INTRODUCTION

The customs and traditions of each of the societies in the world, according to their cultures, affect the nutritional attitudes and behaviors in the family. Nutritional habits guided by various socioeconomic, cultural and educational influences are acquired in children in the early stages of life^1,2. The personality of the child is shaped in the pre-school period, and the acquisition of nutritional habits is generally based on these years, and these habits can cause nutritional problems that may affect later in life and may arise in the future^2,3.

The most important reason for inadequate and unbalanced nutrition is the lack of access to food. In addition, wrong and ongoing nutritional attitudes and behaviors are also an important reason. Growing children are frequently affected by inadequate and unbalanced nutrition problems, especially in the pre-school period, and a tendency to obesity is observed. Wrong and inappropriate eating habits gained during this period also carry important risks related to obesity and cardiovascular diseases in the future^4-6.

In order for parents to evaluate their children’s nutritional behaviors, various scales with objective characteristics have been developed for different age groups. Birch et al.⁷ developed the child feeding questionnaire for children aged five to nine years, to determine the attitudes, behaviors and beliefs of parents while feeding their children. Baughcum et al.⁸ applied a similar nutrition questionnaire for preschool children aged 2-5 years. These surveys are generally carried out to determine the parents’ responsibility for their children’s nutrition, eating pressure, restrictive behaviors, and perception levels of their children’s weight^7-10.

The aim of this study is to determine the anxiety of mothers about the nutrition of their pre-school children and their behaviors and attitudes during feeding, and to reveal the potential physical negativities that could be caused by the incompatibility between the mother and the child about nutrition.

MATERIALS AND METHODS

This cross-sectional study was conducted by using face-to-face interview method among mothers with children aged 2-5 years, who applied to the pediatrics clinic of our hospital between October 2016 and December 2016 and thought that their children had a nutritional problem. A detailed history of the children was taken, their general examinations were carried out, weight and height measurements were performed, body mass index (BMI) was calculated, percentile (p) values were found and recorded for weight, height and BMI from tables created according to their age and gender. BMI <5 p was considered as underweight, BMI 5-85 p as ideal weight, BMI 85-95 p as overweight, and BMI >95 p as obese^11,12.

The demographic characteristics of the mothers, their education level, socioeconomic status, and family income as above or below the minimum wage were classified, and nutritional questionnaire questions were asked in addition to their status. Mothers of children who were born at term and had normal birth weight (>2,500 g), and height and weight not below normal for age and gender (>3 p), and who did not have a known chronic disease were included in the study after obtaining the consent for the questionnaire form. Mothers of children with chronic liver, kidney, heart and neuromuscular diseases, being on continuous drug use, being born prematurely and with low birth weight (<2,500 g), and with height and/or weight <3 p at the time of enrollment in the study and those who did not answer more than 10% questions in the questionnaire forms given to the mothers were excluded from the study.

Characteristics of the Questionnaire

The questionnaire we applied in our study included the feeding behaviors of mothers in preschool children and their evaluations about their children’s nutrition. While 12 questions in the first part defined the demographic characteristics of the family, the remaining 33 questions (13-45) in the second part were about the nutritional survey. While 11 of these 33 questions were examining mothers’ responsibilities in feeding their children, 7 of them were measuring the eating pressure that mothers put on their children. Two questions evaluated the degree of mothers’ dietary restrictions on their children, one question assessed mothers’ perceptions of their children’s weight, and one question evaluated mothers’ levels of interest in their children’s weight. Two of the remaining 11 questions were about the children’s choice of food, 3 questions about the child’s misbehavior that would negatively affect the child’s eating habits, 5 questions about non-mother factors affecting the child’s nutrition, and 1 question about the place of snacks in the child’s nutritional life (Table 1)^7-10. While two of the questions, questions 17 and 28, were multiple-choice type, the answers to the remaining 31 questions were prepared in a five-point Likert scale type (1: Never, 2: Rarely, 3: Sometimes, 4: Often, 5: Always).

Approval for this study was obtained from the Ethics Committee of Health Sciences University Turkey, İstanbul Okmeydanı Training and Research Hospital (27.09.2016/523). Table 1 shows which scales the questions in the questionnaire belong to.

