Childhood obesity is a serious and growing problem especially in low-income populations in the United States (U.S.) (Deckelbaum & Williams, 2001; Ogden et al., 2006). The prevalence of obesity is higher in African American (19%) than non-Hispanic white (11%) children in the U.S. (Dwyer et al., 2000; Hedley et al., 2004; Sherry, Mei, Scanlon, Mokdad, & Grurnmer-Strawn, 2004; Sherwood, Story, & Obarzanek, 2004). In a prospective cohort study of the National Longitudinal Survey of Youth, the prevalence of childhood overweight was 21.5% in African Americans compared to12.3% in Whites (Strauss & Pollack, 2001). Furthermore, a high incidence of obesity was observed among children born to single, non-working, and less educated mothers in a longitudinal study (Strauss & Knight, 1999). Childhood obesity, especially in the toddler years, increases the likelihood of adult obesity (Freedman et al., 2005; Guo, Wu, Chumlea, & Roche, 2002; Magarey, Daniels, Boulton, & Cockington, 2003).
Given the fact that childhood obesity is increasingly prevalent in ethnic minorities, parent food consumption, parent and toddler feeding behaviors, and parental characteristics may be important contributing factors since parental influence on children's food choices predominate during toddlerhood (Bante, Elliott, Harrod, & Haire-Joshu, 2008; Skinner, Carruth, Bounds, & Ziegler, 2002; Wardle, Carnell, & Cooke, 2005). Although obesity is a multi-factorial condition, infant and child feeding practices are among the influencing factors that may lead to excess consumption of calories and thereby result in weight gain (Kumanyika, 2008). In addition, racial/ ethnic differences in feeding behaviors should be an important consideration because studies have shown parent-child correlations in diet, food preferences and diet-related disease risk factors (Skinner, Carruth, Bounds, Ziegler, & Reidy, 2002; Skinner, Carruth, Bounds, & Ziegler, 2002; Wardle et al., 2005).
Culture plays an influential role in parental beliefs, values, and behaviors pertaining to food choices and eating habits and hence parental feeding practices (Bruss et al., 2005). In addition, racial/ethnic disparities in parental feeding behaviors have been shown to be associated with childhood obesity and nutritional deficiencies (Brotanek, Halterman, Auinger, Flores, & Weitzman, 2005; Taveras, Gillman, Kleinman, Rich-Edwards, & Rifas-Shiman, 2010). According to Gregg and Saha (Gregg & Saha, 2006), culture cannot be ignored in health or health care settings because it affects all aspects of life including health behaviors and plays an important role in alleviating/ exacerbating health disparities by potentially working in conjunction with economic and social factors.
An evaluation of a pilot study, the Nutrition Education Aimed at Toddler (NEAT) program with 38 low-income mother-toddler dyads showed that although mothers of the children enrolled in the Early Head Start program had adequate nutrition knowledge and attitudes toward feeding behaviors, they did not apply their knowledge of appropriate feeding practices (Horodynski, Hoerr, & Coleman, 2004). This was especially true in the case of serving fruits and vegetables. This study also documented the poor nutritional quality of the diet of both the mothers and toddlers. Only 13% and 9% of all the mothers and toddlers, respectively, consumed at least one serving of each of the food groups recommended by the food guide pyramid. This was followed by a larger study (Horodynski & Stommel, 2005) with 135 low-income mother-toddler dyads with similar results. In addition, the home environment during mealtimes which included television watching during mealtime affected toddler eating. Consumption of fruits and vegetables by children has been shown to be highly correlated with availability and accessibility at home (Cullen et al., 2003; Kratt, Reynolds, & Shewchuk, 2000).
