Summary of key findings
When we asked low-income mothers open-ended questions about feeding their preschool-aged children, mothers revealed aspirations which could help inform obesity prevention interventions. The mothers described a positive agenda for feeding that included having a calm child in good oral health by limiting children’s sugar consumption; teaching children life lessons by setting limits around junk food and providing structure to eating; and, being responsive to children’s mealtime eating patterns, which guided decisions about portion sizes.
These aspirations were unrelated to preventing obesity. We neither invited nor avoided the topic of obesity in our focus groups, but the discussion of obesity and the connection between feeding and obesity was notably absent. The lack of a discussion surrounding obesity in our focus groups is particularly notable, given that we began each focus group by saying:
We are interested in helping parents have their children grow up with a healthy weight
Why some children become heavy and others do not is still a bit of a mystery
People who have been trying to understand this think that a child can become overweight from eating too much food or the wrong kinds of food
but it is sometimes hard to know how much food and what kinds of foods children need to be healthy
We are interested in what you do and what you think when it comes to feeding your child
Mothers also described a household context that presented challenges in achieving this positive agenda, particularly in limiting sugar consumption. These challenges included being nagged by their children for sweets and snacks, being undermined by other adults in the family who gave children sweets and snacks, and having bad childhood memories that made mothers feel guilty about saying “no” to their children. Below we discuss our interpretation of these findings, place the findings in the context of prior research, note the limitations of our study, and suggest implications for designing obesity prevention interventions.
Aspirations that influence feeding practices
Mothers had aspirations that were consistent with some behavioral goals in childhood obesity prevention—reducing children’s sugar intake, setting limits and structure around eating, and responsive feeding during mealtimes. Mothers wanted to limit their children’s sugar intake to avoid hyperactivity and tooth decay, which could be framed as an aspiration to have a calm child with a beautiful smile. There is some evidence linking sugar intake with dental carries , but there is little evidence linking it with hyperactivity . Other qualitative studies showed that low-income mothers thought about a healthy child in ways that they did not directly relate to nutrition, such as a child with healthy skin and hair or one who was happy, intelligent, and well-behaved [21, 28, 37].
Mothers were also motivated to teach children life lessons by setting limits and providing structure around children’s eating. White and colleagues, in their focus groups with mothers of preschool-aged children across eight US states, noted that mothers valued teaching their children “lessons they’ll use for life”  (p.22). In contrast to our study, however, these lessons were about mothers and children cooking and eating together rather than the lessons our mothers noted about children learning to deal with limit setting and structure in eating.
In response to describing how they determined children’s mealtime portion sizes, mothers indicated that they were responsive to their children’s food preferences and took pride in intimately knowing and responding to those preferences. Mothers in other qualitative studies also suggested that they were guided in their portion size determinations by knowing their child and applying that knowledge to the particulars of an eating occasion, such as the food being eaten, the other foods being served, or the other foods eaten that day [20, 37, 38]. However, the evidence from qualitative studies is mixed about whether low-income mothers trust that their preschool-aged children know when they are full [31, 37].
The question of whether mothers should trust children to decide how much to eat remains controversial [39–41]. A resolution of this controversy is suggested by the mothers in our study who, in general, expressed confidence in their children’s ability to know how much to eat as long as it was not sweets or other palatable snack food. Mothers nearly always served children their portions at mealtimes. However, in determining mealtime portion sizes, some mothers involved children in deciding how large portions should be, while others relied on their knowledge of how much food their children usually ate. In this regard the mothers were responsive to their children in determining portion sizes , but we have no information on whether these were age-appropriate portions. It was not a theme in our study, as in some others, that mothers prepared special or alternate meals to suit children’s food preferences [20, 29, 31].
We suspect that a latent aspiration reflected in mothers’ answers to questions about their feeding practices is the desire to build positive relationships with their children. In other qualitative studies of feeding practices in low-income mothers, the idea of building a positive relationship with children through feeding is often reflected in mothers trying to make children happy through food, regardless of whether this conflicted with the rules and limitations mothers wanted to establish [29, 30]. Instead, our findings indicated that mothers wanted to build positive relationships with their children around food by being responsive to children while still establishing limits and structure, which are aspirations consistent with obesity prevention.