Statistical Analysis

The data obtained as a result of the research were evaluated in the SPSS 16.0 software. While evaluating the data collected with the survey questions, charts showing absolute and percentage numbers were prepared for each question. While analyzing the study data, the conformity of the parameters to the normal distribution was evaluated with the Shapiro-Wilks test. In addition to descriptive statistical methods (mean, standard deviation, frequency), while comparing the quantitative data, the Student’s t-test was used for the comparison of normally distributed parameters between two groups, and the Mann-Whitney U test was used for the comparisons of non-normally distributed parameters between two groups. The chi-square test or Fisher exact test statistics were used to compare categorical variables. The correlation between the variables was determined with the pearson or Spearman’s correlation coefficient. Significance was evaluated at the p<0.05 level.

RESULTS

Five of the 305 mothers who initially participated in the study were excluded from the study because they did not complete the questionnaire. Fifteen cases with a weight or height <3 p after the measurements were also excluded from the study, and the remaining 285 children and their mothers were included in the study. The mean age of all children was 3.8±1.0 years, 3.7±1.0 years in girls and 3.8±1.0 years in boys. There was no statistically significant difference between the two groups in terms of mean age (p=0.328). While the number of children in families ranged from 1 to 6, the median number of children in families was 4. Demographic characteristics of the children included in the study and their mothers are given in Table 2.

While the number of mothers with two or less children was 176, the number of mothers with three or more children was 109. When these two groups were analyzed in terms of the distribution of children with 3-97 p and >97 p, no significant difference was found (p=0.758). Considering the income levels of the families, it was found that the income of 108 families (44.2%) was below the minimum wage, and the income of 177 families (45.8%) was above the minimum wage. There was no statistically significant difference between children with 3-97 p and >97 p in terms of weight according to their income level (p=0.889).

The weight, height and BMI percentile distributions of the children included in the study are shown in Table 3. Of the 285 children included in the study, 276 children (96.8%) were between 3-97 p in terms of weight, while the number of children >97 p was 9 (3.2%). Among the girls and boys, the distribution of those with 3-97 p and >97 p for weight was similar (p=0.522). Children included in the study were additionally classified according to their BMI percentile values. According to the BMI percentile values of the children, 30 (10.5%) were obese and 47 (16.5%) were overweight (Table 3).

Questionnaires were asked to the mothers about the nutrition of their children. While the number of mothers who let the child choose the food they wanted on the table was 217 (76.2%), 171 (60.0%) stated that they considered themselves successful when their children finished the food. 196 (68.8%) of them stated that they prepared different food when children did not like the food. 77.5% of them were helping their children when they did not finish their meal. Although health professionals said that their children were of normal weight, the number of mothers who thought that their children’s weight was always insufficient was 14 (4.9%). Three (33.3%) of 9 mothers whose children had a weight of >97 p still thought that their children’s weight was insufficient, contrary to what health professionals said. While the number of mothers who thought that their children ate more than necessary was 48 (16.9%), this perception was not present in 33.3% of those with obese children. 43.5% of the mothers stated that they did not punish their children for not eating more or they did not reduce their children’s privileges.

65.6% of them promised their children for after-meal dessert in order to make them eat the food which would be good for their children, but the children did not want to eat. 53.0% of them stated that they often or always played games with their children in order to feed them, 56.2% of them stated that they often or always watched television while feeding their children. Regarding the place of snacks in the child’s diet, 47.3% of the mothers stated that these snacks were included in the child’s diet every day.

Eleven of the questionnaire questions examined mothers’ responsibilities in feeding their children. This scale reflected the mother’s control over the child’s nutrition and her feeling responsible for the portions and for preparing a healthy diet. The degree of mothers’ responsibility for feeding their children (11 questions; 55 points in total), the degree of eating pressure that mothers placed on their children (7 questions; 35 points in total), child nutrition and non-mother factors (5 questions; total 25 points) were evaluated among working and non-working mothers. While there was no statistically significant difference between the mean level of non-maternal factors, it was observed that the mean levels of eating pressure and mother’s responsibility scales were statistically lower in working mothers (p=0.027, p=0.021, respectively) (Table 4).