Feeding practices and mealtime behaviors are also important determinants of food intake patterns and, hence, nutritional adequacy in children (Y. Lee, Mitchell, Smiciklas-Wright, & Birch, 2001). Examples include the extent of parental mealtime involvement and toddler participation in the meal, specifically with regard to exertion of choice in eating and food intake. Others include emphasis on mealtime TV viewing (Coon, Goldberg, Rogers, & Tucker, 2001; Freedman et al., 2005; Horodynski, Brophy-Herb, Henry, Smith, & Weatherspoon, 2009; Jordan & Robinson, 2008), mealtime interactions (Bante et al., 2008; Faith et al., 2003), perceptions of the child as a picky eater (Carruth, Ziegler, Gordon, & Barr, 2004; Horodynski et al., 2009), and a mother's tendency to be distressed (Hurley, Black, Papas, & Canfield, 2008). Parents tend to be role models and thus influence their children's food-related behaviors, especially with regard to critical support for the child to learn self-regulation or exertion of choice in eating and food intake (Carruth, Ziegler, Gordon, & Hendricks, 2004; Fisher & Birch, 1995; S. M. Lee & Reicks, 2004; Savage, Fisher, & Birch, 2007; Young, Fors, & Hayes, 2004). Excessive parental influence over child feeding behaviors such as encouraging them to clean their plate or restricting them to eat only during mealtime may result in low self-regulation of calorie intake in children (Johnson, 2000). At the same time, children tend to make less healthy food choices in the absence of parental supervision (Klesges, Stein, Eck, Isbell, & Klesges, 1991). Parents are, therefore, responsible for providing healthy food choices that are easily accessible and the children need to be allowed to self-select and decide how much to consume (Dietz & Gortmaker, 2001).
Previous studies have shown that African American mothers exhibit more food/meal monitoring, restriction practices, pressure to eat and concern about their child's weight than non-Hispanic white mothers (Spruijt-Metz, Lindquist, Birch, Fisher, & Goran, 2002; Spruit-Metz, Li, Cohen, Birch, & Goran, 2006). In a national longitudinal survey of youth, non-Hispanic white mothers, reported that they offered more food choices during meals than African American or Hispanic mothers (Faith et al., 2003). Thus, ethnic differences in maternal feeding practices could possibly impact weight status and explain the disparity in obesity rates in African American and non-Hispanic white toddlers.
Picky eating behavior has been widely reported by mothers of children of both sexes. In the Feeding Infants and Toddler study (FITS), picky eaters as identified by their caregivers increased from 19% to 50% between infancy and toddlerhood (Carruth, Ziegler, Gordon, & Barr, 2004). Data from the same survey did not show any cultural differences between African American and non-Hispanic white children. However, this could be due to uneven distribution of the sample as 7% were African American and 77% were non-Hispanic white (Carruth, Ziegler, Gordon, & Barr, 2004). Horodynski et al. documented that force-feeding by a few mothers was associated with the fear of malnourishment of their child due to the child's picky eating behavior (Horodynski et al., 2009).
A growing body of literature on toddler health and food consumption identifies TV viewing as a potential influential factor of the childhood obesity epidemic (Jordan & Robinson, 2008; Xu, Li, Ware, & Owen, 2008). TV viewing is not only associated with decreased physical activity, but also with increased exposure to foods rich in fat and added sugars through advertisements and commercials. Borzekowski and Robinson emphasized that the type of television programs could be more influential than the duration of TV viewing. In their study, just one or two exposures were adequate to affect the short-term preferences of 2 - 6 year old children for the advertised products (Borzekowski & Robinson, 2001). At the same time, studies have documented an association between longer hours of TV viewing and overweight children and adolescents (Ariza, Chen, Binns, & Christoffel, 2004; Danner, 2008). Thus, regardless of the hours watched, TV viewing in general could have an impact on the food preferences of toddlers.
In addition to maternal food intake and feeding practices, maternal socio-demographic characteristics could also be important determinants of toddlers' food choices. There is a paucity of studies comparing the above characteristics in relation to the frequency of nutrient-dense and energy-dense food choices made by low-income African American and non-Hispanic white parent-toddler dyads. Therefore, the main objectives of this study were to compare food patterns and mealtime behaviors of low-income African American mothers (AAM) and toddlers (AAT) and non-Hispanic white mothers (NHWM) and toddlers (NHWT), and to determine which factors predict nutrient-dense and energy-dense food intake by AA and NHW mothers and toddlers.
We hypothesized that there would be differences in food patterns and mealtime behaviors between the two racial groups, even though both were low-income, potentially due to cultural differences.
