VOLUME 17 NUMBER 9 | sEptEMBER 2009 | www.obesityjournal.org
Behavior and Psychology
nature publishing group
There is great interest in the role of maternal feeding practices
in the etiology of childhood obesity. Controlling feeding
practices have been associated with increased caloric intake
among young children in unrestricted settings (1–3). These
practices are thought to contribute to the development of
poor child self-regulatory abilities regarding caloric intake and
subsequent excessive weight gain and obesity. Recent Expert
Committee Recommendations state that parents should “avoid
overly restrictive feeding behaviors” when helping children
control their weight (4). However, research on the relation-
ship between controlling feeding practices and child weight
has been inconsistent, with various studies showing a positive
relationship (5,6), a negative relationship (7–9), or no relation-
ship at all (10–13).
Because many studies have been cross-sectional, it is diffi-
cult to determine whether controlling feeding practices lead
to poor child eating behaviors and subsequent weight gain, or
whether these feeding practices arise from concerns over exist-
ing child weight. Some researchers have suggested that restric-
tive and controlling maternal feeding practices (CMFPs) are
a response to concerns over the child’s perceived risk of obes-
ity rather than a cause (11,14,15). It has also been suggested
that the relationship between controlling feeding practices and
future child eating behavior or weight status is moderated by
baseline child or maternal weight. Birch et al. found in a cohort
of 140 white girls that high levels of maternal restrictive feed-
ing practices at age 5 were associated with the child exhibiting
greater eating in the absence of hunger at age 7 and 9, but par-
ticularly for girls who were already overweight at age 5 (ref. 3).
Faith et al. also found in a cohort of 57 children that restrictive
feeding practices at age 5 predicted elevated child BMI z-score
(zBMI) at age 7, but only for high-risk families (i.e., families in
which mothers had an elevated pre-pregnancy weight) (16). So
Maternal Feeding practices Become More
Controlling After and Not Before Excessive
Rates of Weight Gain
Kyung E. Rhee1, Sharon M. Coleman2, Danielle P. Appugliese2, Niko A. Kaciroti3, Robert F. Corwyn4,
Natalie S. Davidson3, Robert H. Bradley5 and Julie C. Lumeng3,6
It is unclear whether controlling maternal feeding practices (CMFPs) lead to or are a response to increases in a child’s BMI.
Our goal was to determine the direction of this relationship. Data were obtained from National Institute of Child Health and
Human Development’s Study of Early Child Care and Youth Development. Child BMI z-score (zBMI) was calculated from
measured weight and height. CMFP was defined by, “Do you let your child eat what he/she feels like eating?”. Change
in child zBMI was calculated between 4–7 years and 7–9 years, and dichotomized into “increasing” vs. “no change or
decreasing”. Change in CMFP was calculated over the same time periods, and dichotomized into “more controlling”
vs. “no change or less controlling.” Multiple logistic regression, stratified by gender and controlling for race, maternal
education, maternal weight status, and baseline child weight status, was used for analysis. A total of 789 children were
included. From 4 to 9 years, mean zBMI increased (P = 0.02) and mothers became more controlling (P < 0.001). Increasing
CMFP between 4 and 7 years was associated with decreased odds of increasing zBMI between 7 and 9 years in boys
(odds ratio = 0.52, 95% confidence interval = 0.27–1.00). There was no relationship in girls. Increasing zBMI between 4
and 7 years was associated with increasing CMFPs between 7 and 9 years in girls (odds ratio = 1.72, 95% confidence
interval = 1.08–2.74), but not boys. Early increases in CMFP were not associated with later increases in zBMI for boys or
girls. However, early increases in zBMI among girls were associated with later increases in CMFP. Clarifying the relationship
between maternal feeding practices and child weight will inform future recommendations.
