Introduction
Coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, was first discovered in Wuhan, China in 2019, causing fever and cough [
1]. It is highly contagious and affects a large portion of the world's population. Over the last two years, Delta and Omicron coronavirus variants have been identified, and now there have been over 530,266,292 confirmed cases and 6,299,364 deaths worldwide [
2]. In order to control the spread of the virus various governments implemented a range of strategies including home isolation requiring people living through the COVID-19 pandemic to adapt their way of life.
Diet is an important part of a healthy lifestyle for children, and under COVID-19 home isolation, parents are responsible for the majority of their children’s feeding. Parental feeding behaviors are usually assessed in terms of feeding style and feeding practices. Feeding style is a relatively fixed form of behavior that combines parental perceptions, attitudes, behaviors, and emotional expressions concerning feeding their children. Feeding practices are goal-oriented, specific behaviors that parents adopt to influence their children's eating behaviors or intake [
3], such as providing a healthy home food environment and modeling eating behaviors that children learn to imitate [
4]. For this reason, feeding practices are more susceptible to change during the COVID-19 pandemic. This study categorized parental feeding practices into three categories based on the food parenting practices framework proposed by Vaughn et al. [
5]: coercive control, structure, and autonomy support. Coercive control refers to parents imposing their ideas on their children (e.g., children eating when they are not hungry) and controlling them through pressure eating and restriction, and is associated with emotional eating and unhealthy dietary intake (high-fat and high-sugar foods) in children [
4,
6,
7], which leads to obesity and disordered eating behaviors in children [
8,
9]. Structure refers to the strategies parents used to help influence children's eating behaviors and organize the home environment, representing a type of parental control involving noncoercive practices [
5]. The goal of autonomy support is to help children to develop their autonomy and independence in making nutritious choices. Children may benefit from structured practices (e.g., healthy food environments) and autonomy-supportive practices (e.g., praise) that promote healthy dietary intake (e.g., fruits, vegetables) and eating behaviors [
10,
11].
Parent–child engagement time has risen as a result of pandemic home isolation measures, as have interactions between children and their parents over food and feeding practices [
12]. However, according to the American Psychological Association survey, parents are under tremendous stress [
13], possibly as a result of parents working from home, home-schooling, unemployment due to the economic downturn, or food insecurity due to the epidemic. Previous studies have found that different types of stress, such as maternal psychological stress [
14], parental emotions [
15], food insecurity [
16], and parenting stress [
17], can affect parental feeding practices. Stressed parents are more likely to exert feeding pressure on their children [
18], in particular, parents who experienced stress in the daytime [
19], which will influence the child's satiety response [
20]. A qualitative study revealed that, despite having different goals for feeding their children (e.g., providing a healthy home food environment, limiting snack intake, etc.), parents are influenced by direct factors (e.g., stress) that make it difficult for them to implement feeding practices as expected [
21], which may be a reason for the shift from structured and autonomy-supportive feeding practices to more coercive feeding practices.
It is unknown whether the COVID-19 outbreak or the isolation measures implemented to combat the disease impacts parental feeding practices. Therefore, the purpose of this study was to analyze changes in parental feeding practices during COVID-19 that may help shape future interventions and make parental guidance more targeted.
Discussion
This study attempted to summarize the changes in parental feeding practices during COVID-19, analyze existing and potential problems, and provide behavioral and nutritional guidance to parents and children. The results showed that parental coercive control practices (e.g., pressure to eat, restricted diets, and food rewards) increased during the COVID-19 pandemic, and that structure and autonomy support practices had different outcomes depending on the content of the study (e.g., structural practices in which parents monitored children more but were not overly prescriptive about children's snack intake).
COVID-19 has had negative short- or long-term effects on parents, children, and families [
39], resulting in increased levels of stress and depression [
40]. Negative parental emotions and stress can affect parents' enthusiasm for feeding practices, leading to an increase in coercive control feeding practices [
26,
27]. This is consistent with previous studies [
17,
41]. Stress can effectively interfere with parents' ability to observe children's behavior and limit children's ability to regulate their energy intake [
29]. Coercive control practices, for example, can reduce vegetable intake over time [
42]. Moreover, to alleviate children’s boredom and distress due to COVID-19 or parents' lack of energy to restrict food provision [
18,
26], stressed parents use food to compensate for the impact on children’s life aspects [
43]; this could also explain why parental stress is associated with increased emotional and snack feeding practices. As a result, parents are less likely to have specific rules or limits on their children's snacks and to provide them on an emotional basis [
21], resulting in greater intake of high-calorie foods such as potato chips and sugar-sweetened beverages among children in home isolation [
44,
45]. Mothers who experienced greater COVID-19 life changes had more rewarding diet-related behaviors and pressure to eat, and mothers with a high body mass index were more likely to use food to control their child's negative emotions [
30]. It has been reported that utilizing snacks as a reward may increase external factors associated with children's diets and may also influence children's eating behaviors by increasing exposure to unhealthy snacks, resulting in childhood overeating and obesity [
46]. Although parents provide proper guidance to their children during a pandemic (e.g., explaining nutrition, involving children in daily meal preparation, and encouraging positive and healthy eating habits), it may be difficult for parents to maintain a stable environment to ensure children's health and nutritional support under economic and life stress. As a result, parents experiencing stress during the pandemic can be advised on how to cope with stress and sustain supportive feeding.
