Children’s optimal growth and development is dependent on the provision of a nurturing environment, particularly during their formative years, specifically the first six years of life. Caregivers and parents, in particular, play a full-time role in influencing a child’s behavior during this crucial period, which can have enduring effects on their lifelong development [1,2].

Eating behavior is highly complex and affected by a variety of factors including physical environment, social environment and individual characteristics [1,3-6]. Parents and caregivers have a significant impact on shaping children’s eating behavior, particularly during toddlerhood and preschool age [1]. They shape eating behaviors by providing access to foods and through their own eating styles, behavior during mealtimes, and child feeding practices [1,4-6]. In a recent review, it was found that parents who adopt a moderate restriction approach, gradually decreasing and limiting unhealthy food items while offering positive messages and encouraging a variety of foods, may promote healthier dietary habits in their children. In contrast, overly restrictive feeding practices have been linked to overeating, particularly among preschool children [4].

It is very common for parents and caregivers of preschool children to be overly concerned about their children’s weight and eating habits. This can be driven by a variety of factors, such as parents’ own weight and body image concerns, societal pressures related to body weight, or worries about their children’s health. However, research suggests that overly concerned parents may be more likely to engage in feeding practices that are counterproductive, such as pressuring their children to eat or restricting their food intake. This can have negative impacts on the children’s relationship with food and overall health. Therefore, healthcare providers should take concerns about child weight seriously, but also work with parents to address their concerns and provide evidence-based guidance on healthy feeding practices. A family-centered approach that takes into account the unique needs and circumstances of each family may be most effective in promoting healthy eating behaviors and preventing eating disorders in children [7-11].

The role of parents in shaping their children’s food preferences and energy intake is well-established in the literature, with certain feeding practices having the potential to significantly impact children’s eating behavior [1,3,5-6,10]. Given the importance of parental influence on young children’s eating habits, this study aimed to investigate the eating behavior of preschool children aged 3-6 years and explore parents’ attitudes toward feeding. Through this research, we hope to gain a better understanding of the factors that contribute to healthy eating behaviors in young children as well as identify areas where parents may benefit from additional guidance and support in promoting positive eating habits in their children.

Our study was designed as observational descriptive research. The instruments employed in the study were a Personal and Parent Information Form and a Children’s Eating Behavior Inventory. Approval was obtained from the Ministry of Health of Istanbul Health Sciences University Training and Research Hospital Clinical Research Ethics Committee on 01/06/2018 under decision nº 1284. The study was conducted in accordance with ethical legislation.

Conveinence sampling method was used in this study. Informed Consent Forms were obtained from parents who volunteered to participate in the study. Children were informed verbally in a language they could understand. Written consent form was obtained from parents. There were no questions for children in the questionnaire form. The entire questionnaire consisted of questions for parents.

The personal and parent information form was prepared by the researchers in order to determine the sociodemographic characteristics of the children and parents participating in the study. Personal information form includes questions about the children and parental age, educational status, income status, children’s height and weight, current chronic disease information, and parents’ thoughts about children’s appetite and development.

The Children’s Eating Behavior Inventory was developed and standardized by Lynda A. Archer in 1990 in Canada [11]. The Turkish validity and reliability of the inventory were performed by Ünlü [12]. In the Turkish version, Cronbach’s alpha coefficient of the inventory was reported as 0.81, and Pearson correlation coefficient, 0.75 (p<0.01). This inventory was prepared to be filled by parents regarding childhood eating behavior and mealtime problems. It was aimed to determine the effect of parental attitude and family structure on children’s eating behavior problems. The inventory consists of 40 items, and some of the questions are about the children and some are about the parents and other family members. Each item of this inventory has been prepared with a five-point Likert system to determine how often the behavior in question occurs, and includes the statements “always”, “often”, “sometimes”, “rarely”, “never”. In the inventory assessment, items were collected and assessed under the headings of children’s positive eating behavior, children’s negative eating behavior (Table 1).