Obesity (2009) 17, 1724–1729. doi:10.1038/oby.2009.54
1Department of Pediatrics, Brown Medical School, Providence, Rhode Island, USA; 2Data Coordinating Center, Boston University School of Public Health, Boston,
Massachusetts, USA; 3Center for Human Growth & Development, University of Michigan, Ann Arbor, Michigan, USA; 4Department of Psychology, University of Arkansas
at Little Rock, Little Rock, Arkansas, USA; 5Family and Human Dynamics Research Institute, Arizona State University, Tempe, Arizona, USA; 6Department of Pediatrics and
Communicable Diseases, University of Michigan, Ann Arbor, Michigan, USA. Correspondence: Kyung E. Rhee (firstname.lastname@example.org)
Received 12 August 2008; accepted 11 February 2009; published online 12 March 2009. doi:10.1038/oby.2009.54
obesity | VOLUME 17 NUMBER 9 | sEptEMBER 2009 1725
Behavior and Psychology
even though controlling feeding practices may be used in over-
weight and nonoverweight children, the relationship between
these practices and greater eating in the absence of hunger or
weight status may only exist among those who are already at
risk for obesity, and not the population at large.
There is also a lack of longitudinal studies examining how
these feeding practices change over time, possibly in response
to changes in child characteristics. Two studies with relatively
homogenous samples noted that parental feeding practices
between the age of 5 and 7 years did not change significantly
over time (16,17). Another study in younger children (age 6–24
months) also found relative stability in maternal feeding prac-
tices, but that higher infant weight at age 1 predicted the use
of more restriction at age 2 (ref. 18). Similar studies evaluating
older children as their weights change have not been done.
The goal of this study was therefore to examine the tempo-
ral relationship between CMFPs and child weight status over a
longer time frame in a larger cohort than previous reports. We
were specifically interested in examining whether changes in
CMFP preceded or followed changes in child zBMI. We sought
to test two hypotheses: (i) increases in CMFP between the ages
of 4 and 7 years predict later increases in child zBMI between
the ages of 7 and 9 years; (ii) increases in child zBMI between the
ages of 4 and 7 years predict later increases in CMFP between
the ages of 7 and 9 years. We stratified these analyses by gen-
der because evidence exists to suggest that children respond
to the same maternal feeding practices differently depending
on gender (1,2) and that some maternal feeding practices vary
based on gender (19). Furthermore, only girls have been the
participants in many prior studies (3,15,17,20,21).
In 1991, 1,364 families were recruited to participate in the National
Institute of Child Health and Human Development Study of Early
Child Care and Youth Development, which sought to examine child
behavior and development over time in relation to childcare experi-
ences. It was conducted at 10 sites across the United States and used a
conditional random sampling plan designed to prevent selection bias
(22). Information about the original cohort is presented elsewhere (23).
The study was approved by the Institutional Review Boards of all rel-
Child heights and weights were measured during laboratory visits
scheduled at age 4, 7, and 9 years (mean ages ± s.d. 4.6 ± 0.1 years,
7.0 ± 0.3 years, and 9.0 ± 0.3 years). The protocol for anthropomet-
ric measures was standardized across sites and is detailed elsewhere
(24). BMI was calculated and zBMI derived based on norms from
the National Center for Health Statistics growth curves (25). Because
the normal distribution of BMI differs by age and gender, using zBMI
was necessary in order to standardize the degree to which child BMI
deviates from the mean across age and gender. Changes in zBMI were
measured between 4 and 7 years (4–7y zBMI Δ) and between 7 and
9 years (7–9y zBMI Δ).
CMFP was measured at ages 4, 7, and 9 years using the question, “Do
you let your child eat what he/she feels like eating?” from the Raising
Children Questionnaire (26), a simplified revision of Greenberger’s Rais-
ing Children Checklist (27), which is a standardized measure of parenting
strategies. This question was scored using a four-point scale: 1—definitely
no, 2—mostly no, 3—mostly yes, 4—definitely yes. Higher CMFP scores
therefore indicated less use of maternal control.
To better understand how this item related to observed feeding behav-
iors, we examined the relationship between CMFP scores and the number
of maternal prompts given to a child to eat, coded to reliability using
a standardized scheme (28) from a 10-min videotaped snack session
with this cohort of mother–child dyads (n = 773) when children were 36
months old. Analysis of variance demonstrated significant differences in
the number of maternal prompts given to the child to eat across the four-
response categories (P = 0.02). Post hoc analyses indicated that mothers
who replied “definitely no” to the question “Do you let your child eat what
he/she feels like eating?” prompted the child to eat more often.
