Systematic Review of Parents' Stress and Feeding Styles and Practices
Condition: Parent-Child Relations; Stress; Feeding Behavior
Study type: Observational

Summary: 
      Parents' mental health contributes to their feeding practices how they perceive and respond
      to their children's behavior. Suboptimal feeding practices may promote dysfunctional eating
      behaviours in children and contribute to children's weigh. The purpose of this review is to
      identify existing literature on the association between parents' stress and their feeding
      styles and practices
    

Detailed description: 
      Background:

      Feeding is a central aspect of parenting that involves interactions between parents and their
      children. Those feeding interaction influence children's eating behaviors during a sensitive
      period of growth and cognitive development. Parents' feeding styles and parents' feeding
      practices are terms that have been used to describe feeding interactions between parents and
      their children. Previous research have found that parents' feeding styles and feeding
      practices are associated with different children's outcomes (e.g. growth, weight).Throughout
      literature, the terms of parents' feeding styles and feeding practices have been used
      interchangeably.

      Parenting styles can be defined as attitudes or an emotional climate that characterizes the
      parents' approach and interaction with their children across different domains of parenting.
      Those domains can be characterized based on demandingness (defined as behavioral control over
      the child) and responsiveness (defined as warmth and supportiveness for the child). Based on
      those domains there are four parenting styles: authoritative, authoritarian, indulgent and
      neglectful. An authoritative parenting style can be characterized as a style associated with
      a high level of responsiveness and demandingness to the child. As for the authoritarian
      parenting style can be defined as style with low responsiveness and high demandingness.
      Whereas the indulgent parenting style can be characterized as a style with high
      responsiveness and engagement with the child but with low demandingness. Finally, an
      uninvolved parenting style is defined as a style with both low responsiveness and low
      demandingness.

      Parenting feeding styles can be defined as attitudes or an emotional climate that
      characterizes the parents' approach with their children during feeding interaction. Feeding
      styles are a sub-category of parenting styles with similar domains of responsiveness and
      demandingness applied within a feeding context. For instance, an authoritarian feeding style
      is where a parent supports and encourages their child eating with directives and rules
      regardless to the child's preferences, whereas a parent with an authoritative feeding style a
      parent encourages eating with a non-directive approach and is responsive to the child's
      preferences and needs.

      Parents' feeding practices concept refers to the strategies and techniques parents may employ
      to maintain or control the feeding context such as when, what or how much their children eat.
      Feeding practices are intended specific behaviors parents use to influence their children's
      eating and differ based on parents' perceptions and beliefs of how to achieve optimal growth
      for their children. For instance, a parent could limit access to certain food types to
      control his/her child's weight, or force feed the child to increase his/her weight. Different
      feeding practices have been discussed in literature such as restriction of certain food
      types, pressuring to eat, or using food as a reward. Feeding practices have been associated
      with weight and eating behaviors in children. Ventura and Birch argue that parental feeding
      practices are a response to a child's behaviour rather than a parental trait.Moreover,
      parental feeding style can be consistent, or found within a parent, but parental feeding
      practices can be different depending on different factors such as a child's weight and
      temperament.

      Parents' mental health influence parents' feeding style and practices.The World Health
      Organization (WHO) defines mental health as "a state of well-being in which individual
      realizes his or her own abilities, can cope with the normal stresses of life, can work
      productively and fruitfully, and is able to make a contribution to his or her community".
      Caregivers' mental health problems are considered to be a major public health challenge
      worldwide. Parents' mental health, such as stress and depression, influences how they
      perceive their children's behavior, as well as how they interpret and respond to their child
      behaviors. In a study by Hurley et al, they found that mothers who experienced more symptoms
      of stress, depression and anxiety were more likely to engage in non-responsive feeding
      practices. In another study by Swyden et al, they found an association between mothers with a
      high level of stress and restrictive feeding practices such as restricting the amount and
      type of food been consumed.

