Mediating effect of the parent-child relationship on the association between parenting stress and children’s eating behaviors

Childhood obesity is a major global health concern given the increased rate of overweight and obesity in children. Data from the United States indicate that the rate of obesity was 13.9% for preschoolers and 18.4% for school-aged children in 2015–2016 [1]. The differing rates of obesity by age highlight the significance and necessity of identifying risk factors that influence childhood obesity in the early stages of life. A comprehensive understanding of these factors can contribute to the development of effective interventions.

Early childhood is a critical developmental stage for establishing health behaviors, including eating behaviors [2]. Compared to children with healthy eating behaviors, those with unhealthy eating behaviors are more likely to experience extra weight gain [3]. Some characteristics of children’s unhealthy eating behaviors associated with higher child body mass index (BMI) include higher responsiveness to food and emotional overeating [4, 5]. In contrast, healthy eating behaviors, such as a higher satiety response and slower eating, are considered protective factors against childhood obesity [5, 6]. Numerous factors influence children’s eating behaviors; notably, researchers have emphasized parents’ influence in establishing child eating behaviors [7, 8].

Parenting stress is a main factor that influences childhood obesity. Parenting stress is defined as an individual parent’s perception of stress regarding the parental role experienced as daily hassles related to a child’s behaviors [9]. In recent review studies, increased parenting stress was found to result in higher rates of childhood obesity and affect children’s health behaviors, including a child’s diet, physical activity, and sedentary behavior [10]. In a cross-sectional study, children in families with higher parenting stress due to economic hardship were more likely to consume foods high in saturated fats and added sugars [11]. Although there is evidence of an association between parenting stress and children’s health behaviors, the nature of the association is still not fully understood, possibly due to a lack of understanding of the mediating factors.

During the early developmental stages of life, children’s principal interactions are with their parents. Parents may guide their children through interactions with them [12]. High-quality interaction is often defined as mutuality and synchrony between parents and children [12]. The quality of the parent–child relationship gradually develops as parents and children adjust their behaviors [13]. In turn, the parent and child learn how to respond to each other’s behaviors and reactions. In a family with high-quality of relationship, the parent appropriately responds to the child’s behaviors and emotional expression (i.e., appropriate communication) [14]. Moreover, parents employ appropriate discipline techniques, including limit setting [15]. Parents who have a high-quality relationship with their children also enjoy their role as parents [16]. However, parents’ insecure attachment to the child has been associated with poor parenting practices, such as fewer mealtime routines, fewer limitations for watching television, and a greater use of unhealthy feeding practices, all of which can contribute to children’s unhealthy behaviors and obesity [17].

According to the family systems theory, one family member is not independent from the others; rather, members continuously interact and influence each other and respond to events as a system [18]. Within the parent–child subsystem, parenting stress may influence the quality of the relationship between parents and children, which, in turn, may influence children’s health behaviors, including eating behaviors. Understanding the mediating effect of the parent–child relationship on the association between parenting stress and children’s eating behaviors is important to understand the key risk factors within a family that influence the obesogenic family environment (Fig. 1). This would lead to effective interventions for better health outcomes. Thus, the purpose of this study was to examine the mediating effect of the parent–child relationship on the association between parenting stress and children’s eating behaviors in families with young children aged four to six years.

This study aimed to examine whether the parent–child relationship mediates the association between parenting stress and children’s eating behaviors. Parenting stress is known to be associated with children’s eating behaviors; however, the underlying mechanism of this association has not been clearly established [29]. To understand this complicated mechanism, prior studies have focused on exploring the mediating role of parental feeding practices [10]. We explored a possible mechanism by examining whether the quality of the relationship between parents and children mediates the association between parenting stress and children’s unhealthy eating behaviors. We used three subcategories of the parent–child relationship: parents’ satisfaction with parenting (i.e., satisfaction), their awareness in communication with their children (i.e., communication), and their perception of control regarding child discipline (i.e., limit setting). Communication mediated the association between parenting stress and children’s food responsiveness. Furthermore, there was a mediating role to limit setting in the association between parenting stress and children’s food responsiveness, as well as between parenting stress and children’s emotional overeating.

Our findings indicate that certain subcategories of the parent–child relationship (i.e., communication and limit setting) were negatively associated with unhealthy eating behaviors in children. According to Gerard [30], the quality of communication between parents and children represents how well parents respond to their children in various circumstances. Parents who have healthy communication with their children can be considered empathetic [31], and healthy communication plays a protective role in children’s engagement in risky behaviors [32]. Limit setting is considered a parenting discipline technique for establishing appropriate behaviors in children [33]. Children with parents who do not establish limits for them may feel insecure and are more likely to exhibit problematic behaviors [34]. We found that specific subcategories of the parent–child relationship, including quality of communication and limit setting, were negatively associated with children’s unhealthy eating behaviors.

Based on our findings, an association between parenting stress and children’s unhealthy eating behaviors may be driven by inappropriate parental awareness in communication with their children (i.e., communication) and inappropriate parental perception of control over the disciplining of their children (i.e., limit setting). In a systematic review study, it was found that parents whose children were overweight or obese were less likely to limit or control what their children eat (i.e., food items) or how (i.e., eating behaviors) [35]. This finding supports emerging evidence of a negative association between the quality of the parent–child relationship and childhood obesity [36]. In a longitudinal study, toddlers who had a poor quality relationship with their mothers were more likely to be overweight or obese later in their childhood [37].

