recruited via participation in Head Start programs in South Central Michigan and enrolled in ABC Preschool, a longi- tudinal study conducted between 2009 and 2011. All mothers enrolled were fluent in English and had less than a 4-year college degree. Approximately 2 years after participation in ABC Pre- school, mothers were invited to partic- ipate in a follow-up study on child feeding, ABC Feeding. Of the 380 care- givers invited, 284 participated and an additional 17 families were newly re- cruited from Head Start, which result- ing in a final sample size of 301. Among these dyads, 5 were excluded because the primary caregiver was male and 32 had incomplete data; this resulted in an analytic sample of 264 (87.7% of the total sample). The study proto- col was approved by the University of Michigan Institutional Review Board.

Measures

Mother–child dyads completed activ- ities over the course of 2 study visits. Mothers were provided a video cam- era during the second visit and were asked to record 3 routine, weeknight,

dinnertime meals within 1 week. After each recorded meal, mothers received a telephone call from a trained inter- viewer to collect information on the foods available to the child during the meal. After the meals were recorded, the camera was collected by study staff. This protocol was previously described in detail elsewhere.21

Maternal concern about child over- weight. Maternalconcernwasmeasured using 1 item from the Child Feeding Questionnaire22 that asked: How con- cernedareyouaboutyourchildbecoming overweight? Responses were rated on a 5-point scale with the response op- tions ranging from unconcerned to concerned. Responses were then cate- gorized into 3 levels of concern: no concern for mothers who reported they were unconcerned, some concern for mothers who reported the next 2 higher levels of concern, and high concern for mothers reporting the highest 2 levels of concern.

Maternal feeding practices. Three feeding practices were measured using the Child Feeding Questionnaire: pres- sure to eat (4 items, Cronbach a ¼ .62), restriction (8 items, Cronbach a ¼ .75), and monitoring (3 items, Cronbach a ¼ .86). Pressure to eat was assessed using items including: My child should always eat all of the food on her plate. Restriction was assessed using items including: I have to be sure that my child does not eat too many sweets (candy, ice cream, cake, or pastries). For both scales, responses were measured using a 5-point scale ranging from disagree to agree. Monitoring was assessed using items including: How much do you keep track of the snack food (potato chips, Doritos, or cheese puffs) that your child eats? Responses were measured using a 5-point scale ranging from never to always.

Meal characteristics. Characteristics of typical family meals were measured using video recorded meal observations and meal information collected from mothers.Tocollectthemealdata,mothers were asked to video record 3 dinner- time family meals over the course of 1 week occurring when the mother was home and awake, when the meal occurred at home, and when the meal was prepared by the primary caregiver.

492 Branch et al Journal of Nutrition Education and Behavior � Volume 49, Number 6, 2017

To record the meals, mothers were instructed to set up the camera so that the child's upper torso, plate, and drink were always visible, and to record the entirety of each meal. To quantify the data collected during the observations, the study team devel- oped a coding scheme adapted from prior approaches23,24 to code each meal with regard to whether the meal was pre-plated (vs served family style or eaten out of the serving package), the television was audible, the mother ate with the child for any portion of the meal, and, if requested by the child, the mother allowed second serv- ings. Coders were trained to increase reliability; 12% of videos were coded by 2 raters and interrater reliability by Cohen's kappa exceeded 0.70 for all codes. Each family meal characteristic was coded affirmatively if it was observed in at least half of meals.

Foods served during family meals. Information on foods served during the meal was obtained from the meal report collected from mothers by inter- viewers after each recorded meal. Each meal report was coded into food and beverage categories determined by the groupings on ChooseMyPlate.gov in accordance with the current US Dietary Guidelines for Americans.25 The pres- enceorabsenceofeachfoodorbeverage group for each meal was coded. The preparation method for meats (ie, deep frying vs not) was identified by the food name (ie, chicken nuggets, fish sticks), and coded accordingly.21

To obtain a composite measure of food and beverage types served during family meals, families were coded as typically serving fruits, vegetables, and refined grains if these foods were reported as present in at least half of meals. Food types that were overall less prevalent and would not be expected to be served at every meal were coded as typically served if they were present in any of the meals. These included dark greenvegetables,wholegrains,deepfried proteins, low-fat or skim milk, diet drinks, sugar-sweetened beverages, and dessert (including ice cream, frozen yogurt, pudding, and other nondairy sweets).