There is an emerging literature on maternal feeding styles and childhood obesity [43, 44] that is based on a typology of four general parenting styles that arise from two dimensions of parenting, responsiveness and demandingness . It was not our purpose to characterize feeding styles using this typology, and feeding was not observed. However, mothers in our study might be best characterized as aspiring to an authoritative feeding style in that they were generally responsive around mealtime portions and wanted to set limits (making demands). The fact that mothers were not always able to set limits due to contextual challenges supports the lack of consistency seen between reported and observed feeding styles . In general, mothers in our study were invested in feeding. They did not appear to have a feeding style that was neglectful, uninvolved, or disengaged , but such a style would be less likely in those who volunteered for a study on perceptions about feeding their children.
Challenges in achieving aspirations
A prior study showed that WIC health professionals felt mothers often had difficulty setting limits with their children in the feeding relationship , and this was also noted by low-income mothers in another study . Our study reveals why low-income mothers say they aspire to set limits and the contextual factors that make limit setting hard to do. We and others have previously noted the influence of other adult family members in the mother-child feeding relationship, especially the mothers of young mothers [21, 30, 37, 47, 48]. In this study, we found that when mothers’ agenda to limit sweets and snacks was undermined by other adult family members in the home, mothers felt guilty about interfering and saying “no” because they did not want to harm the relationship between their child and the other adult. Sweets and snacks were a source of conflict in a three-way relationship between child, mother, and another adult family member in the home. Mothers felt frustrated by the way their preschool-aged children cleverly manipulated or nagged them and other adults to obtain sweets and snacks.
Mothers shared painful childhood memories about being told “no”. In one study that asked low-income mothers about their childhood experiences, mothers described their own parents as being either too strict or neglectful in their feeding practices . In another study, low-income, Latina mothers connected the idea of gratifying children with food and good parenting . Similarly, our mothers implied that in saying “no” they were failing to show love because this is how they experienced hearing “no” as a child. Mothers were then left with internal conflict about if and how to say “no” without making the child feel unloved. This could explain why mothers may not effectively set limits around feeding even though they aspire to do so.
The convenience sample of 32 mothers who participated in the study was not necessarily representative of the low-income mothers in Philadelphia, or in other US cities, who met our inclusion criteria. All but one of the mothers, for example, identified themselves as black or African American. Mothers who volunteered to participate may also have devoted more time and energy to feeding their children than other low-income mothers.
Although there were not any direct references to food insecurity in our focus groups, mothers’ painful childhood memories of hearing “no” and the difficulty of saying “no” to their children may have stemmed from mothers’ material deprivation, including food insecurity, during childhood. Mothers may not have felt comfortable disclosing food insecurity during the focus groups, and we did not specifically ask probing questions about it during the groups. Other qualitative studies have suggested that present or past food insecurity may affect how mothers feed their children [30, 49]. Aside from food insecurity, our study may have missed other social or economic challenges faced by low-income mothers in feeding their children. For example, because the focus groups were held in the daytime during the work week, mothers with full-time jobs or school responsibilities during those hours were under-represented, and we may have missed themes related to how time pressures influence feeding children.
We did not collect weight or height data on children, but the distribution of BMI among the mothers was comparable to that of US black women this age . Our study was not designed to compare differences among mothers’ perceptions about feeding according to their weight or the weight of their children. A larger study with an alternative design would be required to identify such differences. The validity of our findings is supported by achieving data saturation across seven focus groups, using three independent coders, and achieving consensus about themes among five authors with varying disciplinary perspectives. Nonetheless, the perceptions and behaviors mothers reported do not allow us to make inferences about their actual behaviors at home .
Implications for obesity prevention interventions
The healthy feeding practices mothers discussed—setting limits, providing structure, and being responsive—were motivated by parenting aspirations other than obesity prevention. Obesity prevention interventions that target the household feeding of low-income preschool-aged children might benefit from focusing on these aspirations. The mothers did not discuss these aspirations in the context of weight or obesity.
Facilitated discussion might be a mechanism to allow mothers to discuss their aspirations in feeding and to help each other identify and address the contextual challenges they face in achieving these aspirations. Research in the Massachusetts WIC program suggests that mothers enjoyed sharing and learning from each other through facilitated group discussion . Video, which has been used successfully in other parenting interventions [51, 52], may serve as a catalyst for facilitated discussion and help standardize such interventions.
Evoking and affirming mothers’ aspirations and the positive emotions that accompany them may lead to more sustained changes in household behaviors because mothers are likely to be most motivated by those goals and related values that matter to them [53, 54]. If mothers identify their own agendas in feeding that are consistent with obesity prevention, though not necessarily motivated by it, mothers may be more able to overcome challenges in achieving those agendas.