      Stress in general can be characterized as the ability to cope with challenges, or an
      emotional or behavioral response an individual may experience toward an unpleasant event.
      While parenting stress can be conceptualized as psychological distress experienced by parents
      as a response to their efforts to meet parenting demands. Different studies have examined
      parents' stress (either general stress or parenting stress) in association with feeding style
      and practices of parents, child weight and eating behaviours. For instant, in a
      cross-sectional study, mothers who reported a high level of stress symptoms were more likely
      to engage in forceful, controlling and restriction feeding practices. In another
      cross-sectional study by Hughes et al, the relationship between parental emotional distress
      and feeding style in low-income parents with preschool children was examined. They reported
      that parents with uninvolved feeding style had a high level of parenting stress compared to
      parents with other feeding styles: authoritative- authoritarian and indulgent. These results
      support the claim that there is a relationship between parents' stress and their feeding
      styles and/or practices.

      Objective:

      The primary objective of this systematic review and met-analysis is to summarize existing
      literature on the association between parents' stress (both parenting and general stress) and
      parents' feeding styles and practices (both parents' emotional climate and strategies applied
      in the context of feeding).

      Design:

      This systematic review and meta-analysis will be conducted according to the Cochran Handbook
      for Systematic Reviews of Interventions and the results will be reported according to
      Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and Preferred
      Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

      Data Sources:

      The investigators will search the following databases: MEDLINE, EMBASE, and PSYCHINFO
      (accessed via Ovid), CINAHL (accessed via Ebsco). The authors will apply appropriate search
      strategy through database. Searches will be supplemented with manual searches of references
      of included publications.

      Data Extraction:

      Two or more investigators will independently extract relevant data and assess risk of bias.
      First, title and abstract of identified studies will be screened for eligibility. Second,
      full texts will be examined in detail based on eligibility criteria outlined above. Third,
      references of all considered articles will be screened for any potentially eligible studies
      that were not captured in the search strategy. Any disagreement between the reviewers will be
      resolved by author (MV). For missing data, authors of primary publication will be contacted.
      Risk of bias for observational studies will be assessed using the Newcastle Ottawa Scale. As
      for cross-sectional studies, risk of bias will be assessed using the National Institutes of
      Health "Quality assessment tool for observational cohort and cross-sectional studies".

      Data synthesis and statistical analysis:

      The extracted data from included studies (e.g., participants' characteristics, exposure,
      outcomes, results and direction of association) will be used to build an evidence table.
      Also, if sufficient studies are identified and variability is low, data from included studies
      will be pooled using the generic inverse variance method. A random-effect model will be used
      to determine the association between parents' stress and their feeding styles.This will be
      done under the assumption that the true effects are normally distributed. Fixed-effects
      models will be used only where there are <5 included associations.

      Assessment of heterogeneity:

      The investigators will evaluate heterogeneity by estimating the variance between studies
      using Cochran Q statistic and quantified by the I2 statistic. The Cochran's Q test is
      obtained by the weighted sum of the squared differences of the observed effect in each study
      minus the fixed summary effect. The I2 statistic describes the percentage of variability in
      the effect estimate that is not due to chance and (I2 >= 50%) indicates a substantial
      heterogeneity with a p-value of <0.1 as a statistically significant level. To explore sources
      of heterogeneity, investigators will conduct sensitivity analyses in which each study is
      systematically removed. If >=10 studies are available, potential sources of heterogeneity by
      a priori subgroup analyses will be explored. The investigators will conduct subgroup analyses
      that will depend on identified studies; determined by study design (prospective or
      retrospective), follow-up time, setting (developed or developing countries),
      socio-demographic characteristics, sample size and adjustment for confounding variables
      (i.e., gender, education and history of mental health). If >=10 studies are available,
      publication bias will be assessed by an inspection of funnel plots and tested using the Egger
      and Begg test. If publication bias is suspected, the Duval and Tweedie trim and fill method
      will be applied to adjust for funnel plot asymmetry by imputing missing study data.

      Evidence Assessment:

      Two reviewers will independently assess the quality and strength of included studies using
      the Grading of Recommendation Assessment, Development and Evaluation (GRADE) system.

      Observation studies start at low-quality evidence and can be downgraded or upgraded based on
      the following criteria:

        1. Criteria to downgrade evidence: risk of bias, inconsistency, indirectness, imprecision
           and publication bias.

        2. Criteria to upgrade evidence: large effect size, attenuation by all plausible
           confounding effects and dose-response gradient.

      Differences will be reconciled by consensus.
    

Observational model: Other
Time perspective: Other
Sampling method: Probability Sample
Study population: 
        Parents of children (birth- 5 years)