Sociodemographic characteristics. Mothers reported their child's sex and birth date, and maternal education and race/ethnicity. Child birth date

was used to calculate the child's age by subtracting the birth date from the date of the first study visit. Maternal education was included as high school diploma or less or equivalent vs more than high school diploma, with the highest educational level in this sample being less than a 4-year college degree. Maternal race/ethnicity was included as non-Hispanic white vs Hispanic and/or not white.

Maternal and child anthropometrics. Heights and weights of mothers and children were measured according to standardized procedures.26 Body mass index was calculated as weight in kilo- grams divided by height in meters squared. For 12 mothers who were preg- nant or had given birth within the past 3 months, self-reported pre-pregnancy weight was used. Body mass index z- scores and percentiles were calculated for children, and children were catego- rized as being underweight or normal weight (BMI < 85th percentile for age and sex), or overweight or obese (BMI $ 85th percentile for age and sex) based on the US Centers for Dis- ease Control and Prevention growth charts.27 Only 3 children were under- weight; therefore, underweight and normal weight were combined.

Data Analysis

The researchers examined bivariate differences in sociodemographic and anthropometric characteristics by level of maternal concern using ANOVA and Pearson chi square tests. They used MANOVA to identify differences in mean maternal feeding practices by level of maternal concern adjusted for child sex, age, race/ethnicity, BMI z-score, and maternal education and BMI, and calculated adjusted means for each level of maternal concern. For feeding practices in which overall differences in means were detected, pairwise com- parisons wereusedto identifydifferences between levels of concern. Unadjusted prevalence of family meal characteris- tics and foods served were calculated for each level of concern. Multivari- able logistic regression was then used to examine associations between level of maternal concern and each meal characteristic or food served, adjusted for covariates. All analyses were run for the full sample and were also

limited to the dyads with overweight andobesechildren.Findingsdidnotdiffer; therefore, results from the full sample are presented. All analyses were con- ducted using SAS software (version 9.3; SAS Institute, Inc., Cary, NC); P < .05 was used to indicate statistical signifi- cance.

RESULTS Characteristics of Maternal Concern

Among this sample of low-income mothers, 52.7% reported that they were not concerned about their child becoming overweight, 28.4% reported some concern, and 18.9% reported high concern (Table 1). Concern about the child becoming overweight did not differ by maternal education (P ¼ .89) or child's sex (P ¼ .52), race/ethnicity (P ¼ .21), or age (P ¼ .76). Differences in maternal concern were observed by child BMI z-score (P < .001) and weight status (P < .001), and maternal BMI (P < .001). Among mothers of under- weight or normal weight children, 7.2%reportedhighconcernabouttheir child becoming overweight whereas 34.9% of mothers of children with overweight or obesity reported high concern. A total of 29% of mothers of children with overweight or obesity re- ported no concern about their child becoming overweight.

Maternal Concern and Child Feeding Practices

Maternal concern about the child becoming overweight was associated with greater use of restrictive feeding practices (Table 2). Among mothers re- porting no concern, mean restrictive feeding was significantly lower than that for mothers reporting some or high concern (mean [SE], 3.1 [0.08], 3.5 [0.11], and 3.6 [0.14], respectively; P ¼ .004). Mean restrictive feeding scores did not differ between mothers reportingsomevshighconcern.Nodif- ferences were observed by level of concern in mothers' report of moni- toring or pressure to eat.