Changes in scores were measured between 4 and 7 years (4–7y
CMFP Δ) and between 7 and 9 years (7–9y CMFP Δ). If a mother
indicated that she “mostly” allowed her child to eat what he/she felt like
eating (score = 3) at age 4 years, but became more controlling over time
and answered “mostly no” (score = 2) when the child was 7 years old,
the change score would have been 3 − 2 = 1. Thus, those with increasing
control had a positive CMFP Δ score while those with less control over
time had a negative CMFP Δ score.
The National Institute of Child Health and Human Development Study
of Early Child Care and Youth Development data set does not include a
baseline or self-reported maternal weight or height. To include maternal
weight status as a covariate, the nine-point Stunkard Figure Rating Scale
(FRS) (29) was applied to the mother’s videotaped image when the child
was 15, 24, and 36 months old. Each tape was coded by two raters with
high inter-rater reliability (intraclass correlation coefficient 0.90, 0.83, and
0.80 at 15, 24, and 36 months, respectively). FRS codes correlate with
measured BMI in prior studies (r = 0.87) (ref. 30) and with mother’s self-
reported BMI when the child was 15 years old in this cohort (r = 0.74).
Scores range from 1 to 9. Higher scores represent a higher BMI.
Children with missing data for CMFP or child height and weight at
the 7- or 9-year visit were excluded from the analysis, resulting in a final
sample size of 789 participants (58% of the original cohort). The sample
with complete data (n = 789) differed from the sample without complete
data (n = 575) in that the retained sample was more likely to be white
(84 vs. 76%, P < 0.001), female (52 vs. 43%, P < 0.001), and had higher
mean maternal education (14.6 vs. 13.7 years, P < 0.001).
χ2-Statistics, t-tests, and ANOVA were used to describe the sample
by our two primary outcome measures. Multiple logistic regression
models were stratified by gender. Two-category race (white, not white),
maternal education in years (continuous), and maternal FRS score were
included in the models a priori. We also controlled for child weight sta-
tus at the age of 4 years (categorized as “obese” (BMI ≥ 95th percentile)
vs. “not obese”) (4,31,32) because CMFPs could have varied based on
whether or not the child was perceived as “obese” at the beginning of
the study period. Controlling for child weight status also allowed for
focused examination of the effect of zBMI changes between ages 4 and
9 years, independent of the child’s baseline weight status. In the model
examining the effect of change in CMFP on change in zBMI, baseline
CMFP at 4 years was used as a control. SAS v9.1 (SAS Institute, Cary,
NC) was used to perform the analysis.
Main effect of increasing CMFP between 4 and 7 years
predicting an increase in zBMI between 7 and 9 years. The out-
come, 7–9y zBMI Δ, was dichotomized into “increase” (top quartile
of change scores (+0.33 to +2.08)) vs. “no change or decrease” scores
(bottom three quartiles (−2.27 to +0.33)). A child with an increase
in 7–9y zBMI Δ became relatively heavier between the ages of 7 and
9 while a child with no change or decrease in 7–9y zBMI Δ became
relatively thinner or maintained a relatively stable weight percentile
during that period. The predictor, 4–7y CMFP Δ, was trichotomized
into positive, negative, and zero change scores, reflecting increasing,
decreasing, and no change in controlling feeding practices during
this time frame. Zero change scores served as the reference group.
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Behavior and Psychology
Given that maternal weight status and baseline child weight status
may moderate the effect of controlling feeding practices on future
child zBMI (3,16), the interactions of maternal FRS score and baseline
child weight status with increasing CMFP were tested. The interaction
between baseline CMFP and increasing CMFP was also tested.
Main effect of increasing zBMI between 4 and 7 years predicting
an increase in CMFP between 7 and 9 years. The outcome, 7–9y
CMFP Δ, was dichotomized into those who had a positive change
score and became more controlling vs. those who had a negative or
zero change score and became less controlling or did not change.