Participants were determined as those who accepted to participate in the study from parents with children between the ages of 3-6 who applied to the Haseki Education Family Health Center outpatient clinic within the specified time. The questionnaire form prepared for parents was filled by the assistant researcher through on-site interviews with parents of children. Anthropometric measurements of children included in the questionnaire were recorded by the researchers. Anthropometric measurements of children were measured via CDC guidelines [13]. A calibrated scale was used for weight measurement. Weight measurements were taken with children wearing thin clothes and without shoes. Height was measured without shoes with a stadiometer. Children with a chronic disease with potential impact on Body Mass Index (BMI) (such as diabetes, thyroid diseases, malignant diseases) were excluded from the study.

Inclusion criteria for the study, included individuals who are registered as parents of children between the ages of 3 and 6, and whose children are enrolled in the Istanbul Haseki Education Family Health program. Parents must agree to participate in the study.

Exclusion criteria from the study included individuals who were unable to consume food orally, those who required formula or other nutritional interventions due to underlying health conditions, those who fell outside the designated age range of 3 to 6 years old, and those who declined to participate in the study.

The IBM^®SPSS^® 16.0 program (for Windows, Version 16.0.) was used for statistical analysis. Descriptive statistics, such as numbers and percentages for categorical variables, median, interquartile range, minimum and maximum for numerical variables were given. Since the numerical variables did not meet the normal distribution condition, comparisons of two independent groups were made with the Mann-Whitney U test. Comparisons of more than two groups were compared with the Kruskal-Wallis test. The relationships between numerical variables were analysed by Spearman’s correlation analysis. Statistical alpha significance level was accepted as p<0.05.

The sample size for the study was determined using the G*Power 3.1.9.7 software. The effect size was calculated based on the mean and standard deviation of the groups. The significance level (α) was set at 0.05, and the desired power (1 – α) was set at 0.95. Based on these parameters, the calculated power of the study was 96%, and the required sample size was determined to be 206.

The final study sample consisted of 206 parents of children, and their sociodemographic data can be found in Table 2. This study included children with an average age of 4.6±1.0 (3-6) years, comprising 51.2% girls and 48.8% boys. When assessing weight based on percentile ranges, 64.7% of children had normal weight (n=134), 11.5% were underweight (n=24), 7.7% were overweight (n=16), and 15.9% were classified as obese/overweight (n=33). Mothers’ assessments of their children’s weight are also presented in Table 2.

The average score of the answers given by parents to the survey questions is shown in Table 1 (1: Never, 2: Seldom, 3: Sometimes, 4: Often, 5: Always). Our results revealed a statistically significant positive correlation between children’s percentiles and parental education level, maternal BMI level, and income level (p=0.011, p=0.002, p<0.001, p=0.004) (Table 3).

Furthermore, we found that positive eating behaviors in children were positively and statistically significantly correlated with parental age and education level, income level, child age, and child percentile level. Negative eating behaviors were negatively correlated with maternal and paternal age, educational status, income level, and positively correlated with maternal BMI level (Table 4).

In terms of gender differences, our study showed that negative eating behaviors, maternal views and behaviors, child food preparation behavior, and negative meal situations for male children had significantly lower mean scores compared to female children (p=0.001, p=0.007, p<0.001, p=0.001) (Table 5).

Children’s eating behaviors and weight can be influenced by many factors, including parental weight status, education level, income level, dietary behaviors, access to food, availability of home-cooked food, parental stress and portion size [1,3,5-6,8-10-14-16]. Our study found that higher parental socioeconomic level was associated with positive eating behaviors in children. Moreover, as the socioeconomic level decreased, children’s negative eating behavior increased and maternal BMI score increased. In many studies conducted on mothers in the literature, it is found that as maternal educational level increases, children’s healthy eating status increases [17-19]. In a study conducted with elementary school students in China, it was found that parents’ healthy eating behaviors (e.g., daily breakfast, consumption of vegetables and fruits, consumption of dairy products) were strongly related to children’s healthy eating as their status increased [18]. Moreover, a recent USA study found that prevalence of obesity among youths was inversely related to household income and education level of the head of household, and these associations varied by race/ethnicity [20].