Maternal Concern and Meal Characteristics

No differences in characteristics or con- tent of family meals were observed by

Table 1. Sociodemographic and Weight Characteristics of Children and Mothers, in Total and by Maternal Concern

Child and Maternal Characteristics Total Sample

Maternal Concern About Child Becoming Overweight

PNone Some High

Total sample (% [n]) 100.0 (264) 52.7 (139) 28.4 (75) 18.9 (50) Child characteristics Child gender (% [n]) .52 Male 51.5 (136) 55.9 (76) 25.7 (35) 18.4 (25) Female 48.5 (128) 49.2 (63) 31.3 (40) 19.5 (25)

Child race/ethnicity (% [n]) .21 Non-Hispanic white 55.3 (146) 57.5 (84) 25.3 (37) 17.1 (25) Hispanic or not white 44.7 (118) 46.6 (55) 32.2 (38) 21.2 (25) Child age, mo (mean [SD]) 70.8 (8.4) 70.8 (0.7) 70.3 (1.0) 71.5 (1.2) .76 Child BMI z-score (mean [SD]) 0.9 (1.0) 0.4 (0.1) 1.1 (0.1) 1.7 (0.1) <.001

Child weight status (% [n]) <.001 Underweight/normal weight 58.4 (153) 69.9 (107) 22.9 (35) 7.2 (11) Overweight/obese 41.6 (109) 29.4 (32) 35.8 (39) 34.9 (38)

Maternal characteristics Maternal education (% [n]) .89 High school diploma/General Equivalency Diploma/less

47.0 (124) 51.6 (64) 30.0 (37) 18.6 (23)

At least some college education 53.0 (140) 53.6 (75) 27.1 (38) 19.3 (27) Maternal BMI (mean [SD]) 33.2 (9.4) 30.8 (0.8) 34.7 (1.0) 37.8 (1.3) <.001

BMI indicates body mass index. Note: Pearson chi-square and ANOVA were used to examine differences in child and maternal characteristics by level of maternal concern.

Journal of Nutrition Education and Behavior � Volume 49, Number 6, 2017 Branch et al 493

level of mothers' concern (Table 3). For example, the prevalence of mothers pre-platingtheirchildren'smeals,eating withchildren,allowingsecondservings, and serving fruits, vegetables, sugar- sweetened beverages, and desserts were similar across levels of concern. Overall, vegetables, refined grains, and fried proteins were commonly avail- able during meals. For example, vege- tables were served at 89.2% to 94.0% of meals. Sugar-sweetened beverages were also typically available during meals; 60.0% to 68.0% of families

Table 2. Associations Between Maternal C

Maternal Concern About Child Becoming Overweight

Restr Practic

M

None

Some

High

Fdegrees of freedom ¼ 2 P

Notes: Multivariate ANOVA adjusted for education and BMI was used to examine significantly different values by level of co

served a sugar-sweetened beverage during at least 1 meal. Fruit, whole grains, and low fat or skim milk were less commonly served during observed meals.

DISCUSSION

The objectives of the current study were to examine maternal concern regarding youngchildren's risk forbecoming over- weight and to identify differences in child feeding practices and family meal

oncern About Child Becoming Overweight an

ictive Feeding es (Range, 1–5)

Monitoring Ch Eating (Range, 1

ean (SE) Mean (SE)

3.1 (0.1)a 3.9 (0.1)

3.5 (0.1)b 4.0 (0.1)

3.6 (0.1)b 4.3 (0.2)

5.7 1.6

.004 .20

child gender, age, race/ethnicity, body ma differences by level of maternal concern. Di ncern at P < .05.

routines among mothers with differing levels of concern. Approximately half of mothers reported some level of concern about their child becoming overweight; over 70% of mothers of currently overweight or obese children reported at least some concern. These findings run counter to the prominent belief that mothers, especially mothers of young children and those of low so- cioeconomic status, had limited concern about obesity among their children.1-6,14

Thisdifferencemaybebecausearelatively contemporary sample of mothers was

d Maternal Feeding Practices

ild –5)