The predictor, 4–7y zBMI Δ, was also dichotomized into those who
were in the highest quartile of change (+0.42 to +2.59) vs. those in
the bottom three quartiles (+0.41 to −4.93) to represent those with
the greatest increase in child zBMI and those with minimal change
or a decrease in zBMI, respectively. The interactions of maternal FRS
score and baseline child weight status with increasing zBMI were
The sample included 789 children, 52.3% of whom were
female. The majority of the sample was white (83.8%), with
mean maternal education of 14.6 ± s.d. 2.4 years (Table 1).
Both child weight and the degree to which mothers exhibited
controlling feeding practices increased over time. Mean zBMI
for the three age points were: 0.36 ± 1.0 (age 4), 0.44 ± 1.0
(age 7), and 0.51 ± 1.0 (age 9) (P = 0.02). Mean CMFP scores
at the same age points were 2.60 ± 0.62, 2.48 ± 0.64, and 2.10 ±
0.72, respectively (P < 0.001).
table 1 characteristics of the sample by each outcome
Total (N = 789)
7–9y zBMI Δ (N = 728) 7–9y CMFP Δ (N = 789)
(0.33 to 2.08)
(N = 182)
No change or
to 0.33) (N = 546)
(N = 321)
No change or
(N = 468)
Gender (n (%))
Male 376 (47.7)91 (50.0)250 (45.8) 0.32 145 (44.6)236 (50.0) 0.17
Female413 (52.3)91 (50.0)296 (54.2) 180 (55.4)240 (50.4)
Race (n (%))
White661 (83.8)152 (83.5)458 (83.9)0.91247 (84.0)397 (83.4)0.82
Other128 (16.2)30 (16.5)88 (16.1)52 (16.0)79 (16.6)
years (mean, (s.d.))
14.61 (2.39) 14.54 (2.46)14.64 (2.33) 0.6214.72 (2.51)14.53 (2.31) 0.26
Maternal FRS score
4.58 (1.43)4.70 (1.45) 4.46 (1.38)0.04 4.55 (1.48)4.60 (1.41) 0.61
CMFP at 4 years
2.62 (0.62) 2.62 (0.62)2.59 (0.62) 0.51———
CMFP at 7 years
2.48 (0.64)2.49 (0.65) 2.47 (0.63) 0.71———
CMFP at 9 years
2.10 (0.72) 2.14 (0.74)2.08 (0.72)0.33———
4–7y CMFP Δ (n (%))
Increase 208 (26.4)43 (23.6) 147 (26.9)0.31———
Decrease 128 (16.2)25 (13.7)92 (16.9)
No change 453 (57.4) 114 (62.6)307 (56.2)
zBMI at 4 years
0.34 (1.03)——— 0.29 (1.03)0.40 (1.02) 0.13
zBMI at 7 years
0.44 (0.97)———0.40 (0.99)0.46 (0.95)0.41
zBMI at 9 years
0.51 (1.04)——— 0.45 (1.06)0.54 (1.02)0.25
4–7y zBMI Δ (n (%))
(0.42 to 2.59)
198 (25.1)———90 (28.0)108 (23.1)0.28
(−0.29 to 0.41)
394 (49.9)155 (48.3)239 (51.1)
(−4.94 to −0.30)
197 (25.0)76 (23.7) 121 (25.9)
CMFP, controlling maternal feeding practice; FRS, Figure Rating Scale; zBMI, BMI z-score.
obesity | VOLUME 17 NUMBER 9 | sEptEMBER 2009 1727
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Table 1 also shows demographic characteristics of the
sample by each of our primary outcomes (7–9y zBMI Δ and
7–9y CMFP Δ). Those who experienced an increase in zBMI
between 7 and 9 years did not differ by gender, race, or mater-
nal education, but their mothers had a significantly higher FRS
score, as compared to children who did not have an increase
in zBMI. Absolute CMFP scores did not differ significantly at
any time point between children who increased their zBMI
between 7 and 9 years and those who did not. Nearly half
(41.2%) of mothers increased their controlling feeding prac-
tices between 7 and 9 years. Children whose mothers increased
their CMFP score between 7 and 9 years did not differ by gen-
der, race, maternal education, or maternal FRS scores com-
pared to those who did not. Child zBMI also did not differ
significantly at any time point between children whose moth-
ers increased their controlling feeding practices from 7 to 9
years and those who did not.