METHODS
Information on mother and toddler food intake and toddler-mother mealtime interactions was collected in a cross-sectional survey. The participants were 199 African American and 200 non-Hispanic white low-income toddler-mother dyads enrolled in Early Head Start (EHS) programs in a mid-western state. Early Head Start is a two-generational program designed to provide child and family development services including nutrition-related assessments to lower-income pregnant women and their infants or toddlers. Mothers (18-45 yrs) of toddlers (between the ages of 12 and 36 months), who identified themselves as English-speaking and either as African American or non-Hispanic white, were invited to participate in this study. However, the final sample also consisted of a proportion of slightly older children (n=37) who were between 36 and 48 months of age. Written consent was obtained from the participants and an incentive for participation was awarded for the completion of the survey instruments. Mothers were assured that participation in this study would not affect the standard services provided by the EHS program. Institutional Review Board approval for the protection of human subjects was obtained prior to study commencement.
Mothers were recruited by EHS staff verbally as well as through hand-delivered letters and flyers posted in EHS sites and distributed to EHS mothers. A member of the research team contacted interested mothers for further explanations. Mothers completed the survey instruments during an in-home visit with a trained data collector. During the in-home survey, the data collector measured the height and weight of both the toddler and the mother. Data collectors also observed one mealtime feeding situation between the mother and toddler for all participants and two feeding observations for a subset of 80 in order to determine if there were any notable differences or inconsistent observations compared to the reported food frequency data.
Food intake and related information: We adapted the Gladys Block, Food Frequency Questionnaires, which have been validated for adults and children to assess the usual weekly food intake of toddlers and mothers (Boucher et al., 2006; Cullen, Watson, & Zakeri, 2008). Mothers reported the frequency of consumption of commonly eaten foods in a week based on a three-point scale as 'rarely/never', '3 or fewer times/week' or '4 or more times a week' for themselves as well as their toddlers. In addition, mothers were asked if they perceived "cooking as a chore" and their response was measured via a five point Likert scale (1= strongly disagree and 5 = strongly agree). Foods included in the FFQ were classified as nutrient-dense or energy-dense based on their nutrient or calorie density (Drewnowski, 2005). Nutrient-dense (vegetables, fruits, and unsweetened cereals) and calorie/energy-dense (sweetened baked goods, cookies and pastries, salty high fat snacks, fried foods, sweetened cereals and sweetened drinks) food scales were developed by combining responses to the above mentioned four and seven items of the FFQ respectively. The scale values ranged from one to five representing the relative frequency of weekly consumption of nutrient-dense and energy-dense foods.
The Toddler and Parent Mealtime Behavior Questionnaire (TPMBQ): The TPMBQ was adapted from the Children's Eating Behavior Inventory, which assesses toddler-feeding self-involvement (Archer, Rosenbaum, & Streiner, 1991). The instrument consists of six subscales with a total of 34 items and provides a measure of parents' self-report of toddlers' eating and mealtime behaviors. Mothers indicated on a 5-point Likert response scale how often the behavior occurs (i.e., never, rarely, sometimes, often, always). The TPMBQ subscales were validated with mealtime observations by the interviewer. The reliability for subscales were as follows: (i) Emphasis on television watching during mealtime (Cronbach's α=0.89) was assessed by whether the TV was on during mealtimes and present in the same room where the family ate, and whether the mother or child watched TV during meal times; (ii) Mother's supervision over toddler meals (Cronbach's α=0.62) measured the extent of mother's decision making during mealtimes. The items of this subscale pertained to feeding the child, making sure that the child tastes all foods served and/or finishes the food on the plate, number of meals the child eats and decisions about when to eat, what foods to eat, and when the child is done; (iii) Toddler involvement in mealtime (Cronbach's α=0.64) had similar items as the sub-scale that assessed mother's control, however in this case, the toddler made or was allowed to make the decisions about mealtimes; (iv) Mother emphasis on social interaction during mealtime (Cronbach's α=0.83) assessed the interaction between the mother and the child during meals, such as accompaniment of the mother while eating, talk to and listen to the child, encourage the child to talk, face the child and provide complete attention during mealtimes; (v) Toddler viewed as picky eater by the mother (Cronbach's α=0.73) consisted of the items that asked about the toddler's acceptance and willingness to try new foods, refusal of fruits vegetables and meat, preference for fast foods, sweets and fruit juice; and (vi) Mothers' distress during mealtime (Cronbach's α=0.79) was formed by combining items about mothers' perceptions about how enjoyable mealtimes are, how much effort they take, mother's patience, ability to keep the child focused and difficulties in dealing with the child's behavior and activities such as refusing to eat or picking at food.