Limit setting around sweets and snacks was a central challenge noted by mothers in achieving their feeding aspirations. Nagging children, unsupportive adults, and painful childhood memories all made it hard for mothers to say “no.” To address these challenges it may be helpful to draw on some of the positive aspirations of mothers. Interventions might try to empower mothers to set their agendas for feeding and to think of them as household policies and routines. These policies, when developed to achieve mothers’ own healthy agendas for raising children rather than someone else’s agenda, can help prevent children from nagging for sweets or snacks or being undermined by other adults. It can also help mothers enforce their policies and deal with the uncomfortable feelings that may occur when there is resistance to these policies from children or other household adults.
Mothers’ aspirations could be the basis for presenting suggestions about how to change children’s snacking patterns. For example, even if mothers do not or cannot keep sweets or snacks out of the home, mothers can plan snacks, much in the way they already plan meals, so that the time, place, and type of snack offered is proactively established by the mother and the snack is not given as a reaction to the child’s request. A routine for snacks might attract mothers because it fits within the context of teaching a life lesson about the need for structure. Mothers may also have to say “no” less often because the children expect, accept, and respect the structure. If mothers reduce nagging because they have proactively imposed a routine around snack time, then they might be more able to think of saying “no” as loving and teaching their children rather than depriving or neglecting them. In addition, if mothers plan snacks, they can more easily offer children a controlled choice—a choice between options that are all acceptable to the mother. In this way, mothers still maintain their power and authority but share it with children by offering a choice. Mothers have the opportunity to feel gratified because they are attuned and responsive to their children rather than feeling frustrated or guilty because they have given in to a nagging request for junk food. Planning snacks as part of the daily routine and using controlled choice would extend the aspirations of teaching structure and being responsive in feeding from mealtimes to snack time, where it appears that children had more power than mothers wanted them to have.
There are several controlled evaluations of obesity prevention interventions that involve some focus on diet and target preschool-aged children and their parents [5, 6]. Although some of these studies focus on specific parent feeding strategies, only one  places a heavy emphasis on topics in general parenting (e.g., general parenting styles, building bonds with children, and establishing routines). However, none of these studies attempt to identify and focus on mothers’ larger agendas and aspirations in parenting and linking them to relevant obesity prevention strategies, like planning snacks.
The mothers in our focus groups appeared more able to impose structure and practice responsive feeding during mealtimes than during snack times. Although it was not a major theme, it was spontaneously suggested by some mothers that mealtimes were also an opportunity to bond with children and establish positive relationships with them. Because there is some evidence that eating family meals may protect against obesity in preschool-aged children , future research should attempt to further understand mothers’ aspirations about family meals.
It is not surprising that mothers in our study felt a tension about being responsive while also setting limits, because there is a controversy in the literature about how best to apply these approaches in feeding [39–41] and in overall parenting . Much of the controversy appears to stem from how control is defined and when and how exerting control can be healthy or unhealthy for children’s development. As noted by Gronlick and Pomerantz, “Parents cannot allow children to go unrestricted, even while fostering their initiation and considering their input”  (p 166). Our research suggests that obesity prevention interventions that focus on limiting children’s portions and their intake of solid fats and/or added sugars must help parents use control in a way that is healthy and that allows children to become independent and capable eaters who can control their own food intake to maintain a healthy weight. To do this, mothers may need to realize that they have power over children’s eating and how to use that power along with kindness and warmth so that it is seen by both mothers and children as love. If mothers experienced the power of limit setting and structure in their own childhood without parental warmth, then this type of parenting could have felt mean or even abusive. This might explain why mothers felt uncomfortable settings limits with their own children and confused or angry when their own parents did not set limits or provide structure in feeding grandchildren. Interventions with mothers to address limit setting in their children’s eating might benefit from exploring how mothers experienced limit setting as children.
Control does not mean that mothers need to be harsh, intrusive, or domineering. Instead, control can be the application of structure to help children become capable . Structure is characterized by expectations and rules that are understandable to the child and experienced as part of a routine. This type of control does not need to ignore children’s preferences. Applied to eating, this may mean helping mothers provide a structure about when and where children eat. Doing so gives children a sense of safety and predictability which they can experience as maternal love and wisdom. In the case of certain foods, such as snacks and sweets, it may also be necessary for mothers to place structure on what and how much children eat by constraining the food choices they provide and the amount of food served.
In conclusion, our qualitative inquiry with low-income mothers about feeding their preschool-aged children elicited aspirations about feeding that mothers did not necessarily link to their children’s weight, but which might motivate mothers to make sustained change in feeding behaviors that could, nonetheless, help prevent obesity in their children.