Table 2 shows the main effect of increasing CMFP between
4 and 7 years on increases in zBMI between 7 and 9 years in
the adjusted model, stratified by gender. For girls, neither
an increase nor decrease in maternal control over feeding
between 4 and 7 years was associated with later increases in
zBMI. However, boys had decreased odds of increasing zBMI
if mothers increased their CMFP between 4 and 7 years (odds
ratio = 0.52, 95% confidence interval = 0.27–1.00). There was
no significant interaction between baseline CMFP, maternal
FRS score, or baseline child weight status and change in CMFP
between 4 and 7 years in either gender.
We next examined the association between increasing zBMI
between 4 and 7 years and an increase in CMFP between 7 and
9 years using an adjusted model stratified by gender (Table 2).
Among girls, those who had the greatest increase in zBMI
between 4 and 7 years were most likely to have mothers who
increased control over what their children ate between 7 and 9
years (odds ratio = 1.72, 95% confidence interval = 1.08–2.74).
Among boys, there was no association between changing zBMI
and change in later CMFP scores. Again, there was no interaction
between either baseline child weight status or maternal FRS score
and change in zBMI between 4 and 7 years in either gender.
In this study, we examined the longitudinal relationship
between changes in CMFPs and child BMI. Previously, there
has been evidence to suggest that controlling feeding practices
are associated with excessive weight gain in children (1,5,6).
However, this longitudinal study of a large national cohort
demonstrated that early increases in CMFPs were not associ-
ated with later increases in zBMI in girls or boys. In boys, the
odds of increasing one’s zBMI were actually decreased. On the
other hand, increases in child zBMI between 4 and 7 years were
significantly associated with later increases in CMFP among
girls, but not boys.
Our study adds further evidence that controlling feeding
practices may not be associated with future excessive weight
gain in children. Although restrictive feeding practices have
been shown to be associated with increased caloric intake in a
controlled laboratory environment (1,5), restrictive behaviors
outside the laboratory, influenced over time by other environ-
mental and parenting factors, may not show the same asso-
ciations. Therefore, we propose that it may be premature to
recommend for all children that parents avoid restrictive or
controlling feeding practices to prevent excessive weight gain.
We also did not find a moderating effect of maternal weight
status or baseline child weight status on this feeding practice and
its association with future excessive child weight gain. However,
boys were found to have decreased odds of increasing their
zBMI if mothers displayed increasing control between ages 4
and 7 years. This finding supports previous work that boys and
girls may respond differently to maternal feeding practices (1,2).
However, in contrast to their null association for boys, we found
that boys had a significant response to controlling feeding prac-
tices such that their risk for excessive weight gain was reduced.
This again may reflect differences between studying behaviors
in a laboratory setting vs. a naturalistic setting. This result may
also be secondary to different forms of controlling practices
being used for boys compared to girls. Future discrimination
between these forms of controlling practices, used for each gen-
der, may help to clarify our findings.
In actuality, there may be some children for whom these
or similar types of feeding practices are necessary to help
table 2 relationship between change in zBMI and change
Odds of an increase in zBMI between
7 and 9 years (OR (95% CI))
Girls (N = 387)Boys (N = 341)
Change in CMFP between 4 and 7 years
More controlling1.00 (0.54–1.83)0.52* (0.27–1.00)
Less controlling 1.06 (0.52–2.17) 0.47 (0.20–1.08)
No change1.00 1.00
Race (other vs. white)1.63 (0.86–3.09) 0.60 (0.28–1.27)
Maternal education 0.96 (0.86–1.07)1.01 (0.91–1.12)
Maternal FRS score 1.10 (0.92–1.31) 1.20* (1.01–1.43)
Child BMI ≥ 95th
percentile at 4 years
0.15** (0.04–0.67)0.48 (0.19–1.22)
CMFP at 4 years1.05 (0.67–1.66)1.16 (0.72–1.88)
Odds of an increase in CMFP between
7 and 9 years (OR (95% CI))
Girls (N = 413)Boys (N = 376)
Change in zBMI between 4 and 7 years
vs. lowest 75th%
1.72* (1.08–2.74)1.07 (0.66–1.74)
Race (other vs. white) 1.10 (0.63–1.92)0.79 (0.43–1.44)
Maternal education1.01 (0.92–1.10)1.05 (0.96–1.15)
Maternal FRS score0.96 (0.83–1.11) 0.99 (0.85–1.15)
Child BMI ≥ 95th
percentile at 4 years
0.96 (0.47–1.96)1.07 (0.52–2.21)
CI, confidence interval; CMFP, controlling maternal feeding practice; FRS, Figure
Rating Scale; OR, odds ratio; zBMI, BMI z-score.