Data analysis: Data were analyzed using SPSS version 17.0 (SPSS Inc, Chicago, Ill) and preliminary statistics included frequency distributions, measures of central tendency and variability. Body mass index was calculated as kg/m2 for mothers and as percentiles for toddlers based on the CDC (Centers for Disease Control and Prevention) criteria("Centers for Disease Control and Prevention. Adult BMI Calculator: English,"; "Centers for Disease Control and Prevention. BMI-Body mass index: Child and teen calculator"). Independent t-tests were used to compare the mean scores of the six subscales of the TPMBQ as well as mothers' and toddlers' food intake between African Americans and non-Hispanic whites.
Prior to regression analysis, descriptive statistics and correlations among key variables were examined to rule out problems with multicollinearity. Predictors of nutrient-dense and energy-dense food consumption by African American and non-Hispanic white mothers and toddlers were independently determined by forced entry hierarchical linear regression models to be able to effectively compare the magnitude of coefficients between the two racial groups. Step 1 included the demographic characteristics. A few socio-demographic predictors, although not significant, were left in the final model if their p was <.1. The TPMBQ subscale scores were added as independent predictors in step 2. The interaction terms of the predictors with race were included in step 3, if they showed statistical significance (p<0.05). Mothers' consumption of nutrient-dense/ energy-dense foods were added in step 4, in order to examine the unique/additional effect of mothers' frequency of consumption of nutrient-dense/ energy-dense food consumption. The final models were chosen based on the R2 change and model significance (F change).
RESULTS
Sample characteristics: The characteristics of the toddlers and mothers are shown in tables 1 and 2, respectively. Most toddlers were in the 11-36 months of age with 11.5% AA and 13.6% NHW between 36and 48 months. Note regarding the older toddlers, 36-48 months of age. Mothers identified that their toddlers were 3 years old when recruited but were in fact slightly older when data collection occurred. Slightly more than half of the toddlers were females. NHWT were more likely to be in the normal weight range than AAT (55.3% vs. 41.7%; p<.001). The mean age was similar for AAM (26.5 yr) and NHWM (27.8 yr) but AAM were more likely to be single, working full time and students compared to NHWM (p<.01). More than one-third of the families had two or more other children in the household in both racial groups.
Differences in food consumption and mealtime behaviors: Differences in mealtime behaviors and the frequency of consumption of nutrient-dense and energy-dense foods by toddlers and mothers are summarized in Table 3. Mean (SD) frequency of consumption of energy-dense foods was significantly higher for AAM (2.68+0.78) and AAT (2.51+0.72) compared to NHWM (2.44+0.68) and NHWT (2.27+0.69) (p<. 01). With regard to mealtime behaviors, AAM were more likely to exert expectations more often over their toddlers' meals (3.20+0.68) and allow TV watching by the toddler and themselves during mealtimes (2.44+ 1.66) when compared to NHWM (2.93+0.61 and 2.02 +0.98), respectively) (p<. 001). About three-fourths of all the toddlers watched TV for 1-4 hours/day. The proportion of NHWT who never watched TV in a day, was significantly higher than the proportion of AAT (20.5% vs. 12.2%; p<.05) (data not shown). On the other hand, NHWT (3.69+0.69) participated more in mealtime behaviors such as food selection than AAT (3.33+0.77) (p<.001). AAM were also more likely to perceive cooking to be a chore.
Predictors of frequent consumption of nutrient-dense and energy-dense foods among AAT and NHWT: For both AAT and NHWT, Tables 4 and 5 show that mothers' frequent consumption of energy-dense (b=0.613, p<.001) and nutrient-dense foods (b=0.380, p<.001) predict the frequency of consumption of similar foods by the toddlers. In fact, mothers' consumption of energy-dense foods accounts for 37.3% of the variation in toddlers' consumption of these foods, while all other predictors combined account for 9.6% of the latter variation. Emphasis on social interaction during mealtimes (b=-0.132, p=0.001) lessened the frequency of energy-dense food consumption for toddlers. In addition, interaction between toddler control over mealtime behaviors and race was significantly associated with the frequency of energy-dense food consumption by toddlers (interaction b=-0.155, p=0.038). Thus, while average toddler control over mealtime behaviors appears to be higher among NHW toddlers (Table 3), greater control of mealtime behaviors by NHW toddlers is not associated with a decrease in the frequency of consumption of energy-dense foods (b=0.105, p>0.059). By contrast, average toddler control over mealtime behaviors among African Americans is lower than among NHWs (Table 3), but among AA toddlers, an increase in toddler control of mealtime behaviors may actually reduce the frequency of consuming energy-dense foods (b=-0.155, p<0.038).