Pressuring Feeding Practices (Range, 1–5)

Mean (SE)

2.7 (0.1)

2.8 (0.1)

2.8 (0.2)

0.04

.96

ss index (BMI) z-score, and maternal ffering superscripts indicate statistically

Table 3. Associations Between Maternal Concern About Child Becoming Overweight and Family Meal Characteristics

Family Meal Characteristics

Maternal Concern About Child Becoming Overweight Adjusted Comparisonsa

Unadjusted Prevalence OR (95% CI) P

OR (95% CI) PNone Low High Low vs None High vs None

Meal characteristics Dinner pre-plated 87.6 80.3 79.1 0.6 (0.2–1.4) .23 0.8 (0.2–2.5) .66 Television audible during dinner 64.6 68.1 72.7 0.9 (0.4–2.1) .78 1.5 (0.5–4.5) .44 Mother eats with child 82.4 84.1 88.1 1.1 (0.4–2.7) .92 1.5 (0.4–5.8) .53 Mother allows second serving 46.8 44.0 46.0 0.93 (0.5–1.7) .82 1.1 (0.5–2.5) .78

Foods served during meals Fruit 13.0 13.3 18.0 0.9 (0.4–2.2) .78 0.9 (0.3–2.7) .83 Vegetables 89.2 92.0 94.0 1.2 (0.4–3.4) .78 1.5 (0.3–6.4) .61 Dark green vegetables 18.0 24.0 16.0 1.5 (0.7–3.4) .28 0.9 (0.3–2.6) .87 Refined grains 71.9 80.0 72.0 1.1 (0.5–2.4) .75 0.6 (0.3–1.5) .28 Whole grains 12.2 13.3 14.0 1.1 (0.4–2.8) .86 1.5 (0.5–4.5) .51 Fried protein 32.4 44.0 28.0 1.9 (1.0–3.6) .05 1.1 (0.4–2.5) .92 Low fat/skim milk 6.2 9.0 16.3 1.5 (0.5–4.7) .53 2.7 (0.7–10.5) .15 Diet beverages 2.2 2.7 4.0 0.9 (0.1–6.5) .88 1.0 (0.1–10.6) .99 Sugar-sweetened beverages 62.6 68.0 60.0 1.2 (0.6–2.2) .68 0.8 (0.3–1.7) .52 Dessert 19.4 17.3 20.0 0.8 (0.4–1.9) .67 0.8 (0.3–2.3) .73

CI indicates confidence interval; OR, odds ratio. aLogistic regression models adjusted for child gender, age, race/ethnicity, body mass index (BMI) z-score, and maternal education and BMI were used to examine the odds of foods or drinks served given the level of maternal concern.

494 Branch et al Journal of Nutrition Education and Behavior � Volume 49, Number 6, 2017

used among whom obesity was discussed. For example, Head Start regularly provides parental education regarding child nut- rition and obesity prevention. Maternal concern about the child becoming ove- rweight was also positively associated with mothers' own BMI. This heightened concern may reflect that mothers with higher BMIs are more likely to have children with higher BMIs. Mothers with higher BMIs may recognize that their children are at risk of overweight and obesity in the future owing to a family history of obesity.

Despite the high levels of concern about future overweight among low- income mothers, few differences in maternal behavior were observed by level of concern. In particular, concern about children's risk of becoming over- weight did not manifest as differences in family meal practices or food avail- ability. These findings differed from pre- vious studies in which maternal concern about child weight was associated with parental reports that they engaged in actionstotrytoimprovetheirchildren's diets.4,11 The current study differed from those previous studies in the use of observed mealtime characteristics, vs parent-reported behaviors, which may explain the difference in findings.