In our study, we found that as maternal BMI increased, child percentiles also increased. This suggests that a child’s risk of obesity increases if their mother is obese. This may be due to both genetic predisposition and environmental factors. Children often imitate the eating behaviors of their parents, so if a mother has unhealthy eating habits, her child is more likely to become obese due to poor nutrition. Many studies in recent years have shown that parental obesity is a strong predictor of childhood obesity [21-27]. For instance, a study by Tan et al. (2021) found that parental obesity was associated with an increased risk of childhood obesity [25]. Another study by Rhee et al. (2020) found that maternal BMI was a strong predictor of child BMI trajectories [26]. In addition to parental weight status, other factors such as income level, access to healthy food, and stress levels may also play a role in child obesity risk. For instance, a recent study by Pham et al. (2021) found that food supplementation and dietary diversity were associated with better nutritional outcomes in children in Papua New Guinea [27].

According to the findings of our study, adverse eating behaviors exhibited by children were observed to have a negative correlation with the level of education attained by parents. Moreover, these eating behaviors were found to have a significant positive correlation with maternal BMI. In a study conducted in Turkey, negative eating behaviors were found to be negatively associated with paternal education level [12]. When the prevalence of eating behavior while watching television was questioned, 41.5% of parents said that they always watched TV, and 25.6% said that they watched it frequently. Television viewing is a very important risk factor for obesity in terms of both seeing unhealthy products promoted in advertisements, thus increasing the rate of preference, and limiting viewers’ physical activity [28]. Many studies have been conducted on watching television and being overweight, and it has been revealed that television increases the condition of being overweight [29-30].

In a study examining the effects of television advertisements on preschool children in our country, it has been found that children are not only exposed to adult age group programs while watching television (TV) with their families. Not only their own age group, they watch food advertisements on television with interest and are influenced by advertisements and demand these products from their parents [31]. Again, in a study conducted for children in Turkey, it was found that children liked sweetened beverage and chocolate advertisements the most and demanded these foods [32]. In a recent study, it was found that children who watched TV during meals consumed more energy-dense, nutrient poor foods and had higher overall energy intake compared to children who did not watch TV during meals. The authors also noted that TV viewing during mealtimes may interfere with children’s ability to regulate their food intake and recognize satiety cues [33]. In our study, it was found that preschool students were exposed to television, did not take adequate precautions and made their children watch television.

When asked to rate junk food consumption among children alone, which is one of the negative eating behaviors in our study, 50% responded as always or often. A one-year longitudinal study examined children’s fast-food consumption habits. It was found that parental fast food consumption strongly predicted children’s fast food consumption, and children whose parents consumed fast food more frequently had the highest risk for consuming fast food. For children whose parents consumed fast food less frequently, high exposure to fast food advertising TV was as influential as having a parent who consumed fast food more frequently [34].

In our study, when the sub-dimensions of the inventory were assessed in terms of gender, negative eating behaviors were found to be significantly higher in boys, and meal preparation behaviors were found to be significantly lower. In the literature, while some of the studies conducted with preschool children found more behavioral disorders in male, no significant relationship was found with gender in some of them [35-37]. Feeding problems were found to be more common in males in our study, but studies with larger samples are needed to determine the relationship. In our study, boys’ food preparation behaviors were found to be low, and it was thought that this resulted due to gender inequality, which is one of the major problems of our country.

The study shows a link between children’s weight and parental education, income, and maternal BMI level. Positive eating behaviors were related to age, education, income, child age, and percentile level. Negative behaviors were linked to maternal and paternal age, education, income, and maternal BMI level. Male children had lower scores than females in food preparation and negative meal situations. Parental socioeconomic level was associated with positive eating behaviors, while adverse behaviors were tied to lower parental education and higher maternal BMI. TV exposure was also a risk factor for negative behaviors. The study highlights the importance of considering these factors when preventing childhood obesity.

In our study, only a family health center located in Istanbul Bağcılar was used. The fact that the socioeconomic level of the current center is lower than that of Istanbul may have affected the results.