It was evaluated whether the mothers’ responsibility and eating pressure scales were different in the mothers of children with a weight of 3-97 p and >97 p. The total score of the degree of mothers’ responsibility in feeding their children was found to be lower in mothers having children with >97 p than in the other group and this was statistically significant (p=0.010), but no statistical significance was found in the comparison of the total score of the degree of eating pressure that mothers put on their children (p=0.123) (Table 5).

A positive and moderate correlation was found between the total score of the mothers’ responsibility scale to feed their children and the total score of the mothers’ eating pressure scale on their children (r: 0.485; p=0.000).

When the mother’s education level was compared with the mothers’ responsibility scale total score for feeding their children and the mothers’ eating pressure scale total score on children, it was found that the score decreased as the education level increased. It was seen that the group of mothers who felt most responsible and made pressure to eat were literate, while the group of mothers who felt the least responsibility and did not make pressure to eat were university graduates (p=0.003 and p=0.004, respectively). When the mother’s occupation (housewife/working) and the mothers’ responsibility scale total score for feeding their children and the eating pressure scale total score on their children were compared, it was found that both scale scores were lower in working mothers (p=0.013 and p=0.049, respectively) (Table 6).

Mothers’ responsibility and eating pressure were evaluated in the groups formed according to BMI percentile values. While the median value of mothers’ responsibility scale was 32.5 in the group with BMI >95 p, it was 35 in the group with BMI <5 p. In this paired comparison, the mean values of the mothers’ responsibility scale were found to be statistically significantly higher in the underweight group than those in the obese group (p=0.044). No statistically significant difference was found in other pairwise comparisons (p>0.05).

Eating pressure, mother’s responsibility and non-mother factors in child nutrition were evaluated according to weight, weight percentile, BMI and BMI percentiles. When non-mother factors in eating pressure and child nutrition were evaluated, there was no statistical significance (p>0.05). BMI was found to be statistically significant in the mother’s responsibility scale (r: -0.12, p=0.046). However, the same significance was not found in the BMI percentile (r: -0.10, p=0.095) (Table 7).

DISCUSSION

In our study, according to BMI measurements of the children of mothers who thought their children had eating problems, it was determined that 10.5% of were obese, and 16.5% were overweight. In recent years, obesity and being overweight in children stand out as a remarkable problem at the rates between 1.5% and 20% in different countries and in age groups^13-16. In a study conducted in the age group of 5-6 years in our country, the frequency of being overweight was detected to be 8.3% and the frequency of obesity was 10.1%¹⁷. In another study, it was reported that the prevalence of being overweight was 8.6% and the frequency of obesity was 6.6% in the age group of 1-5 years¹⁸. It is thought that being overweight and obesity have increased in the childhood age group in recent years.

It is suggested that the way parents feed their children has an effect on the development of obesity. One of the methods that examines parents’ responsibilities regarding their children’s nutrition, controlling habits, attitudes and beliefs is the parental feeding style questionnaire. The main purpose of this type of survey is to reveal what directs eating habits and why parents use the methods they use. The survey questions we used in our study, on the other hand, were prepared in line with the data obtained from studies conducted in this direction so far, and they tried to descriptively define mothers’ feeding attitudes^7-10. The parental feeding questionnaire developed by Wardle et al.⁹ for children aged 2-9 years was also validated in our country¹⁹. Our study included different questions, the most important of which was the degree of responsibility that mothers showed in feeding their children. It was observed that mothers having children with a weight above normal had a lower mean of responsibility scale than mothers of children with a weight within the normal range.