*P ≤ 0.05; **P ≤ 0.01.
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Behavior and Psychology
regulate a child’s intake and limit excessive weight gain.
Recently Ogden et al. tried to expand the concept of control-
ling feeding practices by distinguishing between overt (i.e.,
being firm about what, when, where, and how much a child
eats) and covert (i.e., not going to restaurants or bringing
sweets and snacks into the house) practices (33). Several stud-
ies have suggested that these different forms of controlling
behavior may be associated with healthier eating behaviors
and less snack food intake (33,34). Aspects of covert control
are currently used in many family-based weight control pro-
grams (35). In addition, controlling feeding practices may be
like many other efforts at providing discipline. Depending on
how it is delivered, it may not have a negative impact on child
eating behaviors or weight. Rather, the more harmful effects
may only occur with more extreme versions of the parent-
ing practice. Again, future discrimination between different
forms of controlling practices and how they are delivered
may help to clarify our findings.
We also found that significant increases in CMFPs occurred
after significant increases in girls’ zBMI, but not boys’. These
findings suggest that mothers are more concerned with a
female child’s rapid weight gain than a male child’s, and will
become more controlling as a result. Our results complement
the results of other cross-sectional studies noting that moth-
ers do not exert different types of controlling feeding practices
in relation to boys’ weight status (36), and parents are much
less likely to recognize or be concerned about the overweight
status of sons compared to daughters (37–39). These behaviors
may represent a sensitivity to societal values that girls should
be slim while boys may have a physical and social advantage by
being larger. The stronger response to rapid weight gain in girls
could also stem from personal factors like dietary restraint or
history of eating disorders that are often projected onto the
same sex child (40,41) and are highly correlated to monitoring
or restriction of daughters’ eating (42,43).
An important limitation of this study is that maternal con-
trolling feeding practices were assessed with a single question.
Psychometrics of this question and how it relates to other com-
monly measured feeding practices, like restriction, pressure and
monitoring, as measured by the Child Feeding Questionnaire
(44) are unknown. However, our study is not the first to use
a single question to capture the concept of maternal feeding
practices (7,45) and using a construct with more than one item
does not necessarily protect against misinterpretation of these
items (46). Of note, in this data set, increased CMFP corre-
lated with increased pressure to eat in the videotaped snack
sessions. Specific restrictive behaviors were not observed.
However, this does not mean that mothers are not restrictive
in other situations and settings. Rather, it was not captured on
this videotaped procedure. Second, interpretation of this ques-
tion between subjects could have been quite variable. However,
as it was asked repeatedly over time, the within subject inter-
pretation of the question likely remained stable. As control-
ling feeding practices are thought to affect child weight gain
through its impact on child eating behaviors, the availability
of these data would have also been helpful. Finally, there were
significant differences between those included and excluded in
the sample and generalizability may be limited.
In conclusion, our study provides further evidence that
CMFPs may not be associated with later increases in child
zBMI, and may instead be a response to increasing child weight.
Recommendations to avoid controlling feeding practices may
need to be clarified, particularly if certain forms of controlling
practices help to promote healthier eating habits (33,34,47,48).
Applying other methodologies that examine dyadic interactions
between parent and child may allow for a richer understanding
of how specific feeding practices play a role in the development
or prevention of obesity. Further definition and exploration of
these types of feeding practices and their relationship with
child weight gain is needed to better inform recommendations
for obesity treatment and prevention.
this study was supported by grants from American Heart Association
Midwest Affiliate Grant-in-Aid 0750206Z to Dr. Lumeng and the Hasbro
pediatric Research Fund to Dr Rhee.
the authors declared no conflict of interest.
© 2009 The Obesity Society
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