We also found that parenting stress was associated with three subcategories of the parent–child relationship (i.e., satisfaction, communication, and limit setting). The negative association between parenting stress and the quality of the parent–child relationship subcategories may be driven by a complicated mechanism. The important point regarding parenting stress is that its source is not only the parents’ personal perception of stress related to parenting but also their relationship with their children, and parenting stress could depend on the children’s personal characteristics [38]. The relationship between a parent and a child is a dynamic interaction that drives both parents’ and children’s behaviors [39], and the quality of the interaction has been examined to better understand children’s social, behavioral, and cognitive development [40]. Thus, the close association between parenting stress and the parent–child relationship may be important for understanding the dynamics of the influence of parenting stress on children’s eating behaviors and obesity.

The influence of parenting stress on the parent–child relationship needs to be interpreted with caution. As previously mentioned, the parent–child relationship is not unidirectional; rather, it is bidirectional [41]. For example, in families with children with type 1 diabetes, communication and interaction between parents and children regarding management of the condition was found to be associated with parenting stress [42]. However, there is limited evidence supporting an association between parenting stress and the quality of the parent–child relationship in families of children with obesity. In this study, we did not assess children’s stress levels in terms of their relationship with their parents. It is possible that children are influenced by the stress level of their parents manifested in the quality of the parent–child relationship. In turn, children’s stress may influence their eating behaviors as a coping mechanism. Further research is needed to explore the association between children’s stress levels and eating behaviors.

To understand the mediating effect of the subcategories of the parent–child relationship on the association between parenting stress and children’s eating behaviors, we need to understand how humans respond to stress. A child’s eating behaviors may be a mechanism for coping with tension in a low-quality relationship with their parents [43]. Responses to stressors, which could be stressful events or events perceived as threatening by an individual, are often described as biological or behavioral. Biological responses to stress are more likely hormonal, involving the hypothalamic–pituitary–adrenal (HPA) axis to maintain homeostasis in the body [44]. Given the connection with biological responses, behavioral coping mechanisms for stress primarily draw attention to eating behaviors. Individuals with high stress levels may be more likely to respond to food and may tend to consume high–calorie foods [45]. Furthermore, individuals with high stress levels may experience more emotional eating and may seek high–fat and carbohydrate–dense foods [46].

Stress arises when an individual perceives the demands placed on them as exceeding their adaptive capacity. Stress can also involve the inability to handle or the challenge of dealing with events that are perceived as threatening [47]. A certain level of stress is considered adaptive; however, consistent and chronic exposure to stressors results in adverse health outcomes [48]. Based on the findings of this study, healthy communication between parents and their children may alleviate tension in the relationship between them, which may reduce children’s stress levels. Furthermore, the children of parents who set appropriate limits feel more secure and confident, and they can thus engage in healthy behaviors [49]. Therefore, the parent–child relationship, particularly parents’ communication and limit setting skills, may be an important intervention component for improving children’s unhealthy eating behaviors in families with high parenting stress levels. In a recent intervention study employing parents’ communication skills and parental monitoring during mealtime, it was found that the intervention was effective in increasing the frequency of family mealtime, increasing parental concerns about their children’s weight, and decreasing parental restriction to eat certain foods, all of which are considered healthy practices [50]. Thus, further development of intervention programs to strengthen the parent–child relationship would be beneficial to improving children’s eating behaviors.

This study has several limitations. First, due to the cross-sectional study design, there is no evidence to indicate a causal association between the variables in the SEM modeling. Moreover, because the study outcomes were drawn from mostly White, middle-income families, the results may not be applicable to families from other socioeconomic classes or from other racial or ethnic backgrounds. We also relied on parents’ self-reported information regarding their relationship with the child as well as on the child’s eating behaviors, thus a validated assessment of the study variables may be limited. Specifically, children’s BMI based on mothers’ self-reports of their child’s height and weight was inconsistent with the national average of overweight and obesity rates. In addition, we used an online survey method. Technology-based surveys may present an obstacle for some potential participating families. One-third of our sample comprised White families, and more than half of the mothers completed at least a high school education. Furthermore, we used subcategories of the parent–child relationship; thus, caution needs to be exercised in interpreting the mediating role of the association between parenting stress and children’s eating behaviors and obesity.

Despite these limitations, this study has important implications for future research. Subsequent studies to assess the key concepts addressed in this study can be undertaken. These complicated concepts can be approached through multiple assessment methods, such as the use of biological markers (e.g., salivary cortisol) to assess parents’ and children’s stress and to assess child obesity and other metabolic risk factors (e.g., BMI, waist circumference, and systolic blood pressure). Moreover, researchers may consider enhancing the rigor of the assessment of the parent–child relationship from the children’s perspective by employing multiple methodologies, such as observational measures. Further research would be conducted with a larger sample to target more racially or ethnically diverse participants with different educational backgrounds. Furthermore, in future studies, researchers would consider developing a study to assess the long-term influence of the parent–child relationship during preschool on health behaviors and obesity later in childhood. Finally, the development of an intervention study to evaluate the efficacy of stress management in the context of improving the parent–child relationship (i.e., parents’ communication and limit setting skills) to reduce childhood obesity is highly recommended.

We examined the mediating effect of several subcategories of the parent–child relationship (i.e., satisfaction with parenting, communication, and limit setting) on the association between parenting stress and children’s eating behaviors and found that appropriate communication and limit setting between parents and children may be a mediating factor. Through this study, we contributed to a better understanding of the complicated relationship between parenting stress and children’s eating behaviors. Parenting stress was negatively associated with the quality of the relationship between parents and children. In turn, the quality of the parent–child relationship was almost significantly associated with children’s unhealthy eating behaviors. Therefore, the parent–child relationship could be an important intervention component for improving children’s eating behaviors in families with high levels of parenting stress.