Social desirability may lead parents with high concern regarding their child's weight to report they are en- gaging in action, even if they are not. Alternatively, the researchers' measure- ment of family meals may not repre- sent behaviors that occurred outside thesemeals:forexample,atothermeals or snacks. Furthermore, the current study drew from an exclusively low- income sample, which may explain dif- ferences in findings. Findings demon- strated that regardless of maternal concern, many family meals did not reflect recommendations to promo- te healthy weight among children. Common family meals had sugar- sweetened beverages, refined grains, and fried proteins available, with the television audible, whereas meals with dark green vegetables, whole grains, and low-fat or skim milk were relatively uncommon. These meal characteris- tics,evenamongmotherswhoreported high concern that their children would becomeoverweight,mayhavereflected unclear guidance regarding what con- stitutes a healthy meal. These meals may also have been a product of time or financial limitations, or competing food preferences among children or other family members in the home.

In the current study, mothers who reported any level of concern about their child becoming overweight also reported greater use of restrictive feeding practices compared with mothers who reported no concern. Similar associa- tions between concern about child weight and restrictive feeding were demonstrated in other studies.1,12-14

Restrictive feeding practices were associated with increased disinhibi- ted eating and weight gain among children28-31; therefore, current obesity prevention and treatment guidelines recommended that parents avoid overly restrictive feeding practices.7 However, additional evidence suggested that mothers' restrictive feeding is often a response to concern about children's weight and obesogenic eating and weight gain among children, and not a cause of these outcomes.13,32 Given the consistency with which maternal con- cern about child weight and use of restrictive feeding practices are assoc- iated, further research is needed to understand how mothers can limit children's eating effectively without promoting negative outcomes.

There were several limitations to the current study. First, only 2–3 meals were observed per family and

Journal of Nutrition Education and Behavior � Volume 49, Number 6, 2017 Branch et al 495

the meals may not be representative of typical meals. Families may have served different foods or conducted the family meal differently than they would typically because they were be- ing recorded. In addition, the authors were not able to capture the portion sizes that were available or served in a valid manner. Although parents with high concern for child weight may not alter what is served, they may modify the amount of each food available to the child. Despite these limitations, objective observa- tions of family meals provide unique information about behavior and food availability during meals that may not be captured through self-report. Sec- ond, the study sample was exclusively low-income families, who often expe- rience unique barriers to providing health-promoting meals; therefore, findings may not be generalizable to higher-income families. Additionally, the pressure to eat sub-scale had only moderate internal reliability. Finally, the current measure of maternal concern about child weight captured concern about future risk of overweight. This measure is commonly used to examine maternal concern about child weight, but it does not capture concern about current weight. Parents who are con- cerned that their child is currently overweight may be more likely to sup- port children's healthy eating and modify family meals, whereas parents who are concerned that their child may become overweight in the future may see less immediate need to imple- ment these changes.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Among low-income mothers, concern regarding children becoming over- weight was common and highly preva- lent among mothers of children who werealreadyoverweightorobese.Whereas restrictive feeding practices were more likely to be reported by mothers who were concerned about their children's future risk of overweight, maternal concernwas notassociatedwithgreater monitoring of child eating or healthier characteristics of family meals. Further research is needed to understand the characteristics of families among whom concern about child weight prompts

healthy actions to prevent obesity. In addition, because the existing litera- ture, including this study, used a vari- ety of measures of parental concern about child weight, greater consis- tency in the use of measures that validly capture bothconcern aboutcur- rent weight and future weight may clarify what types of concern prompt parental action. Currently, these find- ings suggest that future family-based interventions to address childhood obesity may be more likely to be bene- ficial if they do not focus merely on raising parental concern about chil- dren's risk of becoming overweight, but assist parents in overcoming bar- riers to engaging in health-promoting practices.

ACKNOWLEDGMENTS

The ABC Feeding study was supported by the National Institutes of Health/ National Institute of Child Health and Human Development R01 HD061356 (PI: Lumeng). Dr Branch is supported by National Institutes of Health/Na- tional Institute of Child Health and Human Development T32 HD079350 (PI: Lumeng).

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CONFLICT OF INTEREST

The authors have not stated any con- flicts of interest.