We also observed an interaction between marital status and race, which significantly predicted the frequency of energy-dense food consumption by toddlers (interaction b= 0.245, p=0.036). Specifically, toddlers of non-Hispanic white single mothers consumed energy-dense foods less frequently than their married, widowed or divorced counterparts (b=-0.242, p-0.036); however, among African Americans we do not observe such a difference: the frequency of consuming energy-dense foods is virtually the same among toddlers of single AA women and married, widowed or divorced AA women (b=0.530).
Concerning the frequency of consumption of nutrient-dense foods, all the predictors together accounted for 31.4% of the variation in toddlers' consumption of these foods. Again, the mothers' consumption of nutrient-dense foods is the dominant factor, accounting for 15.9% in the variation of toddlers' consumption of nutrient-dense foods, with all other predictors accounting for 15.5%. The more a toddler was viewed as a picky eater by the mother, the less often did the toddler actually consume nutrient-dense foods (b=-0.237, p< .001), a relationship that is equally strong among AAs and NHWs. By contrast, emphasis on social interaction during mealtime tended to increase slightly the frequency of consuming nutrient-dense foods among both AA and NHW toddlers (b=0.097, p<0.046). The interaction between race and emphasis on TV watching during mealtimes was significant (p=0.027), indicating a differential effect of TV watching between the two race groups. While the overall level of emphasis on TV watching during meal time was higher among AA mothers (see Table 3), the more TV watching is emphasized by AA mothers, the less frequent do AA toddlers consume nutrient-dense foods (b=-0.063, p<0.027). Among NHW families, mothers tend to have a lower emphasis on TV watching during meals, but greater emphasis does not appear to affect the toddlers' consumption of nutrient-dense foods (b=0.070, p>0.138).
The unique contribution of the parent's feeding behaviors and its interaction with race accounted for only 1% each of the variation in toddlers' consumption of nutrient-dense and energy-dense foods, while all other predictors combined account for 25.5% of the variation for nutrient-dense and 45.4% for energy-dense food consumption, respectively (data not shown). These findings demonstrate that parent modeling more than the feeding behaviors may be more influential in determining the frequency of consumption of nutrient-dense and/or energy-dense foods by toddlers.
DISCUSSION
The primary purposes of this study were to examine food intake patterns and mealtime behaviors across African American and non-Hispanic white mother-toddler dyads, and to identify predictors of frequent intake of nutrient-dense and energy-dense foods in low-income toddlers and mothers. In general, data supported our hypothesis that food patterns and mealtime behaviors differed between the two racial groups, but the factors that influenced food consumption patterns and mealtime behaviors tend to be similar across the two racial groups.
Food intake patterns across racial groups: Based on our food intake, feeding behavior and maternal characteristics analyses in AA and NHW mothers and toddlers, African American mothers and toddlers consumed energy-dense foods more frequently than non-Hispanic whites. Similarly, for mealtime behavior sub-scales, AA mothers were more likely to exert mealtime and food expectations for their toddler's meals. Excessive parental food and/or eating expectations may be indicative of control and an important factor to be considered in African Americans. AAM also placed more emphasis on TV viewing during mealtimes and were more likely to perceive cooking as a chore than NHWM. Findings also suggested that AA mothers make more energy-dense food choices and practice less nutrient-dense feeding behaviors than NHWM. Because toddler food intake is critically dependent on parental guidance even though the toddlers can determine the amount of food eaten (Satter, 1990), these findings suggest issues of nutritional concern especially in African American parents and toddlers, who are disproportionately afflicted with diet-related diseases such as obesity and diabetes. Health outcomes especially obesity, which is increasing alarmingly in children, is of particular concern for these toddlers.