In addition, the pandemic’s lockdown policy made fresh fruits and vegetables more difficult to obtain, and food insecurity during covid-19 was cited in all three included studies, with the same results as in previous studies [
47,
48]. We found that families with food insecurity used coercive control practices more frequently, including highly stressed parents who may force children to eat to avoid wasting [
49] or restrict intake to avoid food consumption [
50], causing children to overeat when food is plentiful and affecting their dietary regulation [
51]. Meanwhile, children's dietary intake is influenced by their home food environment [
52], children living in food insecurity status have poorer availability, affordability, and accessibility to nutritious foods [
53]. Parents experience various barriers in implementing structured practices [
54], leading to the children receiving poor-quality diet [
55], which results in a rise in the incidences of diet-related chronic childhood diseases such as obesity [
56]. Despite the relaxation of epidemic prevention measures in many regions, food security issues continue to arise, whether as a result of the outbreak or other economic shocks. Food insecurity has been considered now as detrimental to force-feeding [
57,
58]. As educators, we may provide timely and supportive feeding instructions to food insecure families to reduce the negative impact on nutrition from COVID-19 or similar stressful events later in life, which is within our power.
When subsequently creating more rational feeding practices to promote the usage of positive health-related behaviors in children and parents, the age of the child should be considered first. Children had a wide age range throughout the research, with clear distinctions between preschoolers and school-age children. School-age children who acquire a sense of diligence have rapid cognitive and ability development, are more likely to develop healthy eating behaviors, are more inclined to help prepare food at mealtime, and have greater autonomy and skills than preschool children [
21,
59]. Preschoolers are more dependent on their parents for food. Since parents have no specific rules or restrictions on food, the use of treats to reward and comfort behaviors is more frequent [
60]. Consistent with the findings of Yee's research, praise and rewards were dominant for children aged < 6 years, while setting rules or limits was more effective for children aged > 7 years [
4]. There are studies showing that the type of feeding practices parents used is associated with child mood, with positive child mood associated with greater use of autonomy-supportive practices [
26], child boredom with parental use of soothing food or less restriction [
31]. Parents’ behavior may be affected by their children’s emotions. As a result of the elevated negative emotions of children, parents who want their children to be more active but are unable to achieve their goals are likely to be less restrictive to their children's diets and exhibit more tolerant feeding practices. Both of their emotions have a potential impact on feeding practices. Understanding the two-way link between parent and child may be useful in implementing better feeding practices. Future research should strive to explore the long-lasting effects of COVID-19 on parental feeding practices and children, particularly changes in children's eating habits and eating behaviors, as well as the effects on body weight. Children's sedentary behavior [
61], screen time [
62], and dietary changes [
63] are all likely to increase obesity rates in children in the post-pandemic era. Consequently, it might be beneficial to detect these changes in time for child development.
Although we summarized variations in parental feeding practices in this systematic review, some points need to be considered. First, the included studies did not specifically explore whether feeding practices were associated with child outcomes (e.g., changes in diet, eating behaviors, or body composition) to further explore the impact of changes in parental feeding practices. Second, in the included studies, the CFQ and FPSQ were employed beyond the age-applicable range of the questionnaire and may not have correctly assessed children outside the applicable range. The age range of the children surveyed also spanned a wide range and did not fully reflect the feeding practices of children in a particular age group. In addition, the use of self-report questionnaires in all study design methods may have resulted in parental recall bias, and changes in the current social pressures and the feeding practice dynamics may have been underrepresented. The heterogeneity of the study instruments used in the study made direct comparisons of our results impossible during our integration procedure. A reliable method that investigates differences in parental feeding practices would be potentially valuable to the study of parental feeding practices. Finally, the included literature in the study does not specify the government epidemic policies in place when the studies were conducted. In terms of chronology, almost all participating areas were under lockdown, making our results comparable. However, most of the articles included in this study were from cross-sectional surveys conducted in the United States; therefore, studies from other country regions may be a useful addition to the future research. Nevertheless, this study summarizes the variations in parental feeding practices during COVID-19 and serves as a foundation for further exploration of the long-term impacts of the COVID-19 pandemic on children (e.g., dietary regulation/behavior, body weight).
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