In some studies, it has been shown that overweight children are under less pressure to eat, but children with low BMI are under more pressur to eat^15,20,21. In our study, however, no significant difference was found in the comparison of the mean scores on the scale of eating pressure created by mothers on children. In some studies, it has been shown that excessive controlling and restrictive behaviors of parents in children’s nutrition increase the risk of overeating and obesity in children. In a study, it was determined that childhood obesity was related to parental nutritional behaviors, controlling children’s food choices (for example; restricting snack foods) had negative consequences, and children consumed these foods excessively when they had the opportunity. The theoretical relationship between child nutrition practices and body weight stems from the prediction that parents are likely to control the child’s nutrition if they believe the child is at risk of gaining excess weight. In the literature, it is stated that excessive controlling behaviors of parents about nutrition lead to irregularities in caloric intake and weight gain in children. It is claimed that excessive control of nutrition causes the child to ignore hunger and satiety signs and increase the tendency to obesity^21,22. It is thought that avoiding restrictive behaviors in the nutrition of the child will contribute to the prevention of the risk of being overweight and obesity²³.

Parents’ inability to evaluate their children’s weight correctly also prevents them from directing them to a healthy diet. In some studies, it has been shown that families are not aware of that their children’s weight is above normal^24-26. In our survey, when the mothers were asked whether they thought that their children’s weight was still insufficient even if health personnel said that the weight of their children was within normal limits, 14 (4.9%) mothers still thought that their children’s weight was insufficient despite the doctor’s indication, and this rate was 33% in the mothers of obese children. It was thought that the perception disorders of these mothers regarding the weight of their children might be an important cause of obesity in children. It has been shown that parents are not aware of that their children are overweight and do not perceive this situation as a health threat²⁶. In solving this problem, parents’ visual perceptions of their children’s weight are of great importance.

It is important in terms of proper nutrition whether the nutrition of the child is according to the wishes of the child or the wishes of the family. Families affect children’s eating habits not only by the food they offer them, but also by the way they are fed²⁷. Families trying to feed the child by playing games to feed their children, distracting the child with television or moving musical visual content, and giving rewards affect the child’s eating habits in the opposite direction²⁸. In our study, it was seen that the majority of mothers tried similar methods. In order for the child to eat healthy, it is recommended that the family sit at the table and eat together. It has been shown that allowing the child to make his/her own choices by enabling the child to plan his own meals is a necessity for the child’s adherence to nutrition and proper eating habits that will be formed in the future, and it has been reported that these children consume less food when they take their own starter food at the meal²⁹.

It has been suggested that low income level and socioeconomic status cause the child to be fed with fast-consuming high-calorie foods and to be overweight³⁰. It has been shown that the risk of obesity is lower for the children of parents with higher education levels¹⁵. In our study, it was observed that higher education level decreased mother’s responsibility and eating pressure, and this was low in mothers with obese children. It has been reported that the children of mothers with longer working hours are also at higher risk of being overweight³¹. In our study, it was observed that the responsibility and eating pressure scale scores of working mothers were lower than those of non-working mothers. It is thought that the reason for this may be that the working hours were not long or that the children were fed by another adult at home.

Study Limitations

Our study includes several limitations. First, the children included in the study were not evaluated in terms of food allergies. Second, the weight, height and BMI of the families were not evaluated.

CONCLUSION

As a result, the foundations of future nutritional habits are largely provided by the gains in the age period of 2-5 years. The data obtained in our study show that mothers do not fully know the behaviors that can be positive examples while feeding their children and they continue to make common mistakes in the society, such as finishing the meal completely, replacing undesired meals with acceptable ones. The decrease in the excessive pressure for eating, which will negatively affect the future nutrition style, with the level of education, and the decrease in the awareness of the responsibility for feeding the child with the education level show that the society’s awareness should be raised and they should be educated on this issue.

Ethics

Ethics Committee Approval: Approval for this study was obtained from the Ethics Committee of Health Sciences University Turkey, İstanbul Okmeydanı Training and Research Hospital (27.09.2016/523).

Informed Consent: Informed consent was obtained from the patient.

Peer-reviewed: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: M.J., Concept: M.J., Y.T., H.D., O.Ö., Design: M.J., Y.T., H.D., O.Ö., Data Collection or Processing: M.J., Analysis or Interpretation: M.J., Y.T., H.D., O.Ö., Literature Search: M.J., Y.T., H.D., O.Ö., Writing: M.J., Y.T.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.