Allowing the toddler to participate in mealtime food choices was significantly higher in NHWT than AAT further supporting the notion that parenting style in the feeding context could contribute to poor dietary quality and perhaps even weight ( Hughes, Power, Orlet Fisher, Mueller, & Nicklas, 2005). Even though we did not assess self-regulation per se, children may fail to develop appropriate feeding self-regulation if there are extensive parental expectations and exertion of control over their meals (Birch & Fisher, 1998; Zive et al., 1998). Interestingly, a cross-sectional survey in London that assessed fruit and vegetable intake of 2 - 6 year old children showed that more parental control over a child's eating decreased the frequency of consumption of fruits and vegetables and increased their aversion to try new foods (Wardle et al., 2005).
Predictors of toddlers' energy-dense food consumption: In our regression analyses, regardless of ethnicity, maternal food preference/ intake appeared to be the dominant predictor of toddlers' energy-dense food consumption consistent with previous reports (Fisher, Mitchell, Smiciklas-Wright, & Birch, 2001, 2002; Skinner, Carruth, Bounds, Ziegler, et al., 2002). The availability and/or easy access to these food choices and, to some extent, parental modeling likely account for these associations (Cullen et al., 2003; Spurrier, Magarey, Golley, Curnow, & Sawyer, 2008; Tibbs et al., 2001).
Toddler-parent mealtime behaviors: Maternal perceptions of toddler being viewed as a picky eater and TV viewing during mealtimes, significantly predicted less frequent consumption of nutrient-dense foods by toddlers. Other studies have found that perception of children as picky eaters is problematic. For example, Hertler and Fray (1999) conducted a survey among childcare staff in Virginia, and reported picky eating, excessive preference for fast foods, reluctance to try new foods or vegetables and fondness for baked goods to be major caregiver concerns regarding preschool children. This is especially true because of the notion that picky eating might lead to inappropriate food choices in an attempt to appease the child; on the other hand, repeated offering of a variety of nutrient-dense food choices such as fruit and vegetables might actually resolve picky eating behavior by increasing the likelihood of acceptance (Hertzler & Frary, 1999; Skinner, Carruth, Bounds, & Ziegler, 2002). Research shows that at least ten prior exposures are necessary for a child to accept a certain food (Sanders, Patel, Legrice, & Shepherd, 1993; Satter, 1990; Sullivan & Birch, 1994). The child may dislike certain foods if the mother encourages, forces or offers rewards to make the child eat them (Birch & Fisher, 1998; Spurrier et al., 2008). Therefore, the mother should offer nutrient-dense food choices, but allow the child to self-regulate his/her food intake.
There are cultural differences in the maternal perceptions of toddler self-regulation of food intake. In a focus group study with mothers of toddlers African Americans believed that parents should be the primary decision makers of the quantity of foods consumed by toddlers (Horodynski et al., 2009). The same study showed that toddler self-feeding and regulation is sometimes not encouraged by some mothers to avoid the 'mess' and cleaning up (Horodynski et al., 2009). Children should not be encouraged to clean their plate after they feel that they are full. This practice will enable the child to respond to his or her body's hunger cues (Fox, Devaney, Reidy, Razafindrakoto, & Ziegler, 2006).
Lower prevalence of overweight/ obesity has been shown among children who eat dinner as a family (Anderson & Whitaker, 2010). Furthermore the frequency of family dinners were positively associated with reduced risk for being overweight (Veugelers & Fitzgerald, 2005). Studies have also shown that positive interaction with children during mealtimes improved their eating behavior. Interaction with children during mealtimes will facilitate children to have control over their mealtime behaviors and intake. Children with lack of control over eating i.e., consumption of large amounts of food were shown to have experienced lack of healthy communication and interpersonal engagement during mealtimes (Czaja, Hartmann, Rief, & Hilbert, 2011). In a focus group study of low-income African American mothers, the importance of mealtimes as a means of social interaction with the child or other family was not greatly emphasized. Although the mother was physically present during mealtimes, engagement in household chores or other activities were performed in lieu of mealtime interaction with toddlers (Horodynski et al., 2009).
Emphasis on TV watching during mealtimes was an important behavior of concern relative to nutrient-dense food consumption by African American toddlers. Different from white toddlers, a greater emphasis on TV watching during mealtime seemed to lower the consumption of nutrient-dense foods. Hertzler and Fray (1999) showed that parents who allowed their children to watch too much television also encouraged negative eating behaviors. Watching television is an important part of the environment. The mothers who placed more emphasis on TV watching during mealtimes could have impacted their child negatively in terms of higher calorie and less nutrient dense food choices and intake because it is crucial to provide a healthy feeding and eating environment. This environment including the meal structure can in part be impacted by television viewing. According to Patrick and Nicklas (2005), structure at meals can in turn significantly influence the child's eating patterns. The relationship between TV viewing and increased consumption of energy-dense foods and hence obesity among children has been well documented by previous studies (Coon et al., 2001; Feldman, Eisenberg, Neumark-Sztainer, & Story, 2007; Matheson, Killen, Wang, Varady, & Robinson, 2004), warranting some concern relative to our findings and the current childhood obesity crisis.
Socio-demographic factors: Marital status in addition to race also appears to be an important factor to be taken into consideration in this low-income population. While toddlers of single NHW women were the least frequent consumers of energy-dense foods, toddlers of AA women consumed energy-dense foods more frequently, regardless of the mother's marital status. In their prospective cohort study of the National Longitudinal Survey of Youth, Strauss and Knight (1999) showed that children of less educated and single mothers were at increased risk for obesity over a period of six years Given that, for both racial groups, the overwhelming influence on the toddlers' consumption of energy-dense foods are the mothers' consumption patterns, this difference may reflect that single AA mothers themselves consume more energy-dense foods than single NHW mothers. More investigation is required to elucidate the association between marital status and mother's feeding practices across different ethnicities. Our findings are consistent with the study conducted by Hendricks et al. (2006) who showed the relationship of maternal and child characteristics to toddler feeding practices, in a national random sample in their feeding Infants and Toddlers Study (FITS). In this study, age and marital status of the caregiver was associated with positive feeding behaviors. Older and married women were more likely to exhibit positive feeding practices than those who were younger or unmarried (Hendricks et al.).
A key strength of our study was that it was conducted in a "natural setting" with a sample of 400 mother toddler-dyads with an equal proportion in the African American and non-Hispanic white ethnic groups. We were also consistent in our dietary assessment methods, since we used identical FFQs to measure the food intake patterns of both mothers and toddlers. Some limitations are noted. The cross-sectional nature of the data presented here makes it impossible to establish if mothers' perceptions about the toddlers' eating habits are the result or the determinant of the toddler habits. In addition, having only one mealtime observation for the majority of the study participants makes it difficult to establish the reliability of these observations. However, we did conduct a second interview and observation with a subsample of families (N=71), and established test-retest reliability for the "picky eater" scale (r=0.85, p<0.001) and the "emphasis on TV watching" scale (r=0.75, p<0.001). Lastly, the presence of observers in the home could have affected the mothers' feeding behaviors and created bias. However, it does appear that observation does not result in dramatically different changes in behavior. Although the findings from this study are useful for cross-cultural nutrition interventions in this vulnerable population, these findings warrant more in-depth investigation. In addition, the shared home environment such as household food supplies and exposure to and consumption of similar foods as well as cultural influences and subjective norms (e.g., parental or other family member preferences or pressures) may provide more in-depth explanations if our findings are explored further (Wardle et al., 2005).
Summary and implications for practice: Based on our study, mothers' food consumption was the strongest predictor of nutrient-dense and energy-dense food intake among AAT and NHWT. Therefore, interventions to increase children's nutrient-dense food intake should begin with and target parents' intake, and their feeding behaviors. More family meals are encouraged, as parent modeling could facilitate the child's ability to learn healthy food behaviors, highlighting the significance of culture specific family oriented interventions targeting toddlers' health. Some of the important findings of this study such as the emphasis on social interaction during mealtimes, the extent to which toddlers might regulate their meals, a mother's view of their child as a picky eater, and the perception that "cooking takes too much time" may be important considerations when planning culturally relevant interventions targeting AAT. Sitting with toddlers at meals, limiting TV watching during mealtimes, not forcing toddlers to eat all the food that is offered or exerting too many expectations for food consumption, and creating a pleasant mealtime environment are a few examples of positive influences on toddler food habits ( Hughes, Power, Orlet Fisher,. Mueller, & Nicklas, 2005). By identifying the differences in feeding behaviors between African American and non-Hispanic white mothers and toddlers, our results provide important insight into considerations needed for the planning and execution of culturally sensitive interventions targeting these